ANSWER AND RATIONALE

1. Answer - A. Primary prevention precedes disease and applies to

health patients. Secondary prevention focuses on patients who have health
problems and are at risk for developing complications. Tertiary prevention
enables patients to gain health from others’ activities without doing anything
themselves.
2. Answer – C. A safety device on the wrist may impair circulation and
restrict blood supply to body tissues. Therefore, the nurse should assess the
patient for signs of impaired circulation, such as cool, pale fingers. A palpable
radial or lunar pulse and pink nail beds are normal findings.
3. Answer - A. The nurse always should clean around a wound drain,
moving from center outward in ever-larger circles, because the skin near the
drain site is more contaminated than the site itself. The nurse should never
remove the drain before cleaning the skin. Alcohol should never be used to
clean around a drain; it may irritate the skin and has no lasting effect on
bacteria because it evaporates. The nurse should wear sterile gloves to
prevent contamination, but a mask is not necessary.
4. Answer - D. During a rapid assessment, the nurse’s first priority is to
check the patient’s vital functions by assessing his airway, breathing, and
circulation. To check a patient’s circulation, the nurse must assess his heart
and vascular network function. This is done by checking his skin color,
temperature, mental status and, most importantly, his pulse. The nurse
should use the carotid artery to check a patient’s circulation. In a patient with
a circulatory problems or a history of compromised circulation, the radial
pulse may not be palpable. The brachial pulse is palpated during rapid
assessment of an infant
5. Answer – B. The combining form penia means deficiency, as in
thrombocytopenia (deficiency in the number of circulating blood plates).
Rrhexis is a combining form meaning rupture, as in enterorrhexis (rupture of
the intestine). Plast is a combining form meaning formation, as in rhino-plasty
(formation of a nose using plastic surgery). Narco is a combining form
meaning stupor, as in narcolepsy (a condition marked by recurrent attacks of
drowsiness and sleep).
6. Answer – B. Fluid volume deficit related to fever is the appropriate nursing
diagnosis based on this assessment. Potential for impaired skin integrity
states a possible patient response. Potential for fluid volume deficit caused by
fever implies a cause-and-effect relationship, which a nursing diagnosis
should never do. Altered cardiopulmonary tissue perfusion related to fluid
excess is an incorrect diagnosis based on a misinterpretation of the data.
7. Answer – D. Hypercapnia is an elevation in the partial pressure of carbon
dioxide in arterial blood (PaCO2). Hypernatremia is an elevated level of
sodium in venous blood (more than 145 mEq/liter). Hypocalcemia is a
decreased level of calcium in venous blood (less than 9 mg/dl). Hypoxemia is
a reduced level of oxygen in arterial blood (less than 80 mm Hg while
breathing room air).
8. Answer - A. Good Samaritan Act protects those who choose to lend a hand
during emergency situations. In this act, the nurse is not liable to any laws
once she helps an injured individual during this emergency. Options B, C and
D are incorrect because these do not explain what the act is all about.
9. Answer – C. She signs on the medication sheet after administering the medication. A
nurse should record a nursing intervention (ex. Giving medications) after performing
the nursing intervention (not before). Recording should also be done using a pen, be
complete, and signed with the nurse’s full name and title.
10. Answer – C Concern for privacy. A patient’s privacy may be violated if security
measures aren’t used properly or if policies and procedures aren’t in place that
 determines what type of information can be retrieved, by whom, and for what
purpose.
11. Answer – B Sister Callista Roy Sister Roy’s. theory is called the adaptation theory
and she viewed each person as a unified biophysical system in constant interaction
with a changing environment. Orem’s theory is called self-care deficit theory and is
based on the belief that individual has a need for self-care actions. King’s theory is
the Goal attainment theory and described nursing as a helping profession that assists
individuals and groups in society to attain, maintain, and restore health. Henderson
introduced the nature of nursing model and identified the 14 basic needs.
12. Answer – C Health belief. Health belief of an individual influences his/her
preventive health behavior.
13. Answer – B After few minutes, return to that patient’s room and do not leave until
the patient takes the medication. This is to verify or to make sure that the medication
was taken by the patient as directed.
14. Answer – C Capillary refill greater than 3 seconds and buccal. Cyanosis Capillary
refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the
tissues which requires immediate attention/intervention. Oriented to date, time and
place, hemoglobin of 13 g/dl are normal data.
15. Answer – D Educator. When teaching a patient about medications before discharge,
the nurse is acting as an educator. A caregiver provides direct care to the patient. The
nurse acts as s patient advocate when making the patient’s wishes known to the
doctor.
16. Answer – C Patient’s NGT was removed 2 hours ago. The change-of-shift report
should indicate significant recent changes in the patient’s condition that the nurse
assuming responsibility for care of the patient will need to monitor. The other options
are not critical enough to include in the report.
17. Answer – A Ineffective breathing pattern related to pain, as evidenced by shortness
of breath. Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower
needs (such as safety and security, love and belongingness, self-esteem and self-
actualization) can be met. Therefore, physiologic needs have the highest priority.
18. Answer – D 0 degree. The patient should be positioned with the head of the bed
completely flattened to perform an abdominal examination. If the head of the bed is
elevated, the abdominal muscles and organs can be bunched up, altering the findings
19. Answer – C Making of individualized patient care. To be effective, the nursing care
plan developed in the planning phase of the nursing process must reflect the
individualized needs of the patient.
20. Answer –C Client verbalized, “I feel pain when urinating.” Subjective data are those
that can be described only by the person experiencing it. Therefore, only the patient
can describe or verify whether he is experiencing pain or not.
21. Answer – B 37.95 degrees C. To convert °F to °C use this formula, ( °F – 32 ) (0.55).
While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is
5/9 and 1.8 is 9/5.
22. Answer – A Wheezes. Wheezes are indicated by continuous, lengthy, musical; heard
during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles
are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft
intensity on expiration.
23. Answer – D Trial and error. The trial and error method of problem solving isn’t
systematic (as in the scientific method of problem solving) routine, or based on inner
prompting (as in the intuitive method of problem solving).
24. Answer – C Nursing care plan. The outcome, or the product of the planning phase of
the nursing process is a Nursing care plan.
25. Answer – C “The patient will identify all the high-salt food from a prepared list by
discharge.” Expected outcomes are specific, measurable, realistic statements of goal
attainment. The phrases “right amount”, “less nauseated” and “enough sleep” are
vague and not measurable.