Text Mode – Text version of the exam 1. In accordance with standard precaution guidelines, when should a nurse wear gloves during nursing interventions? A. Taking a patient’s blood pressure 2. When a nurse is preparing to measure the temperature of an alert patient admitted to the hospital due to dehydration caused by vomiting and diarrhea, which method is most appropriate? A. Oral method 3. A nurse measures a patient’s pulse rate and discovers that it is higher than normal. The nurse should document this finding as: A. Tachypnea 4. When a nurse is assisting a patient in getting up from a chair, which of the following actions should be taken to establish a wide base of support? A. Bend at the waist, position arms beneath the patient’s arms, and lift 5. A patient has undergone oral surgery after a motor vehicle accident. The nurse assessing the patient notices flushed and warm skin. Which of the following methods would be the most appropriate to measure the patient’s body temperature? A. Oral method 6. When providing mouth care for an unconscious patient, the most appropriate position for the patient is: A. Fowler’s position 7. To ensure the safety of a patient who is hospitalized for the first time, which of the following actions should be taken? A. Remove unnecessary furniture to prevent obstacles 8. A walk-in patient visits the clinic, complaining of abdominal pain and diarrhea. After taking the patient’s vital signs, which phase of the nursing process is the nurse implementing? A. Assessment 9. The following term is best described as a systematic, rational method of planning and providing nursing care for individuals, families, groups, and communities: A. Assessment 10. In which organ does the exchange of gasses primarily occur? A. Kidneys 11. Which chamber of the heart receives oxygen-rich blood from the lungs? A. Left atrium 12. Which muscular, enlarged pouch or sac, located slightly to the left, temporarily stores food? A. Gallbladder 13. What is the body’s ability to protect itself against harmful invading agents such as bacteria, toxins, viruses, and foreign bodies called? A. Hormones 14. Which hormones are secreted by the Islets of Langerhans? A. Progesterone 15. Which part of the eye is a transparent membrane responsible for focusing incoming light onto the retina? A. Lens 16. Which of the following is a component of Orem’s self-care deficit nursing theory? A. Maintenance of a sufficient intake of air 17. Which of the following clusters of data are part of Maslow’s hierarchy of needs? A. Love and belonging 18. Which term is characterized by severe symptoms of relatively short duration? A. Chronic Illness 19. Which of the following represents a nurse’s role in health promotion? A. Health risk appraisal 20. Which term is used to describe a group of people who share certain aspects of their lives? A. Family 21. Five teaspoons are equivalent to how many milliliters (ml)? A. 30 ml 22. How many liters are equivalent to 1800 milliliters (ml)? A. 1.8 23. Which abbreviation represents drops? A. Gtd. 24. What is the abbreviation for micro drop? A. µgtt 25. What does the abbreviation PRN stand for? A. When advised 26. What is the correct meaning of the abbreviation CBR? A. Cardiac Board Room 27. One teaspoon (tsp) is equivalent to how many drops? A. 15 28. 20 cubic centimeters (cc) is equivalent to how many milliliters (ml)? A. 2 29. One cup is equivalent to how many ounces? A. 8 30. What is the safest method for a nurse to verify a client’s identity before administering medication? A. Ask the client their name 31. The nurse prepares to administer buccal medication. The medicine should be placed… A. On the client’s skin 32. Which of the following positions is commonly used by a nurse for administering a cleansing enema? A. Left lateral Sims 33. A patient experiences difficulty swallowing a capsule medication. What should the nurse do to address this issue? A. Dissolve the capsule in water 34. Which of the following routes is suitable for administering insulin? A. Intramuscular (IM) 35. The nurse receives an order to administer ampicillin capsules TID p.o. The medication should be given… A. Three times a day, taken orally 36. Back care can best be defined as: A. Caring for the back by means of massage 37. Which term describes the process of arranging a bed with fresh linens? A. Bed bath 38. What is the primary reason for handwashing? A. Enhancing hand circulation 39. How can one prevent contamination of the surroundings while making a bed? A. Refrain from shaking soiled linens 40. What is the primary objective of administering a cleansing bed bath? A. Provide hygiene, comfort, and refreshment for bedridden patients 41. Which medical examination technique primarily utilizes the sense of vision? A. Inspection 42. Which technique is typically utilized first when examining a patient’s abdomen? A. Palpation 43. Which physical examination technique is employed to evaluate airflow within the tracheobronchial tree? A. Palpation 44. Which tool is commonly utilized for the auscultation technique during a physical examination? A. Reflex hammer 45. How can resonance, a term related to medical percussion, be best characterized? A. Sounds generated by air-filled lungs 46. Which of the following positions is most suitable for performing a rectal examination? A. Prone (Face-down position) 47. What term is used to describe a person’s style of walking? A. Gait 48. When a nurse requests a patient to read the Snellen chart, which of the following senses is being assessed? A. Optic 49. In nursing terminology, an alternative term for the knee-chest position can be referred to as: A. Genu-dorsal 50. The nurse is preparing an intramuscular (IM) injection containing an irritant to subcutaneous tissue. To prevent tracking of the medication, the most suitable action would be to: A. Massage the injection site after administration 1. Correct answer: D. Performing oral hygiene tasks. Standard precautions are designed to protect healthcare workers and patients from the spread of infection. In accordance with these guidelines, a nurse should wear gloves when performing oral hygiene tasks. This is because oral hygiene tasks may involve contact with the patient’s saliva, blood, or mucous membranes, which could potentially transmit pathogens. Incorrect answer options: A. Taking a patient’s blood pressure. Wearing gloves is not typically required when taking a patient’s blood pressure, as there is minimal risk of contact with bodily fluids. However, if the nurse anticipates contact with blood or other bodily fluids, gloves should be worn. B. Assisting a patient with eating. Gloves are not usually necessary when assisting a patient with eating, as there is a low risk of exposure to bodily fluids. If the nurse has cuts or open wounds on their hands, they should wear gloves to protect themselves and the patient. C. Taking care of a patient’s hair. Gloves are not typically required for hair care tasks, as the risk of contact with blood or other bodily fluids is low. However, if the nurse anticipates contact with blood or other bodily fluids, gloves should be worn. 2. Correct answer: B. Axillary method. When a patient is admitted to the hospital due to dehydration caused by vomiting and diarrhea, the most appropriate method to measure their temperature is the axillary method. The axillary method is non-invasive and reduces the risk of further discomfort or infection in a patient who is already experiencing gastrointestinal symptoms. Incorrect answer options: A. Oral method. The oral method is not the most appropriate choice in this situation, as the patient may have difficulty keeping the thermometer in place due to vomiting. Additionally, there is a risk of aspiration if the patient vomits during the temperature measurement. C. Radial method. There is no standard radial method for measuring a patient’s temperature. The radial pulse is used to assess circulation, not temperature. D. Rectal method. While the rectal method is considered to be accurate, it is invasive and can cause discomfort. It is also contraindicated in patients with diarrhea due to the increased risk of infection and tissue damage. 3. Correct answer: D. Tachycardia. When a patient’s pulse rate is higher than normal, the nurse should document this finding as tachycardia. Tachycardia refers to a rapid heartbeat, typically defined as a heart rate greater than 100 beats per minute in adults. Incorrect answer options: A. Tachypnea refers to rapid breathing, not an increased pulse rate. It is typically defined as a respiratory rate greater than 20 breaths per minute in adults. B. Hypotension refers to low blood pressure, not an increased pulse rate. It is generally defined as a systolic blood pressure of less than 90 mm Hg and/or a diastolic blood pressure of less than 60 mm Hg. C. Arrhythmia refers to an irregular or abnormal heartbeat, which can include a rapid, slow, or irregular rhythm. While tachycardia is a type of arrhythmia, it specifically refers to a rapid heartbeat. 4. Correct answer: B. Face the patient, bend knees, place hands on the patient’s forearms, and lift. When a nurse is assisting a patient in getting up from a chair, the appropriate action to establish a wide base of support and ensure proper body mechanics is to face the patient, bend their knees, place their hands on the patient’s forearms, and lift. This technique helps maintain stability and balance while preventing injuries to both the patient and the nurse. Incorrect answer options: A. Bend at the waist, position arms beneath the patient’s arms, and lift. This technique does not provide a wide base of support, and bending at the waist can put unnecessary strain on the nurse’s back, increasing the risk of injury. C. Position their feet apart to maintain balance. While positioning feet apart does provide a wider base of support, it is not the complete action required for safely assisting a patient in getting up from a chair. Facing the patient, bending knees, placing hands on the patient’s forearms, and lifting provides a more comprehensive technique to ensure safety and proper body mechanics. D. Maintain firm contact with the patient during the transfer. While maintaining contact with the patient during the transfer is important, it is not the primary action for establishing a wide base of support. Facing the patient, bending knees, placing hands on the patient’s forearms, and lifting better addresses the proper technique for assisting a patient in getting up from a chair. 5. Correct answer: B. Axillary method. For a patient who has undergone oral surgery, the most appropriate method to measure body temperature is the axillary method. The axillary method is non-invasive and avoids any potential complications or discomfort related to the patient’s oral surgery. Incorrect answer options: A. Oral method. The oral method is not appropriate for a patient who has undergone oral surgery, as it may cause discomfort or exacerbate the patient’s existing oral issues. C. Arterial line method. The arterial line method, while accurate, is invasive and typically reserved for critically ill patients who require continuous blood pressure and blood gas monitoring. It is not necessary for measuring the body temperature of a patient who has undergone oral surgery and is not critically ill. D. Rectal method. The rectal method is accurate but invasive, which makes it less appropriate for a patient who has undergone oral surgery and is not critically ill. The axillary method is a more suitable choice for this patient, as it is non-invasive and avoids potential complications or discomfort related to the oral surgery. 6. Correct answer: B. Side-lying position. When providing mouth care for an unconscious patient, the most appropriate position is the side-lying position. This position allows for better drainage of oral secretions and helps prevent aspiration of fluids into the lungs. Incorrect answer options: A. Fowler’s position. Although this position may be helpful for some procedures, it is not ideal for providing mouth care for an unconscious patient, as it does not provide adequate protection against aspiration. C. Supine position. This position is not appropriate for mouth care in an unconscious patient, as it increases the risk of aspiration due to pooling of secretions in the back of the throat. D. Semi-Fowler’s position. While the semi-Fowler’s position may be more comfortable for some patients, it is not the best choice for providing mouth care for an unconscious patient, as it does not offer optimal protection against aspiration. 7. Correct answer: C. Keep side rails raised when necessary. To ensure the safety of a patient who is hospitalized for the first time, it is important to keep side rails raised when necessary. This provides additional support, prevents falls, and helps the patient feel more secure in an unfamiliar environment. Incorrect answer options: A. Remove unnecessary furniture to prevent obstacles. While removing unnecessary furniture can help minimize potential hazards, it is not the primary action to ensure the safety of a patient who is hospitalized for the first time. Keeping side rails raised when necessary provides a more direct and immediate safety measure. B. Maintain appropriate lighting at all times. Appropriate lighting is important, but it is not the most crucial action to ensure the safety of a patient who is hospitalized for the first time. Raising side rails when necessary is a more specific action that directly addresses patient safety. D. Ensure the floor is clean and free of hazards. Keeping the floor clean and free of hazards is important, but it is not the primary action for ensuring the safety of a patient who is hospitalized for the first time. Keeping side rails raised when necessary offers more immediate protection and support for the patient. 8. Correct answer: A. Assessment. When a nurse takes the patient’s vital signs, they are implementing the assessment phase of the nursing process. Assessment is the first step and involves collecting data about the patient’s health status, including physiological, psychological, and sociocultural factors. Incorrect answer options: B. Diagnosis. The diagnosis phase involves analyzing the collected data from the assessment phase, identifying actual or potential health problems, and formulating nursing diagnoses. C. Planning. During the planning phase, the nurse sets measurable and achievable short-term and long-term goals based on the identified nursing diagnoses, prioritizes these goals, and develops a nursing care plan. D. Implementation. In the implementation phase, the nurse carries out the interventions outlined in the nursing care plan to help the patient achieve their goals and address their health problems. 9. Correct answer: B. Nursing Process. The nursing process is best described as a systematic, rational method of planning and providing nursing care for individuals, families, groups, and communities. It is a framework that guides nursing practice and consists of five interrelated steps: assessment, diagnosis, planning, implementation, and evaluation. Incorrect answer options: A. Assessment. Assessment is the first step of the nursing process, which involves collecting data about a patient’s health status. It is not the overall method for planning and providing nursing care. C. Diagnosis. Diagnosis is the second step of the nursing process, which involves identifying and prioritizing actual or potential health problems based on the assessment data. It is not the overall method for planning and providing nursing care. D. Evaluation. Evaluation is the final step of the nursing process, which involves determining the effectiveness of the nursing care plan and the patient’s progress toward achieving their goals. It is not the overall method for planning and providing nursing care. 10. Correct answer: B. Lungs. The exchange of gasses primarily occurs in the lungs. This process, known as respiration, involves the inhalation of oxygen (O2) and the exhalation of carbon dioxide (CO2). The lungs facilitate this gas exchange between the air and the bloodstream through the respiratory system’s complex network of bronchi, bronchioles, and alveoli. Incorrect answer options: A. Kidneys. The primary function of the kidneys is to filter waste products and excess substances (such as water, salts, and electrolytes) from the blood to form urine, which is then excreted from the body. C. Intestines. The primary function of the intestines is to absorb nutrients from digested food and transport them into the bloodstream. Gas exchange does not primarily occur in the intestines. D. Heart. The heart is responsible for pumping blood throughout the body, which carries oxygen and nutrients to cells and removes waste products. While the heart plays a crucial role in circulating blood, it is not the primary site of gas exchange. 11. Correct answer: A. Left atrium. The left atrium is the chamber of the heart that receives oxygen-rich blood from the lungs. This oxygen-rich blood returns to the heart via the pulmonary veins, which empty into the left atrium. From there, the blood is pumped into the left ventricle and then circulated throughout the body via the aorta. Incorrect answer options: B. Right atrium. The right atrium receives oxygen-poor blood from the body through the superior and inferior vena cava. This blood is then pumped into the right ventricle and sent to the lungs for oxygenation. C. Left ventricle. The left ventricle pumps oxygen-rich blood received from the left atrium out to the body through the aorta. It does not directly receive blood from the lungs. D. Right ventricle. The right ventricle pumps oxygen-poor blood received from the right atrium to the lungs through the pulmonary arteries for oxygenation. It does not receive oxygen-rich blood from the lungs. 12. Correct answer: C. Stomach. The stomach is a muscular, enlarged pouch or sac located slightly to the left, which temporarily stores food. The stomach is responsible for breaking down food through a combination of mechanical and chemical digestion, using stomach muscles to mix and churn the food and gastric juices to break it down further. Incorrect answer options: A. Gallbladder. The gallbladder is a small, pear-shaped organ that stores and concentrates bile produced by the liver. It is not responsible for temporarily storing food. B. Large intestine. The large intestine, also known as the colon, is responsible for absorbing water and electrolytes from the remaining indigestible food matter and forming solid waste (feces) for elimination. It does not temporarily store food. D. Small intestine. The small intestine is the primary site of nutrient absorption. Here, food is broken down further by enzymes and absorbed into the bloodstream. The small intestine does not temporarily store food. 13. Correct answer: C. Immunity. Immunity is the body’s ability to protect itself against harmful invading agents such as bacteria, toxins, viruses, and foreign bodies. The immune system is a complex network of cells, tissues, and organs that work together to defend the body against these threats. Immunity can be innate (natural or non-specific) or adaptive (acquired or specific), with the latter involving the development of antibodies or immune cells in response to specific pathogens. Incorrect answer options: A. Hormones. Hormones are chemical messengers produced by glands in the endocrine system. They regulate various physiological processes in the body, such as growth, metabolism, and reproduction, but are not directly responsible for the body’s defense against harmful agents. B. Inflammation. Inflammation is a protective response of the body’s tissues to injury or infection. While it plays a crucial role in the immune response, it is not the overall term for the body’s ability to protect itself against harmful agents. D. Glands. Glands are organs that produce and secrete substances, such as hormones, enzymes, and sweat. They do not directly provide the body’s protection against harmful invading agents. 14. Correct answers: C. Insulin. The Islets of Langerhans are specialized groups of cells within the pancreas. They secrete two important hormones, insulin and glucagon, which play crucial roles in regulating blood glucose levels. Insulin lowers blood glucose levels by promoting the uptake and storage of glucose in cells, while glucagon raises blood glucose levels by stimulating the breakdown of glycogen in the liver. Incorrect answer options: A. Progesterone. Progesterone is a hormone primarily involved in the menstrual cycle, pregnancy, and embryogenesis. It is not secreted by the Islets of Langerhans but is produced by the ovaries, placenta, and adrenal glands. B. Testosterone. Testosterone is the primary male sex hormone, responsible for the development of male reproductive tissues and secondary sexual characteristics. It is not secreted by the Islets of Langerhans but is produced by the testes in males and the ovaries and adrenal glands in females. D. Hemoglobin. Hemoglobin is not a hormone but a protein found in red blood cells that carries oxygen from the lungs to the body’s tissues and returns carbon dioxide from the tissues back to the lungs. It is not secreted by the Islets of Langerhans. 15. Correct answer: A. Lens. The lens is the part of the eye responsible for focusing incoming light onto the retina. It is a transparent, biconvex structure situated behind the iris and the pupil. The lens changes shape (accommodation) to adjust its refractive power, allowing the eye to focus on objects at varying distances. Incorrect answer options: B. Iris. The iris is the colored, ring-shaped muscular structure surrounding the pupil. It controls the amount of light entering the eye by adjusting the size of the pupil, but it is not responsible for focusing incoming light onto the retina. C. Retina. The retina is the light-sensitive layer of cells at the back of the eye that detects light and converts it into electrical signals that are sent to the brain through the optic nerve. It is not responsible for focusing incoming light. D. Pupils. The pupils are the black, circular openings in the center of the iris. They control the amount of light entering the eye by constricting (narrowing) or dilating (widening) in response to light conditions. The pupils themselves do not focus incoming light onto the retina. 16. Correct answer: A. Maintenance of a sufficient intake of air. Dorothea Orem’s self-care deficit nursing theory emphasizes the importance of self-care and the nurse’s role in helping patients maintain or regain their ability to care for themselves. According to Orem, there are universal self-care requisites (basic needs) that apply to all individuals, including the maintenance of a sufficient intake of air. This need is crucial for overall health, as oxygen is essential for cellular respiration and energy production. Incorrect answer options: B. Self-actualization. Self-actualization is a concept from Abraham Maslow’s hierarchy of needs, which is a motivational theory. It represents the highest level of psychological development and the realization of one’s full potential. While self-actualization is important, it is not a component of Orem’s self-care deficit nursing theory. C. Love and belonging. Love and belonging are also concepts from Maslow’s hierarchy of needs, representing the third level of psychological needs. These needs include friendship, intimacy, and family. Although essential for overall well-being, they are not components of Orem’s self-care deficit nursing theory. D. Physiologic needs. Physiologic needs are the most basic needs in Maslow’s hierarchy, including air, water, food, shelter, sleep, and clothing. While these needs overlap with some of Orem’s universal self-care requisites, the term “physiologic needs” is associated with Maslow’s theory rather than Orem’s theory. 17. Correct answer: D. All of the above. Maslow’s hierarchy of needs is a motivational theory that outlines five levels of human needs, which are often depicted as a pyramid. From the base to the top of the pyramid, the levels are: 1. Physiological needs – These are the most basic needs required for survival, such as air, water, food, shelter, sleep, and clothing. All of the clusters of data mentioned in the answer options are part of Maslow’s hierarchy of needs. 18. Correct answer: B. Acute Illness. Acute illness is characterized by severe symptoms that have a relatively short duration, usually lasting for a few days to a few weeks. Acute illnesses often have a sudden onset and may require immediate medical attention. Examples of acute illnesses include appendicitis, the flu, and pneumonia. Incorrect answer options: A. Chronic Illness. Chronic illnesses are long-lasting health conditions that typically last for at least three months and may persist for years. Examples of chronic illnesses include diabetes, hypertension, and arthritis. C. Pain. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain can be acute or chronic, depending on its duration and cause, but it is not a specific type of illness. D. Infection. Infection refers to the invasion and multiplication of microorganisms, such as bacteria, viruses, and fungi, in the body. Infections can cause acute or chronic illnesses, but the term “infection” does not specifically describe a severe, short-duration illness. 19. Correct answer: B. Teach clients to be an effective health consumer. A nurse’s role in health promotion involves educating and empowering clients to take control of their health, make informed decisions, and adopt healthy lifestyle habits. By teaching clients to be effective health consumers, nurses help them understand their health needs, access appropriate resources, and make choices that promote overall well-being. Incorrect answer options: A. Health risk appraisal. Health risk appraisal is an assessment tool used to evaluate an individual’s risk factors and health behaviors, but it is not a specific nursing role in health promotion. While nurses may use health risk appraisals to gather information and guide their health promotion efforts, the primary nursing role is to educate and empower clients. C. Worksite wellness. Worksite wellness programs focus on promoting health and preventing disease in the workplace. While nurses may participate in or develop worksite wellness programs, it is not a specific nursing role in health promotion. The nurse’s primary role is to teach clients to be effective health consumers, which can occur in various settings, including worksite wellness programs. D. None of the above. This answer option is incorrect because teaching clients to be effective health consumers is a nurse’s role in health promotion. 20. Correct answer: C. Community. A community is a group of people who share certain aspects of their lives, such as geographical location, interests, beliefs, or cultural practices. Communities can be small, like neighborhoods, or large, such as cities or countries. In public health and nursing, understanding the dynamics and needs of a community is essential for promoting health, preventing disease, and providing healthcare services. Incorrect answer options: A. Family. A family is a group of individuals who are related by blood, marriage, or adoption, or who consider themselves family through emotional bonds and support. Although families can be part of a community, the term “family” does not describe a broader group of people who share aspects of their lives. B. Illness. Illness refers to the subjective experience of a person’s health condition or disease. It does not describe a group of people who share certain aspects of their lives. D. Population. A population is a group of individuals who share a common characteristic, such as age, gender, or health condition. While populations can be part of a community, the term “population” does not specifically describe a group of people who share aspects of their lives in the same way that “community” does. 21. Correct answer: B. 25 ml. In the metric system, 1 teaspoon is equivalent to 5 milliliters (ml). Therefore, 5 teaspoons would be equivalent to 25 milliliters: 5 teaspoons x 5 ml/teaspoon = 25 ml 22. Correct answer: A. 1.8 To convert milliliters (ml) to liters (L), divide the number of milliliters by 1,000: 1800 ml ÷ 1,000 = 1.8 L So, 1800 milliliters are equivalent to 1.8 liters. Incorrect answer options: B. 18,000. This option is incorrect because the conversion from milliliters to liters requires dividing by 1,000, not multiplying by 1,000. C. 180. This option is incorrect because 1800 ml is equivalent to 1.8 L, not 180 L. D. 18. This option is incorrect because 1800 ml is equivalent to 1.8 L, not 18 L. 23. Correct answer: B. Gtts. The abbreviation “gtts.” represents drops in medical terms. It is used to indicate the number of drops of a liquid medication or solution to be administered. Incorrect answer options: A. Gtd. This abbreviation is not used to represent drops in medical terms. C. Dp. This abbreviation is not used to represent drops in medical terms. D. Dr. This abbreviation is not used to represent drops in medical terms. “Dr.” is commonly used as an abbreviation for “doctor.” 24. Correct answer: A. µgtt. The abbreviation for micro drop is “µgtt.” The symbol “µ” represents “micro” in the metric system, and “gtt” represents “drop.” Micro drop is used to describe very small drops, typically in the context of intravenous (IV) fluid administration, where the drop size is much smaller than standard drop sizes. Incorrect answer options: B. gtt. This abbreviation represents “drop” or “drops” in medical terms but does not include the “micro” component. C. mdr. This abbreviation is not used to represent micro drop in medical terms. D. µdrop. This abbreviation is not used to represent micro drop in medical terms. 25. Correct answer: C. When necessary. The abbreviation “PRN” stands for the Latin term “pro re nata,” which means “when necessary” or “as needed” in English. It is commonly used in healthcare to indicate that a medication or treatment should be administered only when required by the patient’s condition. Incorrect answer options: A. When advised. This option is incorrect because PRN stands for “when necessary” rather than “when advised.” B. Immediately. This option is incorrect because PRN stands for “when necessary” rather than “immediately.” D. Before meals. This option is incorrect because PRN stands for “when necessary” rather than “before meals.” The abbreviation for “before meals” is “ac” (from the Latin “ante cibum”). 26. Correct answer: C. Complete Bed Rest. The abbreviation “CBR” stands for “Complete Bed Rest.” It is used in healthcare to indicate that a patient should remain in bed and minimize physical activity, often due to illness or injury that requires rest for proper healing and recovery. 27. Correct answer: B. 60. One teaspoon (tsp) is equivalent to approximately 60 drops. This conversion is especially important in the medical field, where precise measurements are necessary for medication administration. Incorrect answer options: A. 15: This option is incorrect because 1 teaspoon (tsp) is equivalent to approximately 5 milliliters (mL) or 5 cubic centimeters (cc), not 15 drops. C. 45: This option is incorrect because 45 drops are less than the 60 drops equivalent to 1 teaspoon (tsp). D. 30: This option is incorrect because 30 drops are only half the amount of drops equivalent to 1 teaspoon (tsp). 28. Correct answer: B. 20. 20 cubic centimeters (cc) is equivalent to 20 milliliters (ml). Both measurements represent volume and are interchangeable in the medical field. Incorrect answer options: A. 2: This option is incorrect because 20 cubic centimeters (cc) is not equivalent to 2 milliliters (ml). The conversion is 1:1, so 20 cc equals 20 ml. C. 2000: This option is incorrect because 20 cubic centimeters (cc) is not equivalent to 2000 milliliters (ml). The conversion is 1:1, so 20 cc equals 20 ml. D. 200: This option is incorrect because 20 cubic centimeters (cc) is not equivalent to 200 milliliters (ml). The conversion is 1:1, so 20 cc equals 20 ml. 29. Correct answer: A. 8. One cup is equivalent to 8 ounces. This conversion is crucial in various fields, including healthcare, where accurate measurements are necessary for medication administration, meal planning, and fluid intake monitoring. Incorrect answer options: B. 80: This option is incorrect because one cup is not equivalent to 80 ounces. A cup contains 8 ounces, a much smaller volume than 80 ounces. C. 16: This option is incorrect because one cup is not equivalent to 16 ounces. A cup contains 8 ounces, while 16 ounces is equivalent to 2 cups or 1 pint. D. 4: This option is incorrect because one cup is not equivalent to 4 ounces. A cup contains 8 ounces, which is twice the volume of 4 ounces. 30. Correct answer: B. Check the client’s identification band. Checking the client’s identification band is the safest method for a nurse to verify a client’s identity before administering medication. The identification band provides a reliable and accurate source of information to confirm the client’s identity, ensuring that the right medication is given to the right person. Incorrect answer options: A. Ask the client their name: This option is not the safest method because clients may be confused, disoriented, or unable to communicate effectively, which can lead to errors in identification. C. State the client’s name aloud and have the client repeat it: This option is not the safest method because, like asking the client their name, it relies on the client’s ability to communicate and understand the information correctly, which may not always be reliable. D. Verify the client’s social security number: This option is not the safest method because social security numbers are not routinely used for identification purposes within healthcare settings, and they should not be shared unnecessarily due to privacy concerns. 31.Correct answer: B. Between the client’s cheeks and gums. When administering buccal medication, the medicine should be placed between the client’s cheeks and gums. This method allows the medication to be absorbed directly into the bloodstream through the oral mucosa, bypassing the gastrointestinal system, and providing a faster onset of action. Incorrect answer options: A. On the client’s skin: This option is incorrect because buccal medication is not meant to be applied to the skin. Topical medications, not buccal medications, are applied to the skin for localized effects or absorption. C. Under the client’s tongue: This option is incorrect because placing medication under the client’s tongue is called the sublingual route, not the buccal route. Sublingual medication is absorbed through the mucous membrane under the tongue and also bypasses the gastrointestinal system, but it is a different method of administration than buccal medication. D. In the client’s ear canal: This option is incorrect because buccal medication is not meant to be placed in the client’s ear canal. Otic medications, not buccal medications, are specifically formulated for administration in the ear canal to treat ear infections or other ear-related conditions. 32. Correct answer: A. Left lateral Sims. The left lateral Sims position is commonly used by a nurse for administering a cleansing enema. This position involves the client lying on their left side with their left leg slightly flexed and the right leg flexed at a greater angle, supported by a pillow. This position allows for optimal flow of the enema solution into the sigmoid and descending colon, facilitating the evacuation of stool. Incorrect answer options: B. Dorsal recumbent: This option is incorrect because, although the dorsal recumbent position (lying on the back with knees bent and feet flat on the bed) may be used for some medical procedures, it is not the optimal position for administering a cleansing enema. C. Trendelenburg: This option is incorrect because the Trendelenburg position (lying on the back with the head lower than the feet) is not commonly used for administering a cleansing enema. This position is typically used to treat hypotension or to facilitate venous return. D. Prone: This option is incorrect because the prone position (lying on the stomach) is not the optimal position for administering a cleansing enema. The left lateral Sims position is more effective in ensuring proper flow and distribution of the enema solution. 33. Correct answer: C. Inquire about the availability of a liquid formulation. When a patient experiences difficulty swallowing a capsule medication, the nurse should inquire about the availability of a liquid formulation. Liquid formulations can be more easily swallowed and are often a suitable alternative for patients who have difficulty swallowing capsules or tablets. Incorrect answer options: A. Dissolve the capsule in water: This option is incorrect because not all capsules can be dissolved in water. Some capsules have specific release mechanisms that can be altered if dissolved, which could potentially affect the medication’s efficacy or cause adverse effects. B. Administer the capsule with a thickened beverage: This option may help with swallowing difficulties, but it is not the best solution. A liquid formulation, if available, would be a more appropriate option to address the issue. D. Crush the capsule and place it under the patient’s tongue: This option is incorrect because crushing the capsule and placing it under the patient’s tongue may alter the release mechanism of the medication and is not the recommended method of administration. Additionally, not all medications can be administered sublingually (under the tongue). 34. Correct answer: C. Subcutaneous (SC). Insulin is typically administered via the subcutaneous (SC) route. This method involves injecting the medication into the fatty tissue just below the skin, allowing for slow and steady absorption of insulin into the bloodstream. Incorrect answer options: A. Intramuscular (IM): This option is incorrect because insulin is not typically administered via the intramuscular route. IM injections are used for medications that require faster absorption and are injected into the muscle tissue. B. Intradermal (ID): This option is incorrect because insulin is not administered via the intradermal route. ID injections are shallow injections into the dermis and are primarily used for skin testing and some vaccinations. D. Transdermal (TD): This option is incorrect because insulin is not administered via the transdermal route. Transdermal medications are applied directly to the skin in the form of patches, gels, or creams and are absorbed slowly through the skin. 35. Correct answer: A. Three times a day, taken orally. When the nurse receives an order to administer ampicillin capsules TID p.o., it means the medication should be given three times a day, taken orally. “TID” stands for “ter in die,” which is Latin for “three times a day,” and “p.o.” stands for “per os,” which is Latin for “by mouth” or “orally.” Incorrect answer options: B. Four times a day, taken orally: This option is incorrect because the abbreviation “TID” indicates that the medication should be administered three times a day, not four times a day. C. Twice a day, taken by mouth: This option is incorrect because the abbreviation “TID” indicates that the medication should be administered three times a day, not twice a day. D. Twice a day, before meals: This option is incorrect because the abbreviation “TID” indicates that the medication should be administered three times a day, not twice a day. Additionally, there is no information in the order regarding the administration of the medication before meals. 36. Correct answer: A. Caring for the back by means of massage. Back care, in the context of nursing, can encompass various techniques to promote the overall well-being and comfort of the patient’s back. This includes not only cleansing the back area but also providing massages to alleviate muscle tension, increase circulation, and promote relaxation. Incorrect answer options: B. Cleansing the back area: While cleansing the back area is essential for maintaining hygiene and skin health, back care involves more than just cleansing, such as providing massages for comfort and well-being. C. Applying a cold compress to the back: Applying a cold compress can be helpful in alleviating pain or reducing inflammation, but it is not the primary focus of back care. Back care involves a broader range of techniques, such as massages and maintaining hygiene. D. Applying a hot compress to the back: Applying a hot compress can be helpful in alleviating pain or muscle tension, but it is not the primary focus of back care. Back care involves a broader range of techniques, such as massages and maintaining hygiene. 37. Correct answer: B. Bed making. Bed making refers to the process of arranging a bed with fresh linens. In a healthcare setting, bed making is an essential nursing skill that promotes patient comfort, cleanliness, and hygiene. It also helps prevent the development of pressure ulcers and contributes to a healing environment. Incorrect answer options: A. Bed bath: This option is incorrect because a bed bath refers to the process of bathing a patient who is unable to get out of bed. It is a method used to maintain personal hygiene for bedridden patients. C. Bed styling: This option is incorrect because bed styling does not refer to a specific term or process in nursing or healthcare. It may be related to interior design, but it is not relevant to the question. D. Bed lining: This option is incorrect because bed lining is not a specific term related to the process of arranging a bed with fresh linens. The correct term is bed making. 38. Correct answer: B. Inhibiting the transmission of microorganisms. The primary reason for handwashing is to inhibit the transmission of microorganisms. Proper hand hygiene is essential in preventing the spread of infection and illness in healthcare settings and everyday life. By washing hands regularly and effectively, healthcare providers can minimize the risk of transmitting microorganisms to themselves, their patients, and others. Incorrect answer options: A. Enhancing hand circulation: This option is incorrect because, while handwashing may have some minor benefits in terms of circulation, the primary purpose of handwashing is to inhibit the transmission of microorganisms. C. Refraining from touching others with unclean hands: This option is incorrect because, while not touching others with unclean hands is a good practice, the primary reason for handwashing is to prevent the transmission of microorganisms by removing them from the hands. D. Improving skin appearance: This option is incorrect because, while handwashing may contribute to overall skin cleanliness, the primary purpose of handwashing is to inhibit the transmission of microorganisms. 39. Correct answer: A. Refrain from shaking soiled linens.To prevent contamination of the surroundings while making a bed, it is important to refrain from shaking soiled linens. Shaking the linens can cause the spread of microorganisms and allergens into the air and onto other surfaces. Instead, gently remove the soiled linens, fold them inward to contain any contaminants, and dispose of or launder them appropriately. Incorrect answer options: B. Remove all linens simultaneously: This option is incorrect because removing all linens at once may not be the most efficient method for bed making and may not prevent contamination of the surroundings. The key is to handle soiled linens carefully, folding them inward and avoiding shaking them. C. Complete both sides of the bed at once: This option is incorrect because completing both sides of the bed at once does not necessarily prevent contamination of the surroundings. The focus should be on handling soiled linens carefully and not shaking them. D. Use disposable gloves while handling linens: While using disposable gloves can protect the caregiver’s hands from contaminants and prevent the spread of infection, this measure alone does not address the prevention of contamination in the surroundings. The primary method for preventing contamination is to avoid shaking soiled linens. 40. Correct answer: A. Provide hygiene, comfort, and refreshment for bedridden patients. The primary objective of administering a cleansing bed bath is to provide hygiene, comfort, and refreshment for bedridden patients. A bed bath helps maintain the patient’s personal hygiene, which is essential for overall well-being and preventing infections, skin irritations, and pressure ulcers. Additionally, the process can be refreshing and comforting, promoting relaxation and a sense of cleanliness. Incorrect answer options: B. Expose essential body parts for examination: While a bed bath may involve exposing certain body parts, the primary objective is to provide hygiene, comfort, and refreshment for bedridden patients. C. Stimulate circulation in immobile patients: While a bed bath may help stimulate circulation to some extent, the primary objective is to provide hygiene, comfort, and refreshment for bedridden patients. D. Assess the body temperature of a client in bed: Assessing body temperature is not the primary objective of a bed bath. The main purpose is to provide hygiene, comfort, and refreshment for bedridden patients. 41. Correct answer: A. Inspection. Inspection is the medical examination technique that primarily utilizes the sense of vision. During inspection, healthcare providers carefully observe the patient’s appearance, body movements, and other visual cues to gather information about their health status. Inspection is often the first step in a physical examination, and it can provide valuable information about the patient’s overall condition. Incorrect answer options: B. Palpation: Palpation primarily involves the use of touch to assess the size, shape, texture, and consistency of various body structures, such as organs or masses. It does not primarily rely on the sense of vision. C. Percussion: Percussion involves tapping on the body’s surface to produce sounds that can provide information about the underlying structures, such as the presence of fluid, air, or solid masses. It primarily relies on the sense of hearing, not vision. D. Auscultation: Auscultation primarily involves listening to the sounds produced by the body, such as heartbeats, breath sounds, or bowel sounds, using a stethoscope. It does not primarily rely on the sense of vision. 42. Correct answer: D. Inspection. Inspection is typically the first technique utilized when examining a patient’s abdomen. During inspection, the healthcare provider observes the patient’s abdominal contour, symmetry, skin color, and any visible abnormalities. This initial step helps gather information about the patient’s overall abdominal condition before proceeding with other examination techniques. Incorrect answer options: A. Palpation: Palpation is used to assess the size, shape, texture, and consistency of various abdominal structures, such as organs or masses. However, it is not the first technique used in abdominal examination, as it typically follows inspection, auscultation, and percussion. B. Auscultation: Auscultation is used to listen to the sounds produced by the abdomen, such as bowel sounds or vascular sounds. It is typically performed after inspection but before palpation and percussion. C. Percussion: Percussion involves tapping on the body’s surface to produce sounds that can provide information about the underlying abdominal structures. It is typically performed after inspection and auscultation but before palpation. 43. Correct answer: B. Auscultation. Auscultation is the physical examination technique employed to evaluate airflow within the tracheobronchial tree. During auscultation, healthcare providers use a stethoscope to listen to breath sounds produced by the flow of air within the lungs and airways. This technique helps assess the quality, intensity, and location of breath sounds, which can provide valuable information about the patient’s respiratory function and identify potential abnormalities or conditions. Incorrect answer options: A. Palpation: Palpation primarily involves the use of touch to assess the size, shape, texture, and consistency of various body structures. It is not the primary technique used for evaluating airflow within the tracheobronchial tree. C. Inspection: Inspection primarily involves observing the patient’s appearance, body movements, and other visual cues. Although inspection is an essential part of the overall respiratory assessment, it does not directly evaluate airflow within the tracheobronchial tree. D. Percussion: Percussion involves tapping on the body’s surface to produce sounds that can provide information about the underlying structures. While percussion is used in assessing the lungs and thoracic cavity, it does not directly evaluate airflow within the tracheobronchial tree. 44. Correct answer: C. Stethoscope. A stethoscope is the tool commonly utilized for the auscultation technique during a physical examination. It allows healthcare providers to listen to internal sounds produced by the body, such as heartbeats, breath sounds, and bowel sounds. The stethoscope amplifies these sounds, enabling the examiner to assess the quality, intensity, and location of the sounds, which can provide valuable information about the patient’s overall health and identify potential abnormalities or conditions. Incorrect answer options: A. Reflex hammer: A reflex hammer is used to test deep tendon reflexes and assess the integrity of the nervous system, not for auscultation. B. Otoscope: An otoscope is used to examine the external auditory canal and tympanic membrane, not for auscultation. D. Sphygmomanometer: A sphygmomanometer is a device used to measure blood pressure, not for auscultation. 45. Correct answer: A. Sounds generated by air-filled lungs. Resonance, in the context of medical percussion, can be best characterized as the sounds generated by air-filled lungs. When percussing the chest, the presence of resonance typically indicates normal lung tissue filled with air. Resonance is low-pitched, hollow, and of moderate intensity, reflecting the vibration of air within the lung tissue. Incorrect answer options: B. Brief, high-pitched, and dull in nature: This description does not accurately characterize resonance. Resonance is low-pitched and hollow, not high-pitched and dull. C. Of moderate volume and possessing a musical quality: This description is more indicative of tympany, a sound typically heard over hollow, air-filled spaces like the stomach, rather than resonance. D. Resembling the sound of a drum: This description also refers to tympany, not resonance. Tympany is characterized by a drum-like sound, while resonance is associated with air-filled lungs and has a hollow, low-pitched quality. 46. Correct answer: C. Knee-chest position. The knee-chest position is most suitable for performing a rectal examination. In this position, the patient is on their hands and knees, with their head down and buttocks elevated. This position provides optimal exposure of the rectal area and allows for a more comfortable examination. Alternatively, the left lateral Sims position or lithotomy position can also be used, depending on patient comfort and the specific procedure being performed. Incorrect answer options: A. Prone (Face-down position): The prone position is not ideal for a rectal examination because it does not provide optimal exposure of the rectal area. B. Fowler’s position: Fowler’s position is a semi-sitting position with the head of the bed elevated. It is not typically used for rectal examinations, as it does not provide optimal exposure of the rectal area. D. Lithotomy position: Although the lithotomy position can be used for rectal examinations, the knee-chest position is generally considered more suitable. In the lithotomy position, the patient lies on their back with their legs in stirrups and knees bent. This position is more commonly used for gynecological examinations and procedures. 47.Correct answer: A. Gait. Gait refers to a person’s style of walking, which includes the manner, rhythm, and speed with which they move. Evaluating a person’s gait can provide important information about their overall health, balance, coordination, and the functioning of their musculoskeletal and nervous systems. Incorrect answer options: B. Locomotion: Locomotion is a broader term that refers to the act of moving or the ability to move from one place to another. It encompasses various types of movement, including walking, running, crawling, and swimming, whereas gait specifically refers to walking. C. Ambulation: Ambulation refers to the act of walking or moving about, particularly for therapeutic purposes or after an injury or surgery. While it involves walking, the term does not specifically describe a person’s style of walking like gait does. D. Hopping: Hopping is a specific form of movement that involves jumping on one foot. It does not describe a person’s general style of walking. 48. Correct answer: A. Optic. When a nurse requests a patient to read the Snellen chart, the optic sense is being assessed. The Snellen chart is used to evaluate visual acuity, which relies on the proper functioning of the optic nerve (cranial nerve II). The chart consists of lines of letters that progressively decrease in size. By identifying the smallest line of letters the patient can read accurately, the nurse can determine the patient’s visual acuity. Incorrect answer options: B. Olfactory: The olfactory sense relates to the sense of smell and is associated with the olfactory nerve (cranial nerve I). It is not assessed using the Snellen chart. C. Oculomotor: The oculomotor nerve (cranial nerve III) controls eye movement and eyelid function, as well as the constriction of the pupil. Although the oculomotor nerve plays a role in eye function, the Snellen chart specifically assesses visual acuity, which is related to the optic nerve. D. Gustatory: The gustatory sense refers to the sense of taste and is not assessed using the Snellen chart. 49. Correct answer: B. Genu-pectoral. In nursing terminology, an alternative term for the knee-chest position is the genu-pectoral position. In this position, the patient is on their hands and knees, with their head down and buttocks elevated. This position provides optimal exposure of the rectal area and is commonly used for rectal examinations and certain gynecological procedures. Incorrect answer options: A. Genu-dorsal: This term is not commonly used in nursing terminology and does not refer to the knee-chest position. C. Lithotomy: The lithotomy position is different from the knee-chest position. In the lithotomy position, the patient lies on their back with their legs in stirrups and knees bent. This position is more commonly used for gynecological examinations and procedures. D. Trendelenburg: The Trendelenburg position involves the patient lying on their back with the head of the bed tilted downward, so the patient’s head is lower than their feet. This position is used in certain medical situations, such as during shock or for certain surgical procedures, but it is not the same as the knee-chest position. 50. Correct answer: D. Employ the Z-track technique. When administering an intramuscular (IM) injection containing an irritant to subcutaneous tissue, using the Z-track technique is the most suitable action to prevent tracking of the medication. The Z-track technique involves pulling the skin and subcutaneous tissue laterally before inserting the needle. After administering the injection, the skin is released, allowing it to return to its original position. This creates a zigzag path that helps to seal the medication in the muscle, preventing leakage into the subcutaneous tissue and reducing the risk of irritation. Incorrect answer options: A. Massage the injection site after administration: Massaging the injection site after administering an irritant medication may increase the risk of spreading the medication to the subcutaneous tissue, leading to further irritation. B. Apply ice to the injection site prior to administration: Applying ice to the injection site prior to administration may help to numb the area and reduce pain, but it does not prevent tracking of the medication. C. Inject the medication at a 45-degree angle: Injecting the medication at a 45-degree angle is not appropriate for an intramuscular injection. IM injections should be administered at a 90-degree angle to ensure the medication is deposited into the muscle tissue.Practice Mode
Exam Mode
Text Mode
Questions
B. Assisting a patient with eating
C. Taking care of a patient’s hair
D. Performing oral hygiene tasks
B. Axillary method
C. Radial method
D. Rectal method
B. Hypotension
C. Arrhythmia
D. Tachycardia
B. Face the patient, bend knees, place hands on patient’s forearms, and lift
C. Position their feet apart to maintain balance
D. Maintain firm contact with the patient during the transfer
B. Axillary method
C. Arterial line method
D. Rectal method
B. Side-lying position
C. Supine position
D. Semi-Fowler’s position
B. Maintain appropriate lighting at all times
C. Keep side rails raised when necessary
D. Ensure the floor is clean and free of hazards
B. Diagnosis
C. Planning
D. Implementation
B. Nursing Process
C. Diagnosis
D. Evaluation
B. Lungs
C. Intestines
D. Heart
B. Right atrium
C. Left ventricle
D. Right ventricle
B. Large intestine
C. Stomach
D. Small intestine
B. Inflammation
C. Immunity
D. Glands
B. Testosterone
C. Insulin
D. Hemoglobin
B. Iris
C. Cornea
D. Pupils
B. Self-actualization
C. Love and belonging
D. Physiologic needs
B. Physiological needs
C. Safety and security
D. All of the above
B. Acute Illness
C. Pain
D. Infection
B. Teach client to be an effective health consumer
C. Worksite wellness
D. None of the above
B. Illness
C. Community
D. Population
B. 25 ml
C. 15 ml
D. 22 ml
B. 18,000
C. 180
D. 18
B. Gtts.
C. Dp.
D. Dr.
B. gtt
C. mdr
D. µdrop
B. Immediately
C. When necessary
D. Before meals
B. Complete Bathroom
C. Complete Bed Rest
D. Comprehensive Bed Rest
B. 60
C. 45
D. 30
B. 20
C. 2000
D. 200
B. 80
C. 16
D. 4
E. 7
B. Check the client’s identification band
C. State the client’s name aloud and have the client repeat it
D. Verify the client’s social security number
B. Between the client’s cheeks and gums
C. Under the client’s tongue
D. In the client’s ear canal
B. Dorsal recumbent
C. Trendelenburg
D. Prone
B. Administer the capsule with a thickened beverage
C. Inquire about the availability of a liquid formulation
D. Crush the capsule and place it under the patient’s tongue
B. Intradermal (ID)
C. Subcutaneous (SC)
D. Transdermal (TD)
B. Four times a day, taken orally
C. Twice a day, taken by mouth
D. Twice a day, before meals
B. Cleansing the back area
C. Applying a cold compress to the back
D. Applying a hot compress to the back
B. Bed making
C. Bed styling
D. Bed lining
B. Inhibiting the transmission of microorganisms
C. Refraining from touching others with unclean hands
D. Improving skin appearance
B. Remove all linens simultaneously
C. Complete both sides of the bed at once
D. Use disposable gloves while handling linens
B. Expose essential body parts for examination
C. Stimulate circulation in immobile patients
D. Assess the body temperature of a client in bed
B. Palpation
C. Percussion
D. Auscultation
B. Auscultation
C. Percussion
D. Inspection
B. Auscultation
C. Inspection
D. Percussion
B. Otoscope
C. Stethoscope
D. Sphygmomanometer
B. Brief, high-pitched, and dull in nature
C. Of moderate volume and possessing a musical quality
D. Resembling the sound of a drum
B. Fowler’s position
C. Knee-chest position
D. Lithotomy position
B. Locomotion
C. Ambulation
D. Hopping
B. Olfactory
C. Oculomotor
D. Gustatory
B. Genu-pectoral
C. Lithotomy
D. Trendelenburg
B. Apply ice to the injection site prior to administration
C. Inject the medication at a 45-degree angle
D. Employ the Z-track techniqueAnswers and Rationales
2. Safety and security – These needs include personal safety, financial security, health, and protection from harm.
3. Love and belonging – These needs involve friendship, intimacy, family, and a sense of connection with others.
4. Esteem – This level includes self-esteem, respect from others, achievement, and confidence.
5. Self-actualization – This is the highest level of psychological development, where a person realizes their full potential, creativity, and self-fulfillment.