PNLE: Fundamentals in Nursing Exam 1

1. Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:

1. Pulse rate greater than 100 beats per minute
2. Blood pressure of 140/90
3. Respiratory rate greater than 20 breaths per minute
4. Frequent bowel sounds

2. The nurse listens to Mrs. Sullen’s lungs and notes a hissing sound or musical sound. The nurse documents this as:

1. Wheezes
2. Rhonchi
3. Gurgles
4. Vesicular

3. The nurse in charge measures a patient’s temperature at 101 degrees F. What is the equivalent centigrade temperature?

1. 36.3 degrees C
2. 37.95 degrees C
3. 40.03 degrees C
4. 38.01 degrees C

4. Which approach to problem solving tests any number of solutions until one is found that works for that particular problem?

1. Intuition
2. Routine
3. Scientific method
4. Trial and error

5. What is the order of the nursing process?

1. Assessing, diagnosing, implementing, evaluating, planning
2. Diagnosing, assessing, planning, implementing, evaluating
3. Assessing, diagnosing, planning, implementing, evaluating
4. Planning, evaluating, diagnosing, assessing, implementing

6. During the planning phase of the nursing process, which of the following is the outcome?

1. Nursing history
2. Nursing notes
3. Nursing care plan
4. Nursing diagnosis

7. What is an example of a subjective data?

1. Heart rate of 68 beats per minute
2. Yellowish sputum
3. Client verbalized, “I feel pain when urinating.”
4. Noisy breathing

8. Which expected outcome is correctly written?

1. “The patient will feel less nauseated in 24 hours.”
2. “The patient will eat the right amount of food daily.”
3. “The patient will identify all the high-salt food from a prepared list by discharge.”
4. “The patient will have enough sleep.”

9. Which of the following behaviors by Nurse Jane Robles demonstrates that she understands well th elements of effecting charting?

1. She writes in the chart using a no. 2 pencil.
2. She noted: appetite is good this afternoon.
3. She signs on the medication sheet after administering the medication.
4. She signs her charting as follow: J.R

10. What is the disadvantage of computerized documentation of the nursing process?

1. Accuracy
2. Legibility
3. Concern for privacy
4. Rapid communication

11. The theorist who believes that adaptation and manipulation of stressors are related to foster change is:

1. Dorothea Orem
2. Sister Callista Roy
3. Imogene King
4. Virginia Henderson

12. Formulating a nursing diagnosis is a joint function of:

1. Patient and relatives
2. Nurse and patient
3. Doctor and family
4. Nurse and doctor

13. Mrs. Caperlac has been diagnosed to have hypertension since 10 years ago. Since then, she had maintained low sodium, low fat diet, to control her blood pressure. This practice is viewed as:

1. Cultural belief
2. Personal belief
3. Health belief
4. Superstitious belief

14. Becky is on NPO since midnight as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response?

1. Low blood pressure
2. Warm, dry skin
3. Decreased serum sodium levels
4. Decreased urine output

15. What nursing action is appropriate when obtaining a sterile urine specimen from an indwelling catheter to prevent infection?

1. Use sterile gloves when obtaining urine.
2. Open the drainage bag and pour out the urine.
3. Disconnect the catheter from the tubing and get urine.
4. Aspirate urine from the tubing port using a sterile syringe.

16. A client is receiving 115 ml/hr of continuous IVF. The nurse notices that the venipuncture site is red and swollen. Which of the following interventions would the nurse perform first?

1. Stop the infusion
2. Call the attending physician
3. Slow that infusion to 20 ml/hr
4. Place a clod towel on the site

17. The nurse enters the room to give a prescribed medication but the patient is inside the bathroom. What should the nurse do?

1. Leave the medication at the bedside and leave the room.
2. After few minutes, return to that patient’s room and do not leave until the patient takes the medication.
3. Instruct the patient to take the medication and leave it at the bedside.
4. Wait for the patient to return to bed and just leave the medication at the bedside.

18. Which of the following is inappropriate nursing action when administering NGT feeding?

1. Place the feeding 20 inches above the pint if insertion of NGT.
2. Introduce the feeding slowly.
3. Instill 60ml of water into the NGT after feeding.
4. Assist the patient in fowler’s position.

19. A female patient is being discharged after thyroidectomy. After providing the medication teaching. The nurse asks the patient to repeat the instructions. The nurse is performing which professional role?

1. Manager
2. Caregiver
3. Patient advocate
4. Educator

20. Which data would be of greatest concern to the nurse when completing the nursing assessment of a 68-year-old woman hospitalized due to Pneumonia?

1. Oriented to date, time and place
2. Clear breath sounds
3. Capillary refill greater than 3 seconds and buccal cyanosis
4. Hemoglobin of 13 g/dl

21. During a change-of-shift report, it would be important for the nurse relinquishing responsibility for care of the patient to communicate. Which of the following facts to the nurse assuming responsibility for care of the patient?

1. That the patient verbalized, “My headache is gone.”
2. That the patient’s barium enema performed 3 days ago was negative
3. Patient’s NGT was removed 2 hours ago
4. Patient’s family came for a visit this morning.

22. Which statement is the most appropriate goal for a nursing diagnosis of diarrhea?

1. “The patient will experience decreased frequency of bowel elimination.”
2. “The patient will take anti-diarrheal medication.”
3. “The patient will give a stool specimen for laboratory examinations.”
4. “The patient will save urine for inspection by the nurse.

23. Which of the following is the most important purpose of planning care with this patient?

1. Development of a standardized NCP.
2. Expansion of the current taxonomy of nursing diagnosis
3. Making of individualized patient care
4. Incorporation of both nursing and medical diagnoses in patient care

24. Using Maslow’s hierarchy of basic human needs, which of the following nursing diagnoses has the highest priority?

1. Ineffective breathing pattern related to pain, as evidenced by shortness of breath.
2. Anxiety related to impending surgery, as evidenced by insomnia.
3. Risk of injury related to autoimmune dysfunction
4. Impaired verbal communication related to tracheostomy, as evidenced by inability to speak.

25. When performing an abdominal examination, the patient should be in a supine position with the head of the bed at what position?

1. 30 degrees
2. 90 degrees
3. 45 degrees
4. 0 degree

Answers and Rationales

1. 1. (C) Respiratory rate greater than 20 breaths per minute. A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.
2. (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. 
   
3. (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.
   
4. (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).
5. (C) Assessing, diagnosing, planning, implementing, evaluating. The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.
6. (C) Nursing care plan. The outcome, or the product of the planning phase of the nursing process is a Nursing care plan.
7. (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.
8. (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.
9. (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. (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. (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. (B) Nurse and patient. Although diagnosing is basically the nurse’s responsibility, input from the patient is essential to formulate the correct nursing diagnosis.
13. (C) Health belief. Health belief of an individual influences his/her preventive health behavior.
14. (D) Decreased urine output. Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.
15. (D) Aspirate urine from the tubing port using a sterile syringe. The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.
16. (A) Stop the infusion. The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.
17. (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.
18. (A) Place the feeding 20 inches above the pint if insertion of NGT. The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.
19. (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.
20. (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.
21. (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.
22. (A) “The patient will experience decreased frequency of bowel elimination.” The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea.
23. (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.
24. (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.
25. (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.