FUNDAMENTAL | 暗記メーカー

暗記メーカー

FUNDAMENTAL

115問 • 1年前

Kyla Angelique Son

問題一覧

1

Objective data are also known as?

Overt data

2

Data or information obtained from the assessment of a patient is primarily used by nurse to:

identify the patient's disease process

3

Two-year-old Aang's mother states "Aang vomited 8 ounces of his formula this morning." This statement is an

Objective data from a secondary source

4

A nurse formulating a plan of care for a client receiving enteral feeding. The nurse identifies which nursing diagnosis as the highest priority for this client?

High risk for aspiration

5

A nurse finds a client in the bedroom, unconscious with pill bottle in hand. The pill bottle contained the SSRI Sertraline (Zoloft). The nurse immediately assesses the client's:

Respirations

6

A nurse is caring for a client admitted to the hospital for subclavian line replacement. Which psychosocial area of assessment should the nurse address with the client?

Possible body image disturbance

7

A hospitalized client who has a living will is being fed through a nasogastric tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take?

Clear the client's airway

8

The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolau test (Pap test). The nurse should reply:

No, because she is not yet 21 years old

9

The nurse is assessing a client who complains of abdominal pain, nausea and diarrhea. When examining the client's abdomen, which sequence should the nurse use?

Inspection, auscultation, percussion, palpation

10

The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 45. Following the Philippine Cancer Society guidelines, the nurse should recommend that the women;

Have a mammogram annually

11

The school nurse is planning a program for a group of teenagers on skin cancer prevention. Which of the following Instruction should the nurse emphasize in her talk?

Examine skin once per month, looking for suspicious lesions or changes in moles

12

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of prevention?

Primary prevention

13

A nurse has just been told by the physician that an order has been written to administer an iron injection to a client. The nurse plans to give the medication in the:

Gluteal muscle using Z-Tract technique

14

A client has just been told by the physician that a cerebral angiogram will be obtained. The nurse then collects data from the client about which of the following pieces of information?

Allergy to iodine/shellfish

15

A client has an order for a wound culture to be performed with the next wound irrigation and dressing change. The nurse would plan to use which of the following solutions for irrigation before this particular procedure?

Normal saline

16

Which of the following is the best indicator in determining that the client's airway needs suctioning?

Breath sounds

17

A nurse is planning to assist a diabetic client to perform self-monitoring of blood glucose level. The nurse should incorporate which of the following strategies to best help the client obtain an adequate capillary sample?

Puncture the finger at the lateral aspect.

18

One hour after the IV was inserted, Nurse Katara found out that the 1 liter of D5NSS was empty. Patient Zuko was in severe respiratory distress with pinkish, frothy sputum. The most probable complication is:

Pulmonary edema

19

When an IV of D5W is not infusing well on patient, it is best to first:

Lower IV to check for return flow

20

The doctor ordered venoclysis of one liter of dextrose 5% in water KVO for 24 hours as a vehicle for IV medications. How many drops per minute should the fluid be regulated?

10 drops per minute

21

The nurse is administering IV fluids to an infant. Infants receiving IV Therapy are particularly vulnerable to:

Fluid overload

22

A client with severe inflammatory bowel disease is receiving TPN. When administering TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:

Hyperglycemia

23

A client's hypertension has been recently diagnosed. The nurse would plan to do which of the following as the first step in teaching the client about the disorder?

Assess the client's knowledge and needs

24

In teaching the sister of a diabetic client about the proper use of a glucometer in determining the blood sugar level of the client. The nurse is focusing in which domain of learning according to bloom?

Psychomotor

25

A diabetic client who is performing self-monitoring of blood glucose at home asks a clinic nurse why a glycosylated hemoglobin level needs to be measured. The nurse should plan to incorporate which of the following into a response.

This laboratory test gives an indication of glycemic control over the last 3 months

26

Which of the following is the most important condition for a diabetic client to learn how to control their diet?

Motivation to be symptom free

27

When you prepare your teaching plan for a group of hypertensive clients, you first formulate your learning objectives. Which of the following steps in the nursing process corresponds to the writing of learning objectives?

Planning

28

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

Sister Callista Roy

29

The theorist whose theory can be defined as the development of a science of humankind, incorporating the concepts of energy fields, openness, pattern and organization is:

Martha Rogers

30

Which psychodynamic theorist believed that an Infant seeking pleasure through oral gratification is important to psychosocial growth?

Sigmund Freud

31

The nurse gives a resident in a nursing home a choice about which color shirt to wear. What level need, according to Maslow's Hierarchy of Needs, has the nurse just met?

Self-esteem

32

The primary effect of oxygen therapy is to:

Increase oxygen in the tissues and cells

33

A nurse suctions a client who has an endotracheal tube in place. Following the procedure, which of the following would indicate to the nurse that the client is experiencing an adverse effect of this procedure?

Cardiac Irregularities

34

The gauge number in ET tubes determines:

The internal diameter of the tube

35

The nurse is correct in performing suctioning when she applies the suction intermittently during;

Withdrawing of the suction catheter

36

The purpose of the cuff in tracheostomy tube is to:

Secure the placement of the tube

37

Based on the nurse's knowledge of surgical wounds, simple surgical incisions heal by:

Primary intention

38

The nurse documents that the wound edges are approximated. When the edges of an incision are said to be approximated, this means edges are:

Brought together by sutures, tapes or staples

39

Which vitamin is most essential for collagen synthesis?

Vitamin C

40

When assessing the client's wound for sign of infection, the nurse should look for the presence of which of the following?

Purulent drainage

41

The nurse is about to change the dressing and provide wound care. Which activity should she perform first?

Wash hands thoroughly

42

The component that should receive the highest priority before physical examination is the:

Physical preparation of the client

43

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?

Circumscribed, elevated, and filled with serous fluid

44

When assessing a cllent with abdominal pain the nurse should assess

The symptomatic quadrant last

45

To assess the client's dorsalis pedis pulse, the nurse should palpate the:

Ventral aspect of the top of the foot

46

Which of the following assessment would be a priority for a 2-year-old after bronchoscopy?

Respiratory quality

47

The nurse checks the client's gag reflex. The recommended technique for testing the gag reflex is to:

Touch the back of the client's throat with a tongue depressor

48

The nurse is evaluating a client's lung sounds. Which of the following breath sounds indicate inadequate ventilation when auscultated over the lung fields?

Adventitious

49

A client has a chest tubes attached to a pleural drainage system. When caring for this client, the nurse should:

Palpate the surrounding area of the tube for subcutaneous crepitus

50

The nurse is teaching a patient how to use an incentive spirometer. The nurse should assist the patient to assume which position?

Sitting

51

Which is the most important action by the nurse after a patient has a thoracotomy?

Maintain the integrity of the patient's chest tube

52

In a client with diabetic ketoacidosis, Kussmaul's respiration is exhibited. This is evidence that there is the presence of:

Metabolic acidosis

53

If the nurse will auscultate the base of the lungs, it is expected that she will here:

Vesicular

54

The respiratory center that controls breathing is found in the:

Medulla oblongata

55

Initially in asthma, you are expecting that the client's acid base disturbance is:

Respiratory alkalosis

56

Mang Sokka was rushed to the hospital after being unconscious inside an enclosed parking lot. Carbon monoxide polsoning is suspected. The pulse oximetry reading of Mang Sokka is 100%. This suggests that:

This is not a reliable sign to rule out carbon monoxide poisoning, further assessment is required.

57

Mang Sokka was rushed to the hospital after being unconscious inside an enclosed parking lot. Carbon monoxide polsoning is suspected. Which is a sign the nurse will expect to see on Mang Sokka?

Cherry-red skin

58

Initially, in patient with suspected inhalation poisoning, the most important intervention at the scene of poisoning is:

Carry the client on the fresh air immediately opening all windows and doors if this is enclosed.

59

Which of the following laboratory result is constantly checked in the client's undergoing treatment for carbon monoxide poisoning?

Carboxyhemoglobin level

60

If a client demonstrates psychoses, visual disturbance, ataxia, amnesia and confusion even after completion of resuscitation and the return of normal oxygenation, this will indicate that:

That the client will need a longer rehabilitation to go back to previous functioning.

61

The physician has ordered 3 units of whole blood to be transfused to Azula following a repair of a dissecting aneurysm of the aorta. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?

4 hours

62

The physician has ordered 3 units of whole blood to be transfused to Azula following a repair of a dissecting aneurysm of the aorta. What should you do FIRST before you administer blood transfusion?

Verify physician's order.

63

As Azula's nurse, what will you do AFTER the transfusion has started?

Stay with Azula for 15 minutes to note for any possible BT reactions.

64

Azula is undergoing blood transfusions of the first unit. The EARLIEST signs of allergic transfusion reactions are:

urticaria and wheezing

65

BLOOD TRANSFUSION In case Azula will experience an acute hemolytic reaction, what will be your PRIORITY intervention?

Immediately stop the BT, infuse NSS, call the physician, and notify the blood bank.

66

The body fluids move using the principle of osmosis and diffusion. This affects the isotonicity or concentration of the body in relation to its solutes and solvents. D5NSS is an example of:

Hypertonic

67

The body fluids move using the principle of osmosis and diffusion. This affects the isotonicity or concentration of the body in relation to its solutes and solvents. Which of the following is NOT an isotonic solution?

D5 1/2NSS

68

The most abundant cation in the Intracellular fluid is:

K+

69

Why is insulin given in clients with Burns?

Insulin improves the metabolism of clients with burn injury to enhance tissue repair and cellular regeneration.

70

In clients with Diabetes Mellitus, the greatest complication that could occur is related to:

Acidosis

71

TPN is delivered at a rate of 50-60 ml/hr during the first 12 hours. Why is this so?

To let the body adjust to the solution

72

What is the flow rate of TPN?

as ordered by physician

73

The site of choice for TPN by the use of the central veins, either via the subclavian or the femoral approach. If this procedure will use the femoral vein, the tip of the catheter Is placed in the:

Superior Vena Cava

74

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. During colostomy irrigation, the client complains of a cramping sensation with the fluid was introduced. Which of the following is a CORRECT nursing action?

Pinch or kink the irrigating tube temporarily

75

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. When is the colostomy appliance best emptied?

When it is two-thirds full

76

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. The client asks the nurse, "WHEN is the best time to perform irrigation?" The nurse would answer:

Same time everyday

77

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. The nurse is teaching a client how to irrigate his stoma. Which action Indicates that the client needs more teaching?

Hanging the irrigation bag 24" to 36" [ 60 to 90 cm] above the stoma

78

The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen from the colostomy stoma should

Collect the specimen in a sterile container

79

You are assisting Roku who recently went through colostomy surgery. You plan to teach Roku how to irrigate the colostomy when:

The stool starts to become formed, around the 5th postoperative day.

80

When preparing to teach Roku how to irrigate colostomy, you should plan to do the procedure:

When Roku would have normal bowel movement

81

When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Roku:

Hangs the Irrigating bag on the bathroom door cloth hook during fluid insertion

82

You are aware that teaching about colostomy care is understood when Roku states, "I will contact my physician and report:

If I have any difficulty inserting the tube into the stoma

83

You would know after teaching Roku that dietary instruction for him is effective when he states, "It is important that t eat:

Food low in fiber so that there are fewer stools

84

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. Given the above assessment data, the most immediate goal of the nurse would be which of the following?

Alleviate pain

85

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. After Princess Yue went through an IVP, a renal stone was confirmed. Left nephrectomy was done. Her post operative order includes "daily urine specimen to be sent to the laboratory." Princess Yue has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?

Remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container

86

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. Where would the nurse tape Princess Yue's indwelling catheter in order to reduce urethral irritation?

To the patient's inner thigh

87

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. Which of the following menu is appropriate for Princess Yue who requires a low sodium diet?

White chicken sandwich, vegetable salad and tea

88

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. How will you prevent ascending infection to Princess Yue who has an indwelling catheter?

See to it that the drainage tubing does not touch the level of the urine.

89

Iroh is an elderly client who is immobile and sedentary Iroh is frequent complaining of dry skin. Which of the following is the BEST way to prevent dry skin?

Apply lotion or skin moisturizer.

90

Which of the following is a frequently used dressing for pressure sores?

Transparent

91

Heat is an old remedy for aches and pain. People equate heat with comfort and relief.

It promotes blood circulation and tissue oxygenation through vasodilatation.

92

Heat and cold applications should not exceed:

30 minutes

93

A client with deep wounds undergone hydrocolloid dressing. Which of the following is TRUE with regards to this dressing?

They can be molded to uneven skin surfaces thus, best used in pressure ulcers.

94

A patient performs rehabilitative exercises with resistance after a knee injury. The nurse interprets this type of exercise as which of the following?

Isometric

95

Which of the following would the nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured?

Negative nitrogen balance

96

While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations?

Each joint is exercised to the point of resistance but not pain.

97

In many situations, a patient has sufficient strength to walk if he or she can do which of the following?

Raise the foot off the bed 1 inch

98

When a patient is using a cane for maximal support, the nurse is aware that the patient should do which of the following?

Distribute weight evenly between the feet and the cane

99

The nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep?

Stage I NREM sleep

100

The nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects which of the following to be true?

It would be most difficult to awaken him at this time.

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問題一覧

1

Objective data are also known as?

Overt data

2

Data or information obtained from the assessment of a patient is primarily used by nurse to:

identify the patient's disease process

3

Two-year-old Aang's mother states "Aang vomited 8 ounces of his formula this morning." This statement is an

Objective data from a secondary source

4

A nurse formulating a plan of care for a client receiving enteral feeding. The nurse identifies which nursing diagnosis as the highest priority for this client?

High risk for aspiration

5

A nurse finds a client in the bedroom, unconscious with pill bottle in hand. The pill bottle contained the SSRI Sertraline (Zoloft). The nurse immediately assesses the client's:

Respirations

6

A nurse is caring for a client admitted to the hospital for subclavian line replacement. Which psychosocial area of assessment should the nurse address with the client?

Possible body image disturbance

7

A hospitalized client who has a living will is being fed through a nasogastric tube. During a bolus feeding, the client vomits and begins choking. Which of the following actions is most appropriate for the nurse to take?

Clear the client's airway

8

The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolau test (Pap test). The nurse should reply:

No, because she is not yet 21 years old

9

The nurse is assessing a client who complains of abdominal pain, nausea and diarrhea. When examining the client's abdomen, which sequence should the nurse use?

Inspection, auscultation, percussion, palpation

10

The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 45. Following the Philippine Cancer Society guidelines, the nurse should recommend that the women;

Have a mammogram annually

11

The school nurse is planning a program for a group of teenagers on skin cancer prevention. Which of the following Instruction should the nurse emphasize in her talk?

Examine skin once per month, looking for suspicious lesions or changes in moles

12

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of prevention?

Primary prevention

13

A nurse has just been told by the physician that an order has been written to administer an iron injection to a client. The nurse plans to give the medication in the:

Gluteal muscle using Z-Tract technique

14

A client has just been told by the physician that a cerebral angiogram will be obtained. The nurse then collects data from the client about which of the following pieces of information?

Allergy to iodine/shellfish

15

A client has an order for a wound culture to be performed with the next wound irrigation and dressing change. The nurse would plan to use which of the following solutions for irrigation before this particular procedure?

Normal saline

16

Which of the following is the best indicator in determining that the client's airway needs suctioning?

Breath sounds

17

A nurse is planning to assist a diabetic client to perform self-monitoring of blood glucose level. The nurse should incorporate which of the following strategies to best help the client obtain an adequate capillary sample?

Puncture the finger at the lateral aspect.

18

One hour after the IV was inserted, Nurse Katara found out that the 1 liter of D5NSS was empty. Patient Zuko was in severe respiratory distress with pinkish, frothy sputum. The most probable complication is:

Pulmonary edema

19

When an IV of D5W is not infusing well on patient, it is best to first:

Lower IV to check for return flow

20

The doctor ordered venoclysis of one liter of dextrose 5% in water KVO for 24 hours as a vehicle for IV medications. How many drops per minute should the fluid be regulated?

10 drops per minute

21

The nurse is administering IV fluids to an infant. Infants receiving IV Therapy are particularly vulnerable to:

Fluid overload

22

A client with severe inflammatory bowel disease is receiving TPN. When administering TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:

Hyperglycemia

23

A client's hypertension has been recently diagnosed. The nurse would plan to do which of the following as the first step in teaching the client about the disorder?

Assess the client's knowledge and needs

24

In teaching the sister of a diabetic client about the proper use of a glucometer in determining the blood sugar level of the client. The nurse is focusing in which domain of learning according to bloom?

Psychomotor

25

A diabetic client who is performing self-monitoring of blood glucose at home asks a clinic nurse why a glycosylated hemoglobin level needs to be measured. The nurse should plan to incorporate which of the following into a response.

This laboratory test gives an indication of glycemic control over the last 3 months

26

Which of the following is the most important condition for a diabetic client to learn how to control their diet?

Motivation to be symptom free

27

When you prepare your teaching plan for a group of hypertensive clients, you first formulate your learning objectives. Which of the following steps in the nursing process corresponds to the writing of learning objectives?

Planning

28

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

Sister Callista Roy

29

The theorist whose theory can be defined as the development of a science of humankind, incorporating the concepts of energy fields, openness, pattern and organization is:

Martha Rogers

30

Which psychodynamic theorist believed that an Infant seeking pleasure through oral gratification is important to psychosocial growth?

Sigmund Freud

31

The nurse gives a resident in a nursing home a choice about which color shirt to wear. What level need, according to Maslow's Hierarchy of Needs, has the nurse just met?

Self-esteem

32

The primary effect of oxygen therapy is to:

Increase oxygen in the tissues and cells

33

A nurse suctions a client who has an endotracheal tube in place. Following the procedure, which of the following would indicate to the nurse that the client is experiencing an adverse effect of this procedure?

Cardiac Irregularities

34

The gauge number in ET tubes determines:

The internal diameter of the tube

35

The nurse is correct in performing suctioning when she applies the suction intermittently during;

Withdrawing of the suction catheter

36

The purpose of the cuff in tracheostomy tube is to:

Secure the placement of the tube

37

Based on the nurse's knowledge of surgical wounds, simple surgical incisions heal by:

Primary intention

38

The nurse documents that the wound edges are approximated. When the edges of an incision are said to be approximated, this means edges are:

Brought together by sutures, tapes or staples

39

Which vitamin is most essential for collagen synthesis?

Vitamin C

40

When assessing the client's wound for sign of infection, the nurse should look for the presence of which of the following?

Purulent drainage

41

The nurse is about to change the dressing and provide wound care. Which activity should she perform first?

Wash hands thoroughly

42

The component that should receive the highest priority before physical examination is the:

Physical preparation of the client

43

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle?

Circumscribed, elevated, and filled with serous fluid

44

When assessing a cllent with abdominal pain the nurse should assess

The symptomatic quadrant last

45

To assess the client's dorsalis pedis pulse, the nurse should palpate the:

Ventral aspect of the top of the foot

46

Which of the following assessment would be a priority for a 2-year-old after bronchoscopy?

Respiratory quality

47

The nurse checks the client's gag reflex. The recommended technique for testing the gag reflex is to:

Touch the back of the client's throat with a tongue depressor

48

The nurse is evaluating a client's lung sounds. Which of the following breath sounds indicate inadequate ventilation when auscultated over the lung fields?

Adventitious

49

A client has a chest tubes attached to a pleural drainage system. When caring for this client, the nurse should:

Palpate the surrounding area of the tube for subcutaneous crepitus

50

The nurse is teaching a patient how to use an incentive spirometer. The nurse should assist the patient to assume which position?

Sitting

51

Which is the most important action by the nurse after a patient has a thoracotomy?

Maintain the integrity of the patient's chest tube

52

In a client with diabetic ketoacidosis, Kussmaul's respiration is exhibited. This is evidence that there is the presence of:

Metabolic acidosis

53

If the nurse will auscultate the base of the lungs, it is expected that she will here:

Vesicular

54

The respiratory center that controls breathing is found in the:

Medulla oblongata

55

Initially in asthma, you are expecting that the client's acid base disturbance is:

Respiratory alkalosis

56

Mang Sokka was rushed to the hospital after being unconscious inside an enclosed parking lot. Carbon monoxide polsoning is suspected. The pulse oximetry reading of Mang Sokka is 100%. This suggests that:

This is not a reliable sign to rule out carbon monoxide poisoning, further assessment is required.

57

Mang Sokka was rushed to the hospital after being unconscious inside an enclosed parking lot. Carbon monoxide polsoning is suspected. Which is a sign the nurse will expect to see on Mang Sokka?

Cherry-red skin

58

Initially, in patient with suspected inhalation poisoning, the most important intervention at the scene of poisoning is:

Carry the client on the fresh air immediately opening all windows and doors if this is enclosed.

59

Which of the following laboratory result is constantly checked in the client's undergoing treatment for carbon monoxide poisoning?

Carboxyhemoglobin level

60

If a client demonstrates psychoses, visual disturbance, ataxia, amnesia and confusion even after completion of resuscitation and the return of normal oxygenation, this will indicate that:

That the client will need a longer rehabilitation to go back to previous functioning.

61

The physician has ordered 3 units of whole blood to be transfused to Azula following a repair of a dissecting aneurysm of the aorta. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it?

4 hours

62

The physician has ordered 3 units of whole blood to be transfused to Azula following a repair of a dissecting aneurysm of the aorta. What should you do FIRST before you administer blood transfusion?

Verify physician's order.

63

As Azula's nurse, what will you do AFTER the transfusion has started?

Stay with Azula for 15 minutes to note for any possible BT reactions.

64

Azula is undergoing blood transfusions of the first unit. The EARLIEST signs of allergic transfusion reactions are:

urticaria and wheezing

65

BLOOD TRANSFUSION In case Azula will experience an acute hemolytic reaction, what will be your PRIORITY intervention?

Immediately stop the BT, infuse NSS, call the physician, and notify the blood bank.

66

The body fluids move using the principle of osmosis and diffusion. This affects the isotonicity or concentration of the body in relation to its solutes and solvents. D5NSS is an example of:

Hypertonic

67

The body fluids move using the principle of osmosis and diffusion. This affects the isotonicity or concentration of the body in relation to its solutes and solvents. Which of the following is NOT an isotonic solution?

D5 1/2NSS

68

The most abundant cation in the Intracellular fluid is:

K+

69

Why is insulin given in clients with Burns?

Insulin improves the metabolism of clients with burn injury to enhance tissue repair and cellular regeneration.

70

In clients with Diabetes Mellitus, the greatest complication that could occur is related to:

Acidosis

71

TPN is delivered at a rate of 50-60 ml/hr during the first 12 hours. Why is this so?

To let the body adjust to the solution

72

What is the flow rate of TPN?

as ordered by physician

73

The site of choice for TPN by the use of the central veins, either via the subclavian or the femoral approach. If this procedure will use the femoral vein, the tip of the catheter Is placed in the:

Superior Vena Cava

74

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. During colostomy irrigation, the client complains of a cramping sensation with the fluid was introduced. Which of the following is a CORRECT nursing action?

Pinch or kink the irrigating tube temporarily

75

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. When is the colostomy appliance best emptied?

When it is two-thirds full

76

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. The client asks the nurse, "WHEN is the best time to perform irrigation?" The nurse would answer:

Same time everyday

77

ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. The nurse is teaching a client how to irrigate his stoma. Which action Indicates that the client needs more teaching?

Hanging the irrigation bag 24" to 36" [ 60 to 90 cm] above the stoma

78

The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen from the colostomy stoma should

Collect the specimen in a sterile container

79

You are assisting Roku who recently went through colostomy surgery. You plan to teach Roku how to irrigate the colostomy when:

The stool starts to become formed, around the 5th postoperative day.

80

When preparing to teach Roku how to irrigate colostomy, you should plan to do the procedure:

When Roku would have normal bowel movement

81

When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Roku:

Hangs the Irrigating bag on the bathroom door cloth hook during fluid insertion

82

You are aware that teaching about colostomy care is understood when Roku states, "I will contact my physician and report:

If I have any difficulty inserting the tube into the stoma

83

You would know after teaching Roku that dietary instruction for him is effective when he states, "It is important that t eat:

Food low in fiber so that there are fewer stools

84

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. Given the above assessment data, the most immediate goal of the nurse would be which of the following?

Alleviate pain

85

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. After Princess Yue went through an IVP, a renal stone was confirmed. Left nephrectomy was done. Her post operative order includes "daily urine specimen to be sent to the laboratory." Princess Yue has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen?

Remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container

86

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. Where would the nurse tape Princess Yue's indwelling catheter in order to reduce urethral irritation?

To the patient's inner thigh

87

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. Which of the following menu is appropriate for Princess Yue who requires a low sodium diet?

White chicken sandwich, vegetable salad and tea

88

Princess Yue, 42 years old is admitted to the hospital with diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 degrees Celsius. How will you prevent ascending infection to Princess Yue who has an indwelling catheter?

See to it that the drainage tubing does not touch the level of the urine.

89

Iroh is an elderly client who is immobile and sedentary Iroh is frequent complaining of dry skin. Which of the following is the BEST way to prevent dry skin?

Apply lotion or skin moisturizer.

90

Which of the following is a frequently used dressing for pressure sores?

Transparent

91

Heat is an old remedy for aches and pain. People equate heat with comfort and relief.

It promotes blood circulation and tissue oxygenation through vasodilatation.

92

Heat and cold applications should not exceed:

30 minutes

93

A client with deep wounds undergone hydrocolloid dressing. Which of the following is TRUE with regards to this dressing?

They can be molded to uneven skin surfaces thus, best used in pressure ulcers.

94

A patient performs rehabilitative exercises with resistance after a knee injury. The nurse interprets this type of exercise as which of the following?

Isometric

95

Which of the following would the nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured?

Negative nitrogen balance

96

While doing range-of-motion exercises with a patient who is bedridden, the nurse is aware of which of the following considerations?

Each joint is exercised to the point of resistance but not pain.

97

In many situations, a patient has sufficient strength to walk if he or she can do which of the following?

Raise the foot off the bed 1 inch

98

When a patient is using a cane for maximal support, the nurse is aware that the patient should do which of the following?

Distribute weight evenly between the feet and the cane

99

The nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep?

Stage I NREM sleep

100

The nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects which of the following to be true?

It would be most difficult to awaken him at this time.