Which intervention is an example of primary prevention?
A. Administering digoxin (Lanoxicaps) to a patient with heart failure.
B. Administering measles, mumps, and rubella immunization to an infant.
C. Obtaining a Papanicolaou smear to screen for cervical cancer.
D. Using occupational therapy to help a patient cope with arthritis.
Correct Answer:B. Administering measles, mumps, and rubella immunization to an infant.
Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems developing in the future.
Option A: Administering d
igoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness, or injury to prevent more severe problems developing. Here health educators such as Health Extension Practitioners can help individuals acquire the skills of detecting diseases in their early stages.
Option C: Obtaining a Papanicolau smear is a secondary prevention. Secondary prevention includes those preventive measures that lead to early diagnosis and prompt treatment of a disease, illness or injury. This should limit disability, impairment, or dependency and prevent more severe health problems developing in the future.
Option D: Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring. Tertiary prevention includes those preventive measures aimed at rehabilitation following significant illness. At this level, health educators work to retrain, re-educate and rehabilitate the individual who has already had an impairment or disability.
FNDNRS-02-002
The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?
A. Auscultation
B. Inspection
C. Percussion
D. Palpation
Correct Answer:B. Inspection
Inspection always comes first when performing a physical examination. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
Option A: The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance.
Option C: A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly).
Option D: The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation.
FNDNRS-02-003
Which statement regarding heart sounds is correct?
A. S1 and S2 sound equally loud over the entire cardiac area.
B. S1 and S2 sound fainter at the apex.
C. S1 and S2 sound fainter at the base.
D. S1 is loudest at the apex, and S2 is loudest at the base.
Correct Answer: D. S1 is loudest at the apex, and S2 is loudest at the base.
The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1. Heart sounds are created from blood flowing through the heart chambers as the cardiac valves open and close during the cardiac cycle. Vibrations of these structures from the blood flow create audible sounds — the more turbulent the blood flow, the more vibrations that get created.
Option A: The S1 heart sound is produced as the mitral and tricuspid valves close in systole. This structural and hemodynamic change creates vibrations that are audible at the chest wall. The mitral valve closing is the louder component of S1. It also occurs sooner because of the left ventricle contracts earlier in systole.
Option B: Changes in the intensity of S1 are more attributable to forces acting on the mitral valve. Such causes include a change in left ventricular contractility, mitral structure, or the PR interval. However, under normal resting conditions, the mitral and tricuspid sounds occur close enough together not to be discernible. The most common reasons for a split S1 are things that delay right ventricular contraction, like a right bundle branch block.
Option C: The S2 heart sound is produced with the closing of the aortic and pulmonic valves in diastole. The aortic valve closes sooner than the pulmonic valve, and it is the louder component of S2; this occurs because the pressures in the aorta are higher than the pulmonary artery.
FNDNRS-02-004
The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Correct Answer:B. Nursing diagnosis
The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community.
Option A: During the assessment step, the nurse systematically collects data about the patient or family. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option C: During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome.
Option D: During the evaluation step, the nurse determines the effectiveness of the plan of care. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
FNDNRS-02-005
A female patient is receiving furosemide (Lasix), 40 mg P.O. B.I.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:
A. Fresh, green vegetables
B. Bananas and oranges
C. Lean red meat
D. Creamed corn
Correct Answer: B. Bananas and oranges
Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work as they should. The right balance of potassium also keeps the heart beating at a steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
Option A: GLVs are considered as natural caches of nutrients for human beings as they are a rich source of vitamins, such as ascorbic acid, folic acid, tocopherols, β-carotene, and riboflavin, as well as minerals such as iron, calcium, and phosphorous.
Option C: Lean red meat is an excellent source of high biological value protein, vitamin B12, niacin, vitamin B6, iron, zinc, and phosphorus. It is a source of long‐chain omega‐3 polyunsaturated fats, riboflavin, pantothenic acid, selenium, and, possibly, also vitamin D. It is also relatively low in fat and sodium.
Option D: Corn has several health benefits. Because of the high fiber content, it can aid with digestion. It also contains valuable B vitamins, which are important to your overall health. Corn also provides our bodies with essential minerals such as zinc, magnesium, copper, iron, and manganese.
FNDNRS-02-006
The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?
A. Lethal arrhythmias
B. Malignant hypertension
C. Status epilepticus
D. Bone marrow suppression
Correct Answer: D. Bone marrow suppression
The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is a synthetically manufactured broad-spectrum antibiotic. It was initially isolated from the bacteria Streptomyces venezuelae in 1948 and was the first bulk produced synthetic antibiotic. However, chloramphenicol is a rarely used drug in the United States because of its known severe adverse effects, such as bone marrow toxicity and grey baby syndrome. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
Option A: Chloramphenicol is associated with severe hematological side effects when administered systemically. Since 1982, chloramphenicol has reportedly caused fatal aplastic anemia, with possible increased risk when taken together with cimetidine. This adverse side effect can occur even with the topical administration of the drug, which is most likely due to the systemic absorption of the drug after topical application.
Option B: Besides causing fatal aplastic anemia and bone marrow suppression, other side effects of chloramphenicol include ototoxicity with the use of topical ear drops, gastrointestinal reactions such as oesophagitis with oral use, neurotoxicity, and severe metabolic acidosis.
Option C: Optic neuritis is the most commonly associated neurotoxic complication that can arise from chloramphenicol use. This adverse effect usually takes more than six weeks to manifest, presenting with either acute or subacute vision loss, with possible fundal changes. It may also present with peripheral neuropathy, which may present as numbness or tingling. If optic neuropathy occurs, the drug should be withdrawn immediately, which will usually lead to partial or complete recovery of vision.
FNDNRS-02-007
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?
A. Impaired gas exchanges related to increased blood flow.
B. Fluid volume excess related to peripheral vascular disease.
C. Risk for injury related to edema.
D. Altered peripheral tissue perfusion related to venous congestion.
Correct Answer:D. Altered peripheral tissue perfusion related to venous congestion.
Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke.
Option A: Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Depending on the relative balance between the coagulation and thrombolytic pathways, thrombus propagation occurs. DVT is commonest in the lower limb below the knee and starts at low-flow sites, such as the soleal sinuses, behind venous valve pockets.
Option B: Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Nurses need to educate the patients on the importance of ambulation, being compliant with compression stockings, and taking the prescribed anticoagulation medications.
Option C: Option C may be warranted but is secondary to altered tissue perfusion. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis.
FNDNRS-02-008
When positioned properly, the tip of a central venous catheter should lie in the:
A. Superior vena cava
B. Basilica vein
C. Jugular vein
D. Subclavian vein
Correct Answer: A. Superior vena cava
When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
Option B: There are three main access sites for the placement of central venous catheters. The internal jugular vein, common femoral vein, and subclavian veins are the preferred sites for temporary central venous catheter placement. Additionally, for mid-term and long-term central venous access, the basilic and brachial veins are utilized for peripherally inserted central catheters (PICCs).
Option C: The internal jugular vein (IJ) is often chosen for its reliable anatomy, accessibility, low complication rates, and the ability to employ ultrasound guidance during the procedure. The individual clinical scenario may dictate laterality in some cases (such as with trauma, head and neck cancer, or the presence of other invasive devices or catheters), but all things being equal, many physicians prefer the right IJ. As compared to the left, the right IJ forms a more direct path to the superior vena cava (SVC) and right atrium. It is also wider in diameter and more superficial, thus presumably easier to cannulate.
Option D: The subclavian vein site has the advantage of low rates of both infectious and thrombotic complications. Additionally, the SC site is accessible in trauma, when a cervical collar negates the choice of the IJ. However, disadvantages include a higher relative risk of pneumothorax, less accessibility to use ultrasound for CVC placement, and the non-compressible location posterior to the clavicle.
FNDNRS-02-009
Nurse Nikki is revising a client’s care plan. During which step of the nursing process does such revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer:D. Evaluation
During the evaluation step of the nursing process, the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
Option A: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option B: The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.
Option C: Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.
FNDNRS-02-010
A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” Which statement would be the nurse’s best response?
A. “The contraction phase of wound healing can take 2 to 3 years.”
B. “Wound healing is very individual but within 4 months the scar should fade.”
C. “With your history and the type of location of the injury, it’s hard to say.”
D. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”
Correct Answer: C. “With your history and the type of location of the injury, it’s hard to say.”
Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information. There is no doubt that diabetes plays a detrimental role in wound healing. It does so by affecting the wound healing process at multiple steps. Wound hypoxia, through a combination of impaired angiogenesis, inadequate tissue perfusion, and pressure-related ischemia, is a major driver of chronic diabetic wounds.
Option A: Ischemia can lead to prolonged inflammation, which increases the levels of oxygen radicals, leading to further tissue injury. Elevated levels of matrix metalloproteases in chronic diabetic wounds, sometimes up to 50-100 times higher than acute wounds, cause tissue destruction and prevent normal repair processes from taking place. Furthermore, diabetes is associated with impaired immunity, with critical defects occurring at multiple points within the immune system cascade of the wound healing process.
Option B: To further complicate matters, these wounds have defects in angiogenesis and neovascularization. Normally, wound hypoxia stimulates mobilization of endothelial progenitor cells via vascular endothelial growth factor (VEGF). In diabetic wounds, there are aberrant levels of VEGF and other angiogenic factors such as angiopoietin-1 and angiopoietin-2 that lead to dysangiogenesis.
Option D: Diabetic neuropathy may also play a role in poor wound healing. Lower levels of neuropeptides, as well as reduced leukocyte infiltration as a result of sensory denervation, have been shown to impair wound healing. When combined, all these diverse factors play a role in the formation and propagation of chronic, debilitating wounds in patients with diabetes.
FNDNRS-02-011
One aspect of implementation related to drug therapy is:
A. Developing a content outline.
B. Documenting drugs given.
C. Establishing outcome criteria.
D. Setting realistic client goals.
Correct Answer:B. Documenting drugs given.
Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
Option A: UE has a common goal with the pharmaceutical care it supports: to improve an individual patient’s quality of life through the achievement of predefined, medication-related therapeutic outcomes. Through its focus on the system of medication use, the MUE process helps to identify actual and potential medication-related problems, resolve actual medication-related problems, and prevent potential medication-related problems that could interfere with achieving optimum outcomes from medication therapy.
Option C: Although distinctions historically have been made among the terms drug-use evaluation, drug-use review, and medication use evaluation (MUE), they all refer to the systematic evaluation of medication use employing standard, observational quality-improvement methods. MUE is a quality-improvement activity, but it also can be considered a formulary system management technique. An MUE is a performance improvement method that focuses on evaluating and improving medication-use processes with the goal of optimal patient outcomes.
Option D: MUE encompasses the goals and objectives of drug use evaluation (DUE) in its broadest application, emphasizing improving patient outcomes. The use of MUE, rather than DUE, emphasizes the need for a more multifaceted approach to improving medication use.
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FNDNRS-02-012
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?
A. A history of increased aspirin use.
B. Recent pelvic surgery.
C. An active daily walking program.
D. A history of diabetes.
Correct Answer: B. Recent pelvic surgery
The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Thrombosis is a protective mechanism that prevents the loss of blood and seals off damaged blood vessels. Fibrinolysis counteracts or stabilizes the thrombosis. The triggers of venous thrombosis are frequently multifactorial, with the different parts of the triad of Virchow contributing in varying degrees in each patient, but all result in early thrombus interaction with the endothelium. This then stimulates local cytokine production and causes leukocyte adhesion to the endothelium, both of which promote venous thrombosis.
Option A: Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. The use of thrombolytic therapy can result in an intracranial bleed, and hence, careful patient selection is vital. Recently endovascular interventions like catheter-directed extraction, stenting, or mechanical thrombectomy have been tried with moderate success.
Option C: Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing post-thrombotic syndrome. The cornerstone of treatment is anticoagulation. NICE guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits.
Option D: In general, diabetes is a contributing factor associated with peripheral vascular disease. In the hospital, the most commonly associated conditions are malignancy, congestive heart failure, obstructive airway disease, and patients undergoing surgery. In the hospital, the most commonly associated conditions are malignancy, congestive heart failure, obstructive airway disease, and patients undergoing surgery.
FNDNRS-02-013
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?
A. Administer sleeping medication before bedtime.
B. Ask the client each morning to describe the quantity of sleep during the previous night.
C. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation.
D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.
Correct Answer:D. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks
The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep is a complex biological process. It is a reversible state of unconsciousness in which there are reduced metabolism and motor activity. Sleep disorders are a group of conditions that disturb the normal sleep patterns of a person. Sleep disorders are one of the most common clinical problems encountered. Inadequate or non-restorative sleep can interfere with normal physical, mental, social, and emotional functioning. Sleep disorders can affect overall health, safety, and quality of life.
Option A: Sleep medication should be avoided whenever possible. Histamine type 1 receptor blockers: due to their sedative effects, these drugs can be helpful in patients with sleep disorders. Benzodiazepines (BZD) are the mainstay in the treatment of insomnia. Non-benzodiazepine hypnotics are used for the treatment of acute and short term insomnia.
Option B: At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail. The sleep diary, or sleep log, is a subjective paper record of sleep and wakefulness over a period of weeks to a month. Patients should record the detailed description of sleep, such as bedtime, duration until sleep onset, the number of awakenings, duration of awakenings, and nap times.
Option C: Relaxation techniques may be implemented before sleep. Meditation and breathing exercises are some of the relaxation techniques. It begins with being in a comfortable position and closing eyes. The mind and thoughts should be redirected towards a peaceful image, and relaxation should be allowed to spread throughout the body.
FNDNRS-02-014
While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?
A. Dry sterile dressing
B. Sterile petroleum gauze
C. Moist, sterile saline gauze
D. Povidone-iodine-soaked gauze
Correct Answer: C. Moist, sterile saline gauze
Moist, sterile saline dressings support would heal and are cost-effective. If the wound is infected and there are a lot of sloughs, which cannot be mechanically debrided, then a chemical debridement can be done with collagenase-based products. The goal is to help the wound heal as soon as possible by using an appropriate dressing material to maintain the right amount of moisture. When the wound bed is dry, use a dressing to increase moisture and if too wet and the surrounding skin is macerated, use material that will absorb excess fluid and protect the surrounding healthy skin.
Option A: Dry sterile dressings adhere to the wound and debride the tissue when removed. Tulle is a non-adherent dressing impregnated with paraffin. It aids healing but doesn’t absorb exudate. It also requires a secondary dressing to hold it in place. It is ideal for burns as one can add topical antibiotics to the dressing. It is known to cause allergies, and this limits its wider use.
Option B: Petroleum supports healing but is expensive. The semipermeable dressing allows for moisture to evaporate and also reduces pain. This dressing also acts as a barrier to prevent environmental contamination. The semipermeable dressing does not absorb moisture and requires regular inspection. It also requires a secondary dressing to hold the semipermeable dressing in place.
Option D: Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound. Plastic film dressings are known to absorb exudate and can be used for wounds with a moderate amount of exudate. They should not be used on dry wounds. They often require a secondary dressing to hold the plastic in place.
FNDNRS-02-015
A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and the provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:
A. Unbundling
B. Overbilling
C. Upcoding
D. Misrepresentation
Correct Answer: C. Upcoding
Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Upcoding is fraudulent medical billing in which a bill sent for a health service is more expensive than it should have been based on the service that was performed. An upcoded bill can be sent to any payer—whether a private health insurer, Medicaid, Medicare, or the patient. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
Option A: Unbundling refers to using multiple CPT codes for those parts of the procedure, either due to misunderstanding or in an effort to increase payment.
Option B: Overbilling (sometimes spelled as over-billing) is the practice of charging more than is legally or ethically acceptable on an invoice or bill.
Option D: A misrepresentation is a false statement of a material fact made by one party which affects the other party’s decision in agreeing to a contract. If the misrepresentation is discovered, the contract can be declared void, and depending on the situation, the adversely impacted party may seek damages.
FNDNRS-02-016
A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality.
B. Provide time for privacy.
C. Provide support for the spouse or significant other.
D. Suggest referral to a sex counselor or other appropriate professional.
Correct Answer:D. Suggest referral to a sex counselor or other appropriate professional
The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
Option A: The nurse doesn’t normally provide sex counseling. The nurse is ideally placed in the primary care field to help ease the upset caused; however, in order to offer care that is effective, insight and understanding of the condition are required as well as the various treatment options available to help men manage their health and wellbeing.
Option B: The key goal of management is to diagnose and treat the cause of ED when this is possible, enabling the man or couple to enjoy a satisfactory sexual experience. This can occur when the nurse has identified and treated any curable causes of ED, initiating lifestyle change and risk factor modification, including drug-related factors, and offering education and counselling to patients and their partners.
Option C: The potential benefits of lifestyle changes (e.g. weight management, smoking cessation) may be particularly important in individuals with ED and specific comorbid cardiovascular or metabolic diseases, such as diabetes or hypertension. As well as improving erectile function, lifestyle changes may also benefit overall cardiovascular and metabolic health. Further studies are needed to clarify the role of lifestyle changes in the management of ED and related cardiovascular disease.
FNDNRS-02-017
Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?
A. Security
B. Elimination
C. Safety
D. Belonging
Correct Answer:B. Elimination
According to Maslow, elimination is a first-level or physiological need and therefore takes priority over all other needs. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals. Maslow’s hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
Option A: Once an individual’s physiological needs are satisfied, the needs for security and safety become salient. People want to experience order, predictability, and control in their lives. These needs can be fulfilled by the family and society (e.g. police, schools, business, and medical care).
Option C: Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. For example, emotional security, financial security (e.g. employment, social welfare), law and order, freedom from fear, social stability, property, health, and wellbeing (e.g. safety against accidents and injury).
Option D: After physiological and safety needs have been fulfilled, the third level of human needs is social and involves feelings of belongingness. The need for interpersonal relationships motivates behavior. Examples include friendship, intimacy, trust, and acceptance, receiving and giving affection and love. Affiliating, being part of a group (family, friends, work).
FNDNRS-02-018
A male client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?
A. Inadequate vitamin D intake.
B. Inadequate protein intake.
C. Inadequate massaging of the affected area.
D. Low calcium level.
Correct Answer:B. Inadequate protein intake.
A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Decubitus ulcers, also termed bedsores or pressure ulcers, are skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body such as the ischium, greater trochanter, sacrum, heel, malleolus (lateral than medial), and occiput. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
Option A: Decubitus ulcer formation is multifactorial (external and internal factors), but all these results in a common pathway leading to ischemia and necrosis. Tissues can sustain an abnormal amount of external pressure, but constant pressure exerted over a prolonged period is the main culprit.
Option C: External pressure must exceed the arterial capillary pressure (32 mmHg) to impede blood flow and must be greater than the venous capillary closing pressure (8 to 12 mmHg) to impair the return of venous blood. If the pressure above these values is maintained, it causes tissue ischemia and further resulting in tissue necrosis. This enormous pressure can be exerted due to compression by a hard mattress, railings of hospital beds, or any hard surface with which the patient is in contact.
Option D: Friction caused by skin rubbing against surfaces like clothing or bedding can also lead to the development of ulcers by contributing to breaks in the superficial layers of the skin. Moisture can cause ulcers and worsens existing ulcers via tissue breakdown and maceration.
FNDNRS-02-019
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery.
B. Deficient fluid volume related to blood and fluid loss from surgery.
C. Impaired physical mobility related to surgery.
D. Risk for aspiration related to anesthesia.
Correct Answer:D. Risk for aspiration related to anesthesia.
Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is believed to be an evolutionary reflex that developed as a method to prevent the aspiration of solid food particles. It is an essential component of evaluating the medullary brainstem and plays a role in the declaration of brain death.The other options, although important, are secondary.
Option A: Postoperative pain can additionally characterize as somatic or visceral. The somatic division of pain is composed of a rich input of nociceptive myelinated, rapidly conducting A-beta-fibers found in cutaneous and deep tissue, which contribute to a more localized, sharp quality. The visceral division of pain is composed of a network of unmyelinated C-fibers and thinly myelinated A-delta-fibers that span across multiple viscera and converge together before entering the spinal cord. Also, visceral afferent fibers run close to autonomic ganglia before their entrance into the dorsal root of the spinal cord. These characteristic features of visceral nociceptive fibers are what contribute to a more diffuse, poorly localized pattern of pain that may be accompanied by autonomic reactions such as a change in heart rate or blood pressure.
Option B: The acid-base and electrolyte changes observed in the perioperative period could be secondary to the underlying illness or surgical procedure, for example, hyponatremia occurring with transurethral resection of the prostate where glycine or other hypotonic fluid is used for irrigation. Serum sodium concentration <120 mmol/L will cause confusion and irritability, whereas <110 mmol/L may cause seizures and coma.
Option C: Complete physiologic recovery takes place by 40 min in 40% of the patients. The functional quality of recovery in all domains occurs in only 11% of the patients by day 3. Thus, the concept of awakening is involved with far greater dimensions than judging the anesthetic effect as terminated and assessing a patient as being “recovered” or “awakened.” Patients cannot be considered fully recovered until they have returned to their preoperative physiological state.
FNDNRS-02-020
The nurse inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:
A. Extravasation
B. Osteomalacia
C. Petechiae
D. Uremia
Correct Answer:C. Petechiae
Petechiae are small hemorrhagic spots. Petechiae are tiny purple, red, or brown spots on the skin. They usually appear on the arms, legs, stomach, and buttocks. They can also be found inside the mouth or on the eyelids. These pinpoint spots can be a sign of many different conditions — some minor, others serious. They can also appear as a reaction to certain medications.
Option A: Extravasation is the leakage of fluid in the interstitial space. Extravasation is the leakage of a fluid out of its container into the surrounding area, especially blood or blood cells from vessels. In the case of inflammation, it refers to the movement of white blood cells from the capillaries to the tissues surrounding them (leukocyte extravasation, also known as diapedesis).
Option B: Osteomalacia is the softening of bone tissue. Osteomalacia refers to a marked softening of the bones, most often caused by severe vitamin D deficiency. The softened bones of children and young adults with osteomalacia can lead to bowing during growth, especially in weight-bearing bones of the legs. Osteomalacia in older adults can lead to fractures.
Option D: Uremia is an excess of urea and other nitrogen products in the blood. Uremia is the condition of having high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess of amino acid and protein metabolism end products, such as urea and creatinine, in the blood that would be normally excreted in the urine.
FNDNRS-02-021
Which document addresses the client’s right to information, informed consent, and treatment refusal?
A. Standard of Nursing Practice
B. Patient’s Bill of Rights
C. Nurse Practice Act
D. Code for Nurses
Correct Answer: B. Patient’s Bill of Rights
The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
Option A: Standards of nursing practice developed by the American Nurses’ Association (ANA) provide guidelines for nursing performance. They are the rules or definition of what it means to provide competent care. The registered professional nurse is required by law to carry out care in accordance with what other reasonably prudent nurses would do in the same or similar circumstances. Thus, provision of high-quality care consistent with established standards is critical.
Option C: Every state and territory in the US set laws to govern the practice of nursing. These laws are defined in the Nursing Practice Act (NPA). The NPA is then interpreted into regulations by each state and territorial nursing board with the authority to regulate the practice of nursing care and the power to enforce the laws.
Option D: The ANA Code of Ethics for Nurses serves the following purposes: It is a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. It is the profession’s nonnegotiable ethical standard. It is an expression of nursing’s own understanding of its commitment to society.
FNDNRS-02-022
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
A. Fail to show changes in blood pressure.
B. Produce a false-high measurement.
C. Cause sciatic nerve damage.
D. Produce a false-low measurement.
Correct Answer: B. Produce a false-high measurement.
Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated.
Option A: Using a blood pressure cuff that’s too large or too small can give inaccurate blood pressure readings. The doctor’s office should have several sizes of cuffs to ensure an accurate blood pressure reading. When one measures their blood pressure at home, it’s important to use the proper size cuff.
Option C: The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
Option D: The inflatable part of the blood pressure cuff should cover about 40% of the distance around (circumference of) the upper arm. The cuff should cover 80% of the area from the elbow to the shoulder.
FNDNRS-02-023
Nurse Elijah has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?
A. Baked beans, hamburger, and milk
B. Spaghetti with cream sauce, broccoli, and tea
C. Bouillon, spinach, and soda
D. Chicken cutlet, spinach, and soda
Correct Answer: A. Baked beans, hamburger, and milk
Baked beans, hamburger, and milk are all excellent sources of protein. Good choices include soy protein, beans, nuts, fish, skinless poultry, lean beef, pork, and low-fat dairy products. Avoid processed meats.
Option B: The spaghetti-broccoli-tea choice is high in carbohydrates. The quality of the carbohydrates (carbs) one eats is important too. Cut processed carbs from the diet, and choose carbs that are high in fiber and nutrient-dense, such as whole grains and vegetables and fruit.
Option C: The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates.
Option D: Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
FNDNRS-02-024
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:
A. Assess the client’s airway.
B. Provide pain relief.
C. Encourage deep breathing and coughing.
D. Splint the chest wall with a pillow.
Correct Answer: A. Assess the client’s airway.
The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Blunt trauma, on the whole, is a more common cause of traumatic injuries and can be equally life-threatening. It is important to know the mechanism as management may be different. Most blunt trauma is managed non-operatively, whereas penetrating chest trauma often requires operative intervention. Pain management and splinting are important for the client’s comfort but would come after airway assessment.
Option B: Pain control greatly affects mortality and morbidity in patients with chest trauma. Pain leads to splints which worsen or prevent healing. In many cases, it can lead to pneumonia. Early analgesia should be considered to decrease splinting. In the acute setting, push doses of short-acting narcotics should be used.
Option C: Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries. Minor injuries may simply require close monitoring and pain control. Care should be taken in the young and the elderly. Patients with 3 or more rib fractures, a flail segment, and any number of rib fractures with pulmonary contusions, hemopneumothorax, hypoxia, or pre-existing pulmonary disease should be monitored at an advanced level of care.
Option D: Immediate life-threatening injuries require prompt intervention, such as emergent tube thoracostomy for large pneumothoraces, and initial management of hemothorax. For cases of hemothorax, adequate drainage is imperative to prevent retained hemothorax. Retained hemothorax can lead to empyema requiring video-assisted thoracoscopic surgery.
FNDNRS-02-025
A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and unproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:
A. Unhappiness about the charge in leadership.
B. Unexpected feelings and emotions among the staff.
C. Fatigue from overwork and understaffing.
D. Failure to incorporate staff in decision making.
Correct Answer:B. Unexpected feelings and emotions among the staff.
The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feelings and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
Option A: Providing employees with acknowledgment of the good work that they have done is one of the easiest management tasks. However, it is also as easily neglected. For instance, a study in the financial sector shows that only 20% of employees feel strongly valued at work.
Option C: Another big issue that causes low productivity is workplace stress. A study by Health Advocate shows that there are about one million employees who are suffering from low productivity due to stress, which costs companies $600 dollars per worker every single year.
Option D: An important reason for low employee productivity might be the fact that they do not feel that they belong with the company that they are part of. It is important for every manager to make sure that the environment in their business is welcoming to new hires and does not make them feel underappreciated.
FNDNRS-02-026
A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?
A. Promote fluid balance
B. Prevent infection
C. Promote rest
D. Prevent injury
Correct Answer: B. Prevent infection
The client is at risk for infection because WBC count is dangerously low. Neutrophils play an essential role in immune defenses because they ingest, kill, and digest invading microorganisms, including fungi and bacteria. Failure to carry out this role leads to immunodeficiency, which is mainly characterized by the presence of recurrent infections. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
Option A: Neutrophils play a role in the immune defense against extracellular bacteria, including Staphylococci, Streptococci, and Escherichia coli, among others. They also protect against fungal infections, including those produced by Candida albicans. Once their count is below 1 x 10/L recurrent infections start. As compensation, the monocyte count may increase.
Option C: Application of granulocyte-colony stimulating factor (G-CSF) can improve neutrophil functions and number. Prophylactic use of antibiotics and antifungals is reserved for some forms of alteration in neutrophil function such as chronic granulomatous disease CGD).
Option D: In primary neutropenia disorders such as chronic granulomatous disease presents with recurrent infections affecting many organs since childhood. It is caused by a failure to produce toxic reactive oxygen species so that the neutrophils can ingest the microorganisms, but they are unable to kill them, as a significant consequence granuloma can obstruct organs such as the stomach, esophagus, or bladder. Patients with this disease are very susceptible to opportunistic infections by certain bacteria and fungi, especially with Serratia and Burkholderia.
FNDNRS-02-027
Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
A. Semi-Fowler’s
B. Supine
C. High-Fowler’s
D. Side-lying
Correct Answer: D. Side-lying
Because of lethargy, the post-tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post-tonsillectomy client and increase the risk of blood aspiration.
Option A: Semi-Fowler’s would not be able to facilitate effective drainage. Bleeding is one of the most common and feared complications following tonsillectomy with or without adenoidectomy. A study from 2009 to 2013 involving over one hundred thousand children showed that 2.8% of children had unplanned revisits for bleeding following tonsillectomy, 1.6% percent of patients came through the emergency department, and 0.8% required a procedure.
Option B: Supine position predisposes the patient to aspiration. Frequency is higher at night with 50% of bleeding occurring between 10pm-1am and 6am-9am; this is thought to be from changes in circadian rhythm, vibratory effects of snoring on the oropharynx, or drying of the oropharyngeal mucosa from mouth breathing. Risk of bleeding in patients with known coagulopathies may be significantly higher.
Option C: Tonsillectomy can be either extracapsular or intracapsular. The “hot” extracapsular technique with monopolar cautery is the most popular technique in the United States.
FNDNRS-02-028
The nurse inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:
A. Anisocoria
B. Ataxia
C. Cataract
D. Diplopia
Correct Answer:A. Anisocoria
Unequal pupils are called anisocoria. Anisocoria, or unequal pupil sizes, is a common condition. The varied causes have implications ranging from life-threatening to completely benign, and a clinically guided history and examination is the first step in establishing a diagnosis.
Option B: Ataxia is uncoordinated actions of involuntary muscle use. Ataxia is a degenerative disease of the nervous system. Many symptoms of Ataxia mimic those of being drunk, such as slurred speech, stumbling, falling, and incoordination. These symptoms are caused by damage to the cerebellum, the part of the brain that is responsible for coordinating movement.
Option C: A cataract is an opacity of the eye’s lens. A cataract is a clouding of the normally clear lens of the eye. For people who have cataracts, seeing through cloudy lenses is a bit like looking through a frosty or fogged-up window. Clouded vision caused by cataracts can make it more difficult to read, drive a car (especially at night) or see the expression on a friend’s face.
Option D: Diplopia is double vision. Diplopia is the perception of 2 images of a single object. Diplopia may be monocular or binocular. Monocular diplopia is present when only one eye is open. Binocular diplopia disappears when either eye is closed.
FNDNRS-02-029
The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:
A. He may have a low threshold for pain.
B. He was faking pain.
C. Someone else gave him medication.
D. The pain went away.
Correct Answer:A. He may have a low threshold for pain.
People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up. Italian females reported the highest sensitivity to both mechanical and electrical stimulation, while Swedes reported the lowest sensitivity. Mechanical pain thresholds differed more across cultures than did electrical pain thresholds. Cultural factors may influence response to type of pain test.
Option B: Our pain threshold is the minimum point at which something, such as pressure or heat, causes us pain. For example, someone with a lower pain threshold might start feeling pain when only minimal pressure is applied to part of their body. Pain tolerance and threshold varies from person to person.
Option C: When we feel pain, nearby nerves send signals to the brain through the spinal cord. The brain interprets this signal as a sign of pain, which can set off protective reflexes. For example, when one touches something very hot, the brain receives signals indicating pain. This in turn can make one quickly pull the hand away without even thinking.
Option D: Biofeedback is a type of therapy that helps increase the awareness of how the body responds to stressors and other stimuli. This includes pain. During a biofeedback session, a therapist will teach the client how to use relaxation techniques, breathing exercises, and mental exercises to override the body’s response to stress or pain.
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FNDNRS-02-030
A female client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurse’s assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:
A. A neck tumor
B. An electrolyte imbalance
C. Dehydration
D. Fluid overload
Correct Answer: D. Fluid overload
Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. JVD is a sign of increased central venous pressure (CVP). That’s a measurement of the pressure inside the vena cava. CVP indicates how much blood is flowing back into the heart and how well the heart can move that blood into the lungs and the rest of the body.
Option A: A neck tumor doesn’t typically cause jugular vein distention. Right-sided heart failure is a common cause. Right-sided heart failure usually develops after a left-sided heart failure. The left ventricle pumps blood out through the aorta to most of the body. The right ventricle pumps blood to the lungs. When the left ventricle’s pumping power weakens, fluid can back up into the lungs. This eventually weakens the right ventricle.
Option B: An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention. The pericardium is a thin, fluid-filled sac that surrounds the heart. An infection of the pericardium, called constrictive pericarditis, can restrict the volume of the heart. As a result, the chambers can’t fill with blood properly, so blood can back up into veins, including the jugular veins.
Option C: Dehydration does not cause JVD. Another common cause is pulmonary hypertension. Pulmonary hypertension occurs when the pressure in your lungs increases, sometimes as a result of changes to the lining of the artery walls. This can also lead to right-sided heart failure.
FNDNRS-02-031
Critical thinking and the nursing process have which of the following in common? Both:
A. Are important to use in nursing practice.
B. Use an ordered series of steps.
C. Are patient-specific processes.
D. Were developed specifically for nursing.
Correct Answer:A. Are important to use in nursing practice.
Nurses make many decisions: some require using the nursing process, whereas others are not client related but require critical thinking. Neither is linear. Critical thinking applies to any discipline. n 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.
Option B: The nursing process has specific steps; critical thinking does not. The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.
Option C: The utilization of the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.
Option D: Critical thinking skills will play a vital role as we develop plans of care for these patient populations with multiple comorbidities and embrace this challenging healthcare arena. Thus, the trend towards concept-based curriculum changes will assist us in the navigation of these uncharted waters.
FNDNRS-02-032
In which step of the nursing process does the nurse analyze data and identify client problems?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
Correct Answer:B. Diagnosis
In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.
Option A: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option C: In the planning outcomes phase, the nurse formulates goals and outcomes. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.
Option D: In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client’s responses to nursing care to determine whether client outcomes were met. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
FNDNRS-02-033
In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client’s health problem?
A. Assessment
B. Diagnosis
C. Planning outcomes
D. Evaluation
Correct Answer:D. Evaluation
During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
Option A: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option B: In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community.
Option C: In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome.
FNDNRS-02-034
What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to:
A. Identify personal biases that may affect his thinking and actions.
B. Identify the most effective interventions for a patient.
C. Communicate more efficiently with colleagues, patients, and families.
D. Learn and remember new procedures and techniques.
Correct Answer: A. Identify personal biases that may affect his thinking and actions.
The most basic reason is that self-knowledge directly affects the nurse’s thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affect all the other nursing actions, it is the most basic reason.
Option B: In philosophy, “self-knowledge” standardly refers to knowledge of one’s own sensations, thoughts, beliefs, and other mental states. At least since Descartes, most philosophers have believed that our knowledge of our own mental states differs markedly from our knowledge of the external world (where this includes our knowledge of others’ thoughts).
Option C: Perhaps the most widely accepted view along these lines is that self-knowledge, even if not absolutely certain, is especially secure, in the following sense: self-knowledge is immune from some types of error to which other kinds of empirical knowledge—most obviously, perceptual knowledge—are vulnerable.
Option D: Self-awareness is important because when we have a better understanding of ourselves, we are able to experience ourselves as unique and separate individuals. We are then empowered to make changes and to build on our areas of strength as well as identify areas where we would like to make improvements.
FNDNRS-02-035
Arrange the steps of the nursing process in the sequence in which they generally occur.
1. Assessment
2. Diagnosis
3. Planning outcomes
4. Planning interventions
5. Evaluation
The correct order is shown above.
Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and evaluation. Keep in mind that steps are not always performed in this order, depending on the patient’s needs, and that steps overlap.
1. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
2. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.
3. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.
4. Implementation is the step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.
5. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.
FNDNRS-02-036
How are critical thinking skills and critical thinking attitudes similar? Both are:
A. Influences on the nurse’s problem solving and decision making.
B. Like feelings rather than cognitive activities.
C. Cognitive activities rather than feelings.
D. Applicable in all aspects of a person’s life.
Correct Answer:A. Influences on the nurse’s problem solving and decision making.
Cognitive skills are used in complex thinking processes, such as problem solving and decision making. Critical thinking attitudes determine how a person uses her cognitive skills. Critical thinking attitudes are traits of the mind, such as independent thinking, intellectual curiosity, intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the cognitive activities used in complex thinking processes. A few examples of these skills involve recognizing the need for more information, recognizing gaps in one’s own knowledge, and separating relevant information from irrelevant data. Critical thinking, which consists of intellectual skills and attitudes, can be used in all aspects of life.
Option B: Critical Thinking is, in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism.
Option C: Critical Thinking is a domain-general thinking skill. The ability to think clearly and rationally is important whenever one chooses to do. But critical thinking skills are not restricted to a particular subject area. Being able to think well and solve problems systematically is an asset for any career.
Option D: A critical thinking attitude is related to the motivation to try to reason well, but it can also motivate an attempt to use various strategies to overcome personal limitations. Additionally, a person with the critical thinking attitude should often rely on the expertise of others rather than to try to assess all arguments on her own because expertise is often required to properly evaluate an argument.
FNDNRS-02-037
The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, “I know I tend to feel negatively about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let it be judgmental of this patient.” This best illustrates:
A. Theoretical knowledge
B. Self-knowledge
C. Using reliable resources
D. Use of the nursing process
Correct Answer:B. Self-knowledge
Personal knowledge is self-understanding—awareness of one’s beliefs, values, biases, and so on. That best describes the nurse’s awareness that her bias can affect her patient care. Self-knowledge refers to knowledge of one’s own mental states, processes, and dispositions. Most agree it involves a capacity for understanding the representational properties of mental states and their role in shaping behavior.
Option A: Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Theoretical knowledge is a knowledge of why something is true. A set of true affirmations (factual knowledge) does not necessarily explain anything. In order to explain something, it is necessary to state why these truths are true. An explanation is required.
Option C: Using reliable resources is a critical thinking skill. Critical thinking is, in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism.
Option D: The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process.
FNDNRS-02-038
Which organization’s standards require that all patients be assessed specifically for pain?
A. American Nurses Association (ANA)
B. State nurse practice acts
C. National Council of State Boards of Nursing (NCSBN)
D. The Joint Commission
Correct Answer: D. The Joint Commission
The Joint Commission has developed assessment standards, including that all clients be assessed for pain.
Option A: The ANA has developed standards for clinical practice, including those for assessment, but not specifically for pain. The American Nurses Association (ANA) is the premier organization representing the interests of the nation’s 4 million registered nurses. ANA is at the forefront of improving the quality of health care for all. Founded in 1896, and with members in all 50 states and U.S. territories, ANA is the strongest voice for the profession.
Option B: State nurse practice acts regulate nursing practice in individual states. An NPA is enacted by state legislation and its purpose is to govern and guide nursing practice within that state. An NPA is actually a law and must be adhered to as law. Each state has a Board of Nursing (BON) that interprets and enforces the rules of the NPA.
Option C: The NCSBN asserts that the scope of nursing includes a comprehensive assessment but does not specifically include pain. National Council of State Boards of Nursing (NCSBN) is an independent, not-for-profit organization through which nursing regulatory bodies act and counsel together on matters of common interest and concern affecting public health, safety and welfare, including the development of nursing licensure examinations.
FNDNRS-02-039
Which of the following is an example of data that should be validated?
A. The urinalysis report indicates there are white blood cells in the urine.
B. The client states she feels feverish; you measure the oral temperature at 98°F.
C. The client has clear breath sounds; you count a respiratory rate of 18.
D. The chest x-ray report indicates the client has pneumonia in the right lower lobe.
Correct Answer: B. The client states she feels feverish; you measure the oral temperature at 98°F.
Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.
Option A: When this test is positive and/or the WBC count in urine is high, it may indicate that there is inflammation in the urinary tract or kidneys. The most common cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI), such as a bladder or kidney infection.
Option C: Breath sounds are the noises produced by the structures of the lungs during breathing. Normal lung sounds occur in all parts of the chest area, including above the collarbones and at the bottom of the rib cage. Using a stethoscope, the doctor may hear normal breathing sounds, decreased or absent breath sounds, and abnormal breath sounds. Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.
Option D: The most common organisms which cause lobar pneumonia are Streptococcus pneumoniae, also called pneumococcus, Haemophilus influenzae and Moraxella catarrhalis. Mycobacterium tuberculosis, the tubercle bacillus, may also cause lobar pneumonia if pulmonary tuberculosis is not treated promptly.
FNDNRS-02-040
Which of the following is an example of appropriate behavior when conducting a client interview?
A. Recording all the information on the agency-approved form during the interview.
B. Asking the client, “Why did you think it was necessary to seek health care at this time?”
C. Using precise medical terminology when asking the client questions.
D. Sitting, facing the client in a chair at the client’s bedside, using active listening.
Correct Answer: D. Sitting, facing the client in a chair at the client’s bedside, using active listening.
Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Nonjudgmental interest in the patient’s problems (active listening), empathy (communicating to the patient an accurate assessment of emotional state), and concern for the patient as a unique person are among the most important tools in the physician’s interpersonal repertoire. The difference between interviewing a patient who is lying flat in bed and one who is sitting in a chair can be striking. This simple act can emphasize patient autonomy and active involvement in the interview.
Option A: Note-taking interferes with eye contact. By recognizing the patient’s emotions and responding to them in a supportive manner, the clinician can conduct an effective patient-centered interview.
Option B: Asking “why” may make the client defensive. Frequently used opening questions include, “What problems brought you to the hospital (or office) today?” or “What kind of problems have you been having recently?” or “What kind of problems would you like to share with me?” These open-ended, nondirective questions encourage the patient to report any and all problems. At this point in the interview it is important to let the patient talk spontaneously rather than restricting and directing the flow of information with multiple questions.
Option C: The client may not understand medical terminology or health care jargon. Questions should be worded so that the patient has no difficulty understanding what is being asked. Avoid using technical terms and diagnostic labels. The interviewer’s questions should indicate what type of information is requested, but not what answer is expected.
FNDNRS-02-041
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to: Select all that apply.
A. A body systems model
B. A head-to-toe framework
C. Maslow’s hierarchy of needs
D. Gordon’s functional health patterns
E. Adaptation Model of Nursing
Correct Answer: C & D
Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and Maslow’s hierarchy is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon’s functional health patterns are a nursing model.
Option A: A body system model is not a nursing model. It is a representation of all the systems of the body in a figurine.
Option B: Head-to-toe framework is not a nursing model, and they are not holistic; they focus on identifying physiological needs or disease.
Option C: Maslow’s hierarchy of needs is a motivational theory in psychology comprising a five-tier model of human needs, often depicted as hierarchical levels within a pyramid. From the bottom of the hierarchy upwards, the needs are: physiological (food and clothing), safety (job security), love and belonging needs (friendship), esteem, and self-actualization.
Option D: Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient.
Option E: The Adaptation Model of Nursing is a prominent nursing theory aiming to explain or define the provision of nursing science. In her theory, Sister Callista Roy‘s model sees the individual as a set of interrelated systems that strives to maintain a balance between various stimuli.
FNDNRS-02-042
The nurse is recording assessment data. She writes, “The patient seems worried about his surgery. Other than that, he had a good night.” Which errors did the nurse make? Select all that apply.
A. Used a vague generality.
B. Did not use the patient’s exact words.
C. Used a “waffle” word (e.g., appears).
D. Recorded an inference rather than a cue.
E. Did not record the patient’s vital signs.
Correct Answer:A, C, D & E
The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Subjective and objective data collection are an integral part of this process.
Option A: The nurse recorded a vague generality: “he has had a good night.” The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.
Option B: The nurse did not use the patient’s exact words, but she did not quote the patient at all, so that is not one of her errors.
Option C: The nurse used the “waffle” word, “seems” worried instead of documenting what the patient said or did to lead her to that conclusion. Asking about how the client feels and their response to those feelings is part of a psychological assessment.
Option D: The nurse recorded these inferences: worried and had a good night. The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider.
Option E: Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition appropriate pain scale.
FNDNRS-02-043
A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing?
A. Ongoing assessment
B. Comprehensive physical assessment
C. Focused physical assessment
D. Psychosocial assessment
Correct Answer:C. Focused physical assessment
The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient. This may involve one or more body systems.
Option A: An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. Repeat of the focused or rapid emergency department assessment of a prehospital patient to detect changes in condition and to judge the effectiveness of treatment before or during transport. Repeated every 5 minutes for an unstable patient and every 15 minutes for a stable patient.
Option B: A comprehensive physical assessment includes an interview and a complete examination of each body system. A comprehensive health assessment gives nurses insight into a patient’s physical status through observation, the measurement of vital signs, and self-reported symptoms. It includes a medical history, a general survey, and a complete physical examination.
Option D: A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.
FNDNRS-02-044
The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment?
A. Sitting upright.
B. Lying flat on the back with knees flexed.
C. Lying flat on the back with arms and legs fully extended.
D. Side-lying with the knees flexed.
Correct Answer: A. Sitting upright.
If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient’s physical condition restricts the comfort or ability of the patient to sit upright.
Option B: Lying flat on the back with knees flexed or supine horizontal recumbent is most commonly used during breast exam.
Option C: Lying flat on the back with arms and legs fully extended can make the patient feel uncomfortable.
Option D: Sim’s position is usually used to obtain rectal temperature.
FNDNRS-02-045
For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
The correct order is shown above.
Inspection begins immediately as the nurse meets the patient, as she observes the patient’s appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered. Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment. During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.
1. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders. Distension of the abdomen could be present due to small bowel obstruction, masses, tumors, cancer, hepatomegaly, splenomegaly, constipation, abdominal aortic aneurysm, and pregnancy.
2. The ideal position for abdominal examination is to sit or kneel on the right side of the patient with the hand and forearm in the same horizontal plane as the patient’s abdomen. There are three stages of palpation that include the superficial or light palpation, deep palpation, and organ palpation and should be performed in the same order. Maneuvers specific to certain diseases are also a part of abdominal palpation.
3. A proper technique of percussion is necessary to gain maximum information regarding the abdominal pathology. While percussing, it is important to appreciate tympany over air-filled structures such as the stomach and dullness to percussion which may be present due to an underlying mass or organomegaly (for example, hepatomegaly or splenomegaly).
4. The last step of the abdominal examination is auscultation with a stethoscope. The diaphragm of the stethoscope should be placed on the right side of the umbilicus to listen to the bowel sounds, and their rate should be calculated after listening for at least two minutes. Normal bowel sounds are low-pitched and gurgling, and the rate is normally 2-5/min. Absent bowel sounds may indicate paralytic ileus and hyperactive rushes (borborygmi) are usually present in small bowel obstruction and sometimes may be auscultated in lactose intolerance.
FNDNRS-02-046
The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient’s rectal area?
A. Sims’
B. Supine
C. Dorsal recumbent
D. Semi-Fowler’s
Correct Answer:A. Sims’
Sims’ position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler’s positions without causing harm to the joint.
Option B: Supine position is lying on the back facing upward. The supine position means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the head, neck and extremities.
Option C: The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. A position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward. It is employed in the application of obstetrical forceps, repair of lesions following parturition, vaginal examination, and bimanual palpation.
Option D: In semi-Fowler’s position, the patient is supine with the head of the bed elevated and legs slightly elevated. The Semi-Fowler’s position is a position in which a patient, typically in a hospital or nursing home is positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle.
FNDNRS-02-047
How should the nurse modify the examination for a 7-year-old child?
A. Ask the parents to leave the room before the examination.
B. Demonstrate equipment before using it.
C. Allow the child to help with the examination.
D. Perform invasive procedures (e.g., otoscopic) last.
Correct Answer: B. Demonstrate equipment before using it.
The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The physical examination is often the first direct contact between the nurse and the child. Establishing a trusting relationship between the child and the examiner is important. Throughout the examination the nurse should be sensitive to the cultural needs of and differences among children. Providing a quiet, private environment for the history and physical examination is important. The classic systematic approach to the physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner tailors the physical assessment to the child’s age and developmental level.
Option A: The nurse should make sure parents are not present during the physical examination of an adolescent, but they usually help younger children feel more secure. To establish trust with the school-age child, the examiner asks the child questions the child can answer. Children in elementary school will talk about school, favorite friends, and activities. Older school-age children may have to be encouraged to talk about their school performance and activities. The examiner encourages the parent to support and reinforce the child’s participation in the examination.
Option C: The nurse should allow a preschooler to help with the examination when possible, but not usually a school-age child. The examination proceeds from head to toe. Children of this age prefer a simple drape over their underpants or a colorful examination gown, and the examiner should be sensitive to the child’s modesty. The examination is a wonderful opportunity to teach the child about the body and personal care. The nurse answers questions openly and in simple terms.
Option D: It is best to perform invasive procedures last for all age groups; therefore, this does not represent a modification. Toddlers are often fearful of invasive procedures, so those should be performed last in this age group.
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FNDNRS-02-048
The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination?
A. Dorsal recumbent
B. Semi-Fowler’s
C. Lithotomy
D. Sims’
Correct Answer: B. Semi-Fowler’s
If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. The Semi–Fowler’s position is a position in which a patient, typically in a hospital or nursing home is positioned on their back with the head and trunk raised to between 15 and 45 degrees, although 30 degrees is the most frequently used bed angle.
Option A: Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed.
Option C: Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient’s legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep the patient covered as much as possible.
Option D: The patient in Sim’s position is on the left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind the body; the right arm is placed comfortably. Sims’ position is used to examine the rectal area. In semi-Fowler’s position, the patient is supine with the head of the bed elevated and legs slightly elevated.
FNDNRS-02-049
The nurse should use the diaphragm of the stethoscope to auscultate which of the following?
A. Heart murmurs
B. Jugular venous hums
C. Bowel sounds
D. Carotid bruits
Correct Answer: C. Bowel sounds
The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen. The diaphragm is best for higher-pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds.
Option A: Earpieces should be angled forwards to match the direction of the practitioner’s external auditory meatus. The bell is used to hear low-pitched sounds. Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure.
Option B: The stethoscope bell is lightly applied in each supraclavicular fossa over the subclavian artery. As usual, the examiner’s free hand palpates the contralateral carotid pulse for timing purposes. If a bruit is appreciated, firmly compress the patient’s ipsilateral radial artery, noting the effect on the murmur.
Option D: If the intensity of sound is greater above the clavicle it is most likely a carotid bruit. If it is louder below the clavicle it is most likely a heart murmur. Use either the bell or the diaphragm when listening for the carotid bruit, at a point just lateral to Adam’s apple.
FNDNRS-02-050
The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician’s office for a college physical. This patient is considered:
A. Obese
B. Overweight
C. Average
D. Underweight
CorrectAnswer: D. Underweight
For adults, BMI should range between 20 and 25. Body mass index (BMI) is a person’s weight in kilograms divided by the square of height in meters. BMI is an inexpensive and easy screening method for the weight category—underweight, healthy weight, overweight, and obesity.
Option A: BMI greater than 30 is considered obese For adults 20 years old and older, BMI is interpreted using standard weight status categories. These categories are the same for men and women of all body types and ages.
Option B: BMI 25 to 29.9 is overweight. The prevalence of adult BMI greater than or equal to 30 kg/m2 (obese status) has greatly increased since the 1970s. Recently, however, this trend has leveled off, except for older women. Obesity has continued to increase in adult women who are 60 years and older.
Option C: BMI less than 20 is considered underweight. BMI can be a screening tool, but it does not diagnose the body fatness or health of an individual. To determine if BMI is a health risk, a healthcare provider performs further assessments. Such assessments include skinfold thickness measurements, evaluations of diet, physical activity, and family history.
FNDNRS-02-051
Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions?
A. Providing a back massage.
B. Feeding a client.
C. Providing hair care.
D. Providing oral hygiene.
Correct Answer:D. Providing oral hygiene
Doing oral care requires the nurse to wear gloves. Standard precautions apply to the care of all patients, irrespective of their disease state. These precautions apply when there is a risk of potential exposure to (1) blood; (2) all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin, and (4) mucous membranes. This includes the use of hand hygiene and personal protective equipment (PPE), with hand hygiene being the single most important means to prevent transmission of disease.
Option A: Must be worn when touching blood, body fluids, secretions, excretions, mucous membranes, or non-intact skin. Change when there is contact with potentially infected material in the same patient to avoid cross-contamination. Remove before touching surfaces and clean items. Wearing gloves does not mitigate the need for proper hand hygiene.
Option B: Hand washing after feeding the client is sufficient. Handwashing with soap and water for at least 40 to 60 seconds, making sure not to use clean hands to turn off the faucet, must be performed if hands are visibly soiled, after using the restroom, or if potential exposure to spore-forming organisms.
Option C: Gloves are not needed in providing hair care. Hand rubbing with alcohol applied generously to cover hands completely should be performed and hands rubbed until dry.
FNDNRS-02-052
The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?
A. Oral
B. Axillary
C. Radial
D. Heat sensitive tape
Correct Answer:B. Axillary
Axilla is the most accessible body part in this situation. Body temperature is a numerical expression of the body’s heat and metabolic activity balance and can be a major indicator of a person’s health status. Assessing a patient’s body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic distress.
Option A: The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin, flexible catheter that has a rounded tip that should be lubricated with water-soluble lubricant before being placed through the nares or mouth, extending into the esophagus at least 2 to 3 in (5 to 7.6 cm). The external end portion of the catheter has a small, coated wire with a plug that can be attached to a telemetry monitor for continuous temperature monitoring.
Option C: The ETP and RTP (rectal temperature probe) are the same device but can be used in either orifice depending on the patient’s medical condition. Again, the tip should be lubricated with water-soluble lubricant, and then placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also be attached to a telemetry monitor cable for continuous temperature monitoring.
Option D: This is a latex-free, disposable, adhesive strip that can be applied to the forehead. These strips contain embedded liquid crystals and chemical compounds that react to the temperature (heat) of the skin by changing colors. After it has been on the forehead for approximately 2 minutes, the color will illuminate a line and correlate numeric temperature. The strips measure temperatures ranging from 96.6[degrees] F to 104.6[degrees] F (35.8[degrees] C to 40.3[degrees] C). Consider use for infants, children, and adults with cognitive deficits because they’re painless.
FNDNRS-02-053
A nurse obtained a client’s pulse and found the rate to be above normal. The nurse document these findings as:
A. Tachypnea
B. Hyperpyrexia
C. Arrhythmia
D. Tachycardia
Correct Answer: D. Tachycardia
Tachycardia means rapid heart rate. Tachycardia refers to a heart rate that’s too fast. How that’s defined may depend on age and physical condition. Generally speaking, for adults, a heart rate of more than 100 beats per minute (BPM) is considered too fast.
Option A: Tachypnea refers to rapid respiratory rate. Tachypnea is a respiration rate greater than normal, resulting in abnormally rapid breathing. In adult humans at rest, any respiratory rate between 12 and 20 breaths is normal and tachypnea is indicated by a rate greater than 20 breaths per minute.
Option B: Hyperpyrexia means increase in temperature. Hyperpyrexia is another term for a very high fever. The medical criterion for hyperpyrexia is when someone is running a body temperature of more than 106.7°F or 41.5°C. Hyperpyrexia is an emergency that needs immediate attention from a medical professional.
Option C: Arrhythmia means irregular heart rate. An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slowly, or with an irregular rhythm. When a heart beats too fast, the condition is called tachycardia. When a heart beats too slowly, the condition is called bradycardia.
FNDNRS-02-054
Which of the following actions should the nurse take to use wide base support when assisting a client to get up in a chair?
A. Bend at the waist and place arms under the client’s arms and lift.
B. Face the client, bend knees, and place hands-on client’s forearm and lift.
C. Spread his or her feet apart.
D. Tighten his or her pelvic muscles.
Correct Answer: B. Face the client, bend knees, and place hands-on client’s forearm and lift.
This is the proper way of supporting the client to get up in a chair that conforms to safety and proper body mechanics. It is important to use proper body mechanics as a health care professional for many reasons, foremost of which is to prevent injuries to both patient and provider. Health care professionals at the front line, especially those who deliver direct care to patients, are often in situations where they have to assist with moving patients from one position to another.
Option A: Keep the back straight throughout the transfer to avoid bending or straining the back. Get as close to the person as possible while still allowing him/her to lean forward as needed to assist with the transfer.
Option C: Allow the patient to help as much as possible. Estimate the patient’s weight and mentally practice. Make sure that the floor is free of any obstacles or liquids. Keep your feet shoulder-width apart. Keep the person (or object) as close to your body as possible. Tighten your stomach muscles.
Option D: Position patients appropriately for transfer. While standing in front of the patient, maintain proper posture with the back straight and knees bent. Hold a strong abdominal contraction. Position the body close to the patient to decrease strain on the back. Before movement, contract the abdominal muscles to protect the back. Use the knees and the lower body during transfer to decrease strain on the back.
FNDNRS-02-055
A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature?
A. Oral
B. Axillary
C. Arterial line
D. Rectal
Correct Answer:B. Axillary
Taking the temperature via the axilla is the most appropriate route. Body temperature is a numerical expression of the body’s heat and metabolic activity balance and can be a major indicator of a person’s health status. Assessing a patient’s body temperature is a common procedure nurses perform to monitor for signs of infection, environmental exposure, shock, ovulation, or therapeutic response to medications or medical procedures. A normal body temperature can be a potentially positive sign that the patient isn’t experiencing a disease process, infection, or trauma and that the body’s cells, tissues, and organs aren’t under metabolic distress.
Option A: Taking the temperature via the oral route is incorrect since the client had oral surgery. The esophageal temperature probe (ETP) is an 18-in (45.7 cm) long, thin, flexible catheter that has a rounded tip that should be lubricated with water-soluble lubricant before being placed through the nares or mouth, extending into the esophagus at least 2 to 3 in (5 to 7.6 cm). The external end portion of the catheter has a small, coated wire with a plug that can be attached to a telemetry monitor for continuous temperature monitoring.
Option C: A PiCCO thermodilution catheter (Pulsion Medical Systems) containing a temperature thermistor was inserted into the brachial artery at the antecubital fossa and doubled as the arterial pressure monitoring line and arterial blood sampling portal. This measured brachial artery temperature from the time of insertion to the time the patient left the operating room.
Option D: This is unnecessary. The ETP and RTP (rectal temperature probe) are the same device but can be used in either orifice depending on the patient’s medical condition. Again, the tip should be lubricated with water-soluble lubricant, and then placed approximately 3 in (7.6 cm) inside the rectal vault. The RTP can also be attached to a telemetry monitor cable for continuous temperature monitoring.
FNDNRS-02-056
A client who is unconscious needs frequent mouth care. When performing mouth care, the best position of a client is:
A. Fowler’s position
B. Side-lying
C. Supine
D. Trendelenburg
Correct Answer:B. Side-lying
An unconscious client is best placed on his side when doing oral care to prevent aspiration. An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration. Oral hygiene is especially important for patients receiving oxygen therapy, patients who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster than normal due to their mouth-breathing.
Option A: A soft toothbrush or gauze-padded tongue blade may be used to clean the teeth and mouth. The patient should be positioned in the lateral position with the head turned toward the side to provide for drainage and to prevent aspiration.
Option C: This is the most common position for surgery with a patient lying on his or her back with head, neck, and spine in neutral positioning and arms either adducted alongside the patient or abducted to less than 90 degrees.
Option D: A variation of supine in which the head of the bed is tilted down such that the pubic symphysis is the highest point of the trunk facilitates venous return and improves exposure during abdominal and laparoscopic surgeries.
FNDNRS-02-057
A client is hospitalized for the first time, which of the following actions ensure the safety of the client?
A. Keep unnecessary furniture out of the way.
B. Keep the lights on at all times.
C. Keep side rails up at all times.
D. Keep all equipment out of view.
Correct Answer:C. Keep side rails up at all time
Keeping the side rails up at all times ensures the safety of the client. The risk of falling increases with age and the number of times someone has been in hospital. During the client’s hospital stay, he may be more unsteady on his feet because of illness or surgery, or because he is unfamiliar with the hospital environment or is taking new medication.
Option A: Home health care providers need to know the risk factors for falls and demonstrate effective assessment and interventions for fall and injury prevention. Falls are generally the result of a complex set of intrinsic patient and extrinsic environmental factors. Use of a fall-prevention program, standardized tools, and an interdisciplinary approach may be effective for reducing fall-related injuries.
Option B: Make sure the client’s pajamas, dressing gown, and day clothes are the right length so they don’t trip over them. Check that their slippers or other footwear fit properly and are not slippery. If they have to wear pressure stockings, wear slippers over them so they do not slip.
Option D: Keep personal items and the call button within reach to avoid standing and walking to get them. Ask for help when in need to get out of bed to use the toilet if not feeling at all unsteady.
FNDNRS-02-058
A walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of the nursing process is being implemented here by the nurse?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer:A. Assessment
Assessment is the first phase of the nursing process where a nurse collects information about the client. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option B: Diagnosis is the formulation of the nursing diagnosis from the information collected during the assessment. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.
Option C: In Planning, the nurse sets achievable and measurable short and long-term goals. The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.
Option D: Implementation is where nursing care is given. Implementation is the step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.
FNDNRS-02-059
It is best described as a systematic, rational method of planning and providing nursing care for individual, families, group, and community
A. Assessment
B. Nursing Process
C. Diagnosis
D. Implementation
Correct Answer: B. Nursing Process
The statement describes the Nursing Process. The Nursing Process is the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.
Option A: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option C: The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community.
Option D: Implementation is the step which involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards.
FNDNRS-02-060
Exchange of gases takes place in which of the following organs?
A. Kidney
B. Lungs
C. Liver
D. Heart
Correct Answer:B. Lungs
Gas exchange is the transport of oxygen from the lungs to the bloodstream and the expulsion of carbon dioxide from the bloodstream to the lungs. It transpires in the lungs between the alveoli and a network of tiny blood vessels called capillaries, which are located in the walls of the alveoli.
Option A: The renal system consists of the kidney, ureters, and urethra. The overall function of the system filters approximately 200 liters of fluid a day from renal blood flow which allows for toxins, metabolic waste products, and excess ions to be excreted while keeping essential substances in the blood. The kidney regulates plasma osmolarity by modulating the amount of water, solutes, and electrolytes in the blood. It ensures long-term acid-base balance and also produces erythropoietin which stimulates the production of red blood cells.
Option C: The liver is a critical organ in the human body that is responsible for an array of functions that help support metabolism, immunity, digestion, detoxification, vitamin storage among other functions. It comprises around 2% of an adult’s body weight. The liver is a unique organ due to its dual blood supply from the portal vein (approximately 75%) and the hepatic artery (approximately 25%).
Option D: The heart is a muscular organ situated in the center of the chest behind the sternum. It consists of four chambers: the two upper chambers are called the right and left atria, and the two lower chambers are called the right and left ventricles. The right atrium and ventricle together are often called the right heart, and the left atrium and left ventricle together functionally form the left heart.
FNDNRS-02-061
The chamber of the heart that receives oxygenated blood from the lungs is the:
A. Left atrium
B. Right atrium
C. Left ventricle
D. Right ventricle
Correct Answer:A. Left atrium
The left atrium receives oxygenated blood from the lungs and pumps it to the left ventricle. In the lungs, the blood oxygenates as it passes through the capillaries where it is close enough to the oxygen in the alveoli of the lungs. This oxygenated blood is collected by the four pulmonary veins, two from each lung. All four of these veins open into the left atrium that acts as a collection chamber for oxygenated blood. Just like the right atrium, the left atrium passes the blood onto its ventricle both by passive flow and active pumping.
Option B: The right atrium receives blood from the veins and pumps it to the right ventricle. The right atrium receives deoxygenated blood from the entire body except for the lungs (the systemic circulation) via the superior and inferior vena cavae. Also, deoxygenated blood from the heart muscle itself drains into the right atrium via the coronary sinus. The right atrium, therefore, acts as a reservoir to collect deoxygenated blood.
Option C: The left ventricle (the strongest chamber) pumps oxygen-rich blood to the rest of the body, its vigorous contractions create the blood pressure. Oxygenated blood thus fills the left ventricle, passing through the mitral valve. The left ventricle, which is the main pumping chamber of the left heart, then pumps, sending freshly oxygenated blood to the systemic circulation through the aortic valve
Option D: The right ventricle receives blood from the right atrium and pumps it to the lungs, where it is loaded with oxygen. The right ventricle pumps blood through the right ventricular outflow tract, across the pulmonic valve, and into the pulmonary artery that distributes it to the lungs for oxygenation.
FNDNRS-02-062
A muscular enlarged pouch or sac that lies slightly to the left which is used for temporary storage of food…
A. Gallbladder
B. Urinary bladder
C. Stomach
D. Lungs
E. Rugae of the stomach
Correct Answer:C. Stomach
The stomach is a muscular organ located on the left side of the upper abdomen. It is a saclike expansion of the digestive tract of a vertebrate that is located between the esophagus and duodenum. The major part of the digestion of food occurs in the stomach.
Option A: The gallbladder is a small hollow organ about the size and shape of a pear. It is a part of the biliary system, also known as the biliary tree or biliary tract. The biliary system is a series of ducts within the liver, gallbladder, and pancreas that empty into the small intestine. There are intrahepatic (within the liver) and extrahepatic (outside of the liver) components. The gallbladder is a component of the extrahepatic biliary system where bile is stored and concentrated.
Option B: The bladder forms an integral part of the genitourinary system. Urine, created by the kidneys, is drained into the bladder by the bilateral ureters. The bladder then acts as the storage site for this waste product until higher-order centers within the central nervous system initiate the micturition (i.e., urination) process, which permits the expulsion of urine into the urethra, located on the inferior aspect of the bladder.
Option D: The purpose of the lung is to provide oxygen to the blood. Anatomically, the lung has an apex, three borders, and three surfaces. The apex lies above the first rib. The function of the lung is to get oxygen from the air to the blood, performed by the alveoli. The alveoli are a single cell membrane that allows for gas exchange to the pulmonary vasculature. There are a couple of muscles that help with inspiration and expiration, such as the diaphragm and intercostal muscles.
Option E. The inner layer of the stomach is full of wrinkles known as rugae (or gastric folds). Rugae both allow the stomach to stretch in order to accommodate large meals and help to grip and move food during digestion.
FNDNRS-02-063
The ability of the body to defend itself against scientific invading agent such as bacteria, toxin, viruses, and foreign body:
A. Hormones
B. Secretion
C. Immunity
D. Glands
Correct Answer:C. Immunity
Immunity is the ability of an organism to resist a particular infection or toxin by the action of specific antibodies or sensitized white blood cells. The Immune response is the body’s ability to stay safe by affording protection against harmful agents and involves lines of defense against most microbes as well as specialized and highly specific responses to a particular offender. This immune response classifies as either innate which is non-specific and adaptive acquired which is highly specific.
Option A: The endocrine hormones are a wide array of molecules that traverse the bloodstream to act on distant tissues, leading to alterations in metabolic functions within the body. They can broadly divide into peptides, steroids, and tyrosine derivatives that may work on either cell surface or intracellular receptors.
Option B: Secretion, in biology, production and release of a useful substance by a gland or cell; also, the substance produced. In addition to the enzymes and hormones that facilitate and regulate complex biochemical processes, body tissues also secrete a variety of substances that provide lubrication and moisture.
Option D: A gland is an organ which produces and releases substances that perform a specific function in the body. There are two types of gland. Endocrine glands are ductless glands and release the substances that they make (hormones) directly into the bloodstream.
FNDNRS-02-064
Hormones secreted by Islets of Langerhans
A. Progesterone
B. Testosterone
C. Insulin
D. Hemoglobin
Correct Answer:C. Insulin
The Islets of Langerhans are the regions of the pancreas that contain its endocrine cells. Insulin is a peptide hormone secreted in the body by beta cells of islets of Langerhans of the pancreas and regulates blood glucose levels. Medical treatment with insulin is indicated when there is inadequate production or increased demands of insulin in the body.
Option A: Progesterone (Choice A) is produced by the ovaries. Progesterone is an endogenous steroid hormone that is commonly produced by the adrenal cortex as well as the gonads, which consist of the ovaries and the testes. Progesterone is also secreted by the ovarian corpus luteum during the first ten weeks of pregnancy, followed by the placenta in the later phase of pregnancy.
Option B: Testosterone (Choice B) is secreted by the testicles of males and ovaries of females. Testosterone is the primary male hormone responsible for regulating sex differentiation, producing male sex characteristics, spermatogenesis and fertility. Testosterone is responsible for the development of primary sexual development, which includes testicular descent, spermatogenesis, enlargement of the penis and testes, and increasing libido.
Option D: Hemoglobin (Choice D) is a protein molecule in the red blood cells that carries oxygen from the lungs to the body’s tissues and returns carbon dioxide. Hemoglobin is an oxygen-binding protein found in erythrocytes which transports oxygen from the lungs to tissues. Each hemoglobin molecule is a tetramer made of four polypeptide globin chains. Each globin subunit contains a heme moiety formed of an organic protoporphyrin ring and a central iron ion in the ferrous state (Fe2+). The iron molecule in each heme moiety can bind and unbind oxygen, allowing for oxygen transport in the body.
FNDNRS-02-065
It is a transparent membrane that focuses the light that enters the eyes to the retina.
A. Lens
B. Sclera
C. Cornea
D. Pupils
Correct Answer: A. Lens
The lens is located in the eye. By changing its shape, the lens changes the focal distance of the eye. In other words, it focuses the light rays that pass through it (and onto the retina) in order to create clear images of objects that are positioned at various distances. It also works together with the cornea to refract, or bend, light. The lens consists of the lens capsule, the lens epithelium, and the lens fibers. The lens capsule is the smooth, transparent outermost layer of the lens, while the lens fibers are long, thin, transparent cells that form the bulk of the lens. The lens epithelium lies between these two and is responsible for the stable functioning of the lens. It also creates lens fibers for the lifelong growth of the lens.
Option B: The sclera is the white part of the eye that surrounds the cornea. In fact, the sclera forms more than 80 percent of the surface area of the eyeball, extending from the cornea all the way to the optic nerve, which exits the back of the eye. Only a small portion of the anterior sclera is visible.
Option C: The cornea is the eye’s clear, protective outer layer. Along with the sclera (the white of your eye), it serves as a barrier against dirt, germs, and other things that can cause damage. The cornea can also filter out some of the sun’s ultraviolet light. It also plays a key role in vision. As light enters the eye, it gets refracted, or bent, by the cornea’s curved edge. This helps determine how well the eye can focus on objects close-up and far away.
Option D: Pupils are the black center of the eye. Their function is to let in light and focus it on the retina (the nerve cells at the back of the eye) so one can see. Muscles located in the iris (the colored part of your eye) control each pupil.
FNDNRS-02-066
Which of the following is included in Orem’s theory?
A. Maintenance of a sufficient intake of air.
B. Self perception.
C. Love and belongingness.
D. Physiologic needs.
Correct Answer: A. Maintenance of a sufficient intake of air.
Dorothea Orem’s Self-Care Theory defined Nursing as “The act of assisting others in the provision and management of self-care to maintain or improve human functioning at home level of effectiveness.” The Self-Care or Self-Care Deficit Theory of Nursing is composed of three interrelated theories: (1) the theory of self-care, (2) the self-care deficit theory, and (3) the theory of nursing systems, which is further classified into wholly compensatory, partial compensatory and supportive-educative. Choices B, C, and D are from Abraham Maslow’s Hierarchy of Needs.
Option B: At the fourth level in Maslow’s hierarchy is the need for appreciation and respect. When the needs at the bottom three levels have been satisfied, the esteem needs begin to play a more prominent role in motivating behavior. At this point, it becomes increasingly important to gain the respect and appreciation of others. People have a need to accomplish things and then have their efforts recognized. In addition to the need for feelings of accomplishment and prestige, esteem needs include such things as self-esteem and personal worth.
Option C: The social needs in Maslow’s hierarchy include such things as love, acceptance, and belonging. At this level, the need for emotional relationships drives human behavior. In order to avoid problems such as loneliness, depression, and anxiety, it is important for people to feel loved and accepted by other people. Personal relationships with friends, family, and lovers play an important role, as does involvement in other groups that might include religious groups, sports teams, book clubs, and other group activities.
Option D: The basic physiological needs are probably fairly apparent—these include the things that are vital to our survival. In addition to the basic requirements of nutrition, air and temperature regulation, the physiological needs also include such things as shelter and clothing. Maslow also included sexual reproduction in this level of the hierarchy of needs since it is essential to the survival and propagation of the species.
FNDNRS-02-067
Which of the following cluster of data belong to Maslow’s hierarchy of needs
A. Love and belonging
B. Physiological needs
C. Self actualization
D. All of the above
Correct Answer:D. All of the above
All of the choices are part of Maslow’s Hierarchy of Needs. Maslow first introduced his concept of a hierarchy of needs in his 1943 paper “A Theory of Human Motivation” and his subsequent book Motivation and Personality. This hierarchy suggests that people are motivated to fulfill basic needs before moving on to other, more advanced needs. As a humanist, Maslow believed that people have an inborn desire to be self-actualized, that is, to be all they can be. In order to achieve these ultimate goals, however, a number of more basic needs must be met such as the need for food, safety, love, and self-esteem.
Option A: The social needs in Maslow’s hierarchy include such things as love, acceptance, and belonging. At this level, the need for emotional relationships drives human behavior. In order to avoid problems such as loneliness, depression, and anxiety, it is important for people to feel loved and accepted by other people. Personal relationships with friends, family, and lovers play an important role, as does involvement in other groups that might include religious groups, sports teams, book clubs, and other group activities.
Option B: The basic physiological needs are probably fairly apparent—these include the things that are vital to our survival. In addition to the basic requirements of nutrition, air and temperature regulation, the physiological needs also include such things as shelter and clothing. Maslow also included sexual reproduction in this level of the hierarchy of needs since it is essential to the survival and propagation of the species.
Option C: At the very peak of Maslow’s hierarchy are the self-actualization needs. “What a man can be, he must be,” Maslow explained, referring to the need people have to achieve their full potential as human beings. According to Maslow’s definition of self-actualization, “It may be loosely described as the full use and exploitation of talents, capabilities, potentialities, etc. Such people seem to be fulfilling themselves and to be doing the best that they are capable of doing. They are people who have developed or are developing to the full stature of which they are capable.”
FNDNRS-02-068
This is characterized by severe symptoms relatively of short duration.
A. Chronic Illness
B. Acute Illness
C. Pain
D. Syndrome
Correct Answer:B. Acute Illness
Acute illnesses are different than chronic illnesses in that they usually develop quickly and they only last a short time – usually a few days or weeks. Acute illnesses are often caused by viral or bacterial infections.
Option A: Chronic Illness (Choice A) are illnesses that are persistent or long-term. A chronic illness is a condition that develops over time and is present for a long period of time. Some people have chronic conditions for many years. Technically, a chronic disease is defined as a health condition that lasts anywhere from three months to a lifetime. Chronic conditions may get worse over time.
Option C: Pain refers to the product of higher brain center processing; it entails the actual unpleasant emotional and sensory experience generated from nervous signals.
Option D: A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek σύνδρομον, meaning “concurrence”.
FNDNRS-02-069
Which of the following is the nurse’s role in health promotion?
A. Health risk appraisal
B. Teach client to be effective health consumer
C. Worksite wellness
D. None of the above
Correct Answer: B. Teach client to be effective health consumer
Nurses play a huge role in illness prevention and health promotion. Nurses assume the role of ambassadors of wellness. The World Health Organization (WHO) defines health promotion as a process of enabling people to increase control over and to improve their health (WHO, 1986). Nurses are best qualified to take on the job of health promoter due to their expertise. There are few health care occupations that have the high level of health education knowledge, skills, theory, and research to be able to focus on prevention because it is considered part of their professional development focus.
Option A: An HRA may be a simple questionnaire eliciting self-reported information on risk factors, behaviors, or diagnoses. Questionnaires may be supplemented with clinical examinations to obtain data on variables such as height, weight, body mass index (BMI), heart rate, or blood pressure. Some HRAs may include performance tests such as grip strength, timed-up-and-go, chair rise, or four-meter walk test.
Option C: Studies show that employees are more likely to be on the job and performing well when they are in optimal health. Benefits of implementing a wellness program include: improved disease management and prevention, and a healthier workforce in general, both of which contribute to lower health care costs.
Option D: One of the most critical roles that nurses have in health promotion and disease preventions is that of an educator. Nurses spend the most time with the patients and provide anticipatory guidance about immunizations, nutrition, dietary, medications, and safety.
FNDNRS-02-070
It is described as a collection of people who share some attributes of their lives.
A. Family
B. Illness
C. Community
D. Nursing
Correct Answer: C. Community
A community is defined by the shared attributes of the people in it, and/or by the strength of the connections among them. When an organization is identifying communities of interest, the shared attribute is the most useful definition of a community.
Option A: In human society, family is a group of people related either by consanguinity (by recognized birth) or affinity (by marriage or other relationship). The purpose of families is to maintain the well-being of its members and of society. Ideally, families would offer predictability, structure, and safety as members mature and participate in the community.
Option B: Illness is a condition of being unhealthy in the body or mind; a specific condition that prevents the body or mind from working normally; a sickness or disease.
Option D: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well, and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people.
FNDNRS-02-071
Five teaspoons is equivalent to how many milliliters (ml)?
A. 30 ml
B. 25 ml
C. 12 ml
D. 22 ml
Correct Answer: B. 25 ml
One teaspoon is equal to 5ml. Drug calculations require the use of conversion factors, for example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows clinicians to work with various units of measurement, converting factors to find the answer. These methods are useful in checking the accuracy of the other methods of calculation, thus acting as a double or triple check.
Option A: 30 ml is equal to 6 teaspoons. When clinicians are prepared and know the key conversion factors, they will be less anxious about the calculation involved. This is vital to accuracy, regardless of which formula or method employed.
Option C: 12 ml is equal to 2.4 teaspoons. Units of measurement must match, for example, milliliters and milliliters, or one needs to convert to like units of measurement.
Option D: 22 ml is equal to 4.4 teaspoons. Medication errors can be detrimental and costly to patients. Drug calculation and basic mathematical skills play a role in the safe administration of medications.
FNDNRS-02-072
1800 ml is equal to how many liters?
A. 1.8
B. 18000
C. 180
D. 2800
Correct Answer: A. 1.8
1,800 ml is equal to 1.8 liters.
Option B: 18000 liters is equal to 18,000,000 ml.
Option C: 180 liters is equal to 180,000 ml.
Option D: 2800 liters is equal to 280,000 ml.
FNDNRS-02-073
Which of the following is the abbreviation of drops?
A. Gtt.
B. Gtts.
C. Dp.
D. Dr.
Correct Answer:B. Gtts.
Gtt (Choice A) is an abbreviation for drop. Dp and Dr are not recognized abbreviations for measurement. Standardization and uniform use of codes, symbols, and abbreviations can improve communication and understanding between health care practitioners, leading to safer and more effective care for patients.
Option A: Appropriate use of abbreviations is particularly important. Numerous studies have focused on health care practitioners’ understanding and interpretation of abbreviations in medical documents, such as medical records, discharge summaries, and medication orders. Findings indicate that it is not uncommon for practitioners to have difficulty understanding the abbreviations used in their hospitals.
Option C: To prevent misunderstandings and potential risks to patient safety, MOI.4 requires hospitals to establish lists for approved and do-not-use abbreviations and monitor for appropriate abbreviation use. There are resources for identifying abbreviations for the do-not-use list, such as the Institute for Safe Medication Practices (ISMP), which publishes a list of dangerous abbreviations not to be used due to frequent misinterpretation and associated medication errors.
Option D: When developing lists, hospitals need to ensure that abbreviations on the approved list are not also on the do-not-use list, and vice versa. In addition, abbreviations can have only one meaning within the entire organization—for example, the abbreviation NKDA could mean “no known drug allergies,” or it could mean “nonketotic diabetic acidosis,” but it cannot have both meanings in an organization.
FNDNRS-02-074
The abbreviation for microdrop is…
A. µgtt
B. gtt
C. mdr
D. mgts
Correct Answer:A. µgtt
The abbreviation for microdrop is µgtt. When abbreviations are used in documents given to the patient, the potential for misunderstanding can increase. Information needs to be clear and unambiguous to improve patients’ comprehension.
Option B: When abbreviations are used in documents given to the patient, the potential for misunderstanding can increase. Information needs to be clear and unambiguous to improve patients’ comprehension.
Option C: As stated in MOI.4, ME 5, “Abbreviations are not used on informed consent and patient rights documents, discharge instructions, discharge summaries, and other documents patients and families receive from the hospital about the patient’s care.”
Option D: No abbreviations of any kind should appear in informed consent documents, patient rights documents, and discharge instructions. These documents are meant for the patient and every effort should be made to increase the readability and clarity of the documents.
FNDNRS-02-075
Which of the following is the meaning of PRN?
A. When advice
B. Immediately
C. When necessary
D. Now.
Correct Answer:C. When necessary
PRN comes from the Latin “pro re nata” meaning, “for an occasion that has arisen or as circumstances require”. When an abbreviation is less known outside of the organization or clinical specialty, it is necessary to spell out the abbreviation throughout the discharge summary to prevent misunderstanding and confusion by the physician or health care organization that receives the summary.
Option A: The practice of spelling out an abbreviation when first mentioned, then using the abbreviation thereafter in the document is acceptable only in discharge summaries. Abbreviations are not to be used in the other types of documents listed in the measurable element.
Option B: Laboratory test results sometimes go to patients, but it is not the intent of the standard for the abbreviations of the laboratory tests to be spelled out. When test results are given to patients, they are shared with their physician who can help explain the results.
Option D: Hospitals may want to consider providing a separate form or resource to patients for information about the tests — such as a handout or website that has the names of common laboratory tests along with their definitions or descriptions. Results of diagnostic imaging studies also go to a patient’s physician, after interpretation by a radiologist.
The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed?
A. Bathe the patient’s entire body using 8 to 10 washcloths.
B. Assist the patient to a chair and provide bathing supplies.
C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and provide a bath chair.
Correct Answer:A. Bathe the patient’s entire body using 8 to 10 washcloths.
A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth.
Option B: A bag bath is not given in a chair or in the tub. The bag bath is one alternative to the traditional bed bath used in some nursing homes. The bath is performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close the door and windows to prevent cold drafts and wash hands with warm water before beginning.
Option C: Moisten the washcloths with water and put in a plastic bag with the cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the temperature of the clothes before touching a resident with them and be careful when you open the bag, as steam can burn.
Option D: Take the bag to the resident’s bedside. When you are not cleaning a body part, keep it covered. Only expose as much of the resident’s body as necessary to adequately clean him or her. Be especially sensitive to exposing genitals, buttocks, and breasts. Bathing can be an extremely stressful experience for residents, so try to make it as easy as possible.
FNDNRS-03-002
For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds?
A. Cover the mattress with a sheepskin.
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
Correct Answer: C. Separate the skin folds with towels.
Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and groins may be ignored, leading to an increased risk of skin breakdown in these areas.
Option A: Sheepskins are not recommended for use at all. Skin folds present a challenge in the management of patients who are morbidly obese. The weight from excess adipose tissue in skinfold areas can have an increased risk of skin injury such as friction, maceration, skin tears and pressure ulcer development.
Option B: Skin folds and areas vulnerable to skin injury should be cleaned and dried several times a day. Alcohol-based lotions and harsh soaps, as well as talcum powders, should be avoided in these areas. If necessary, dry cloths to absorb moisture can be left in skin folds in between washing and drying of the skin folds.
Option D: Petrolatum barrier creams are used to minimize moisture caused by incontinence. Patient hydration should also be considered in the nutrition plan for the patients and the health of their skin.
FNDNRS-03-003
A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
Correct Answer:B. Intact skin
Intact skin is considered a primary defense against infection. Usually, the skin prevents invasion by microorganisms unless it is damaged (for example, by an injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are also effective barriers. Typically, mucous membranes are coated with secretions that fight microorganisms. For example, the mucous membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.
Option A: Body temperature increases as a protective response to infection and injury. An elevated body temperature (fever) enhances the body’s defense mechanisms, although it can cause discomfort. A part of the brain called the hypothalamus controls body temperature. Fever results from an actual resetting of the hypothalamus’s thermostat. The body raises its temperature to a higher level by moving (shunting) blood from the skin surface to the interior of the body, thus reducing heat loss.
Option C: Any injury, including an invasion by microorganisms, causes inflammation in the affected area. Inflammation, a complex reaction, results from many different conditions. During inflammation, the blood supply increases, helping carry immune cells to the affected area. Because of the increased blood flow, an infected area near the surface of the body becomes red and warm. The walls of blood vessels become more porous, allowing fluid and white blood cells to pass into the affected tissue. The increase in fluid causes the inflamed tissue to swell. The white blood cells attack the invading microorganisms and release substances that continue the process of inflammation.
Option D: Lethargy refers to a state of lacking energy. People who are experiencing fatigue or tiredness can also be said to be lethargic because of low energy. The same medical conditions that can lead to tiredness or fatigue can also lead to lethargy.
FNDNRS-03-004
A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions?
A. A clean gown and gloves must be worn when in contact with the client.
B. Everyone who enters the room must wear a N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard waste.
D. Place the client in a room with a client with an upper respiratory infection.
Correct Answer:A. A clean gown and gloves must be worn when in contact with the client.
A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. Visitors might also be asked to wear a gown and gloves. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests.
Option B: A respirator mask is required only with airborne precautions, not contact precautions. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA.
Option C: All linen must be double-bagged and clearly marked as contaminated. When leaving the room, healthcare providers and visitors remove their gown and gloves and clean their hands.
Option D: The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections. Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA.
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FNDNRS-03-005
A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One:
A. Admitted with unstable diabetes mellitus.
B. Who underwent surgical repair of a perforated bowel.
C. With a stage 3 sacral pressure ulcer.
D. Admitted with a urinary tract infection.
Correct Answer: A. Admitted with unstable diabetes mellitus.
The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Protective Isolation aims to protect an immunocompromised patient who is at high risk of acquiring micro-organisms from either the environment or from other patients, staff or visitors.
Option B: Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. Patients should remain in isolation whilst they remain symptomatic; a risk assessment should be undertaken to ascertain if and when isolation precautions can be relaxed.
Option C: A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer. Patient’s requiring protective isolation should be nursed in a single room. Where possible this room should have an ante-room, positive pressure ventilation and Hepa filtered air. The room should have an en-suite and hand washing facilities and the doors(s) should be kept closed at all times.
Option D: A client in protective isolation should not be paired with a client who has a urinary tract infection. Many infections acquired by immunocompromised patients are endogenous infections (An infection caused by an infectious agent that is already present in the body, but has previously been inapparent or dormant), however transmission of infection from other patients, staff or the environment can be a risk and therefore extra precautions are required.
FNDNRS-03-006
A newly hired at NCLEX-Question Medical Center is assigned to the OR Department. Which action demonstrates a break in sterile technique?
A. Remaining 1 foot away from non sterile areas.
B. Placing sterile items on the sterile field.
C. Avoiding the border of the sterile drape.
D. Reaching 1 foot over the sterile field.
Correct Answer: D. Reaching 1 foot over the sterile field.
Reaching over the sterile field while wearing sterile garb breaks the sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from non-sterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. The principles of the Sterile Technique are applied in various ways. If the principle itself is understood, the applications of it become obvious. A strict aseptic technique is needed at all times in the Operating Room.
Option A: Sterile persons avoid leaning over an unsterile area; non-sterile persons avoid reaching over a sterile field. Unsterile persons do not get closer than 12 inches from a sterile field.
Option B: Persons who are sterile touch only sterile articles; persons who are not sterile touch only unsterile articles. If in doubt about the sterility of anything consider it not sterile. If a non-sterile person brushes close consider yourself contaminated.
Option C: Sterile persons keep contact with sterile areas to a minimum. Do not lean on the sterile tables or on the draped patient. Do not lean on the nurse’s mayo tray.
FNDNRS-03-007
Nurse Berta is facilitating a monthly mothers’ class at a small village. As a knowledgeable nurse, she must know that a mother who breastfeeds her child passes on which antibody through breast milk?
A. IgA
B. IgE
C. IgG
D. IgM
Correct Answer:A. IgA
Antibodies, which are also called immunoglobulins, take five basic forms, indicated as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk, but by far the most abundant type is IgA, particularly the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues.
Option B: IgE is a monomer. It has a molecular weight of 188 Kd and a serum concentration of 0.00005 mg/mL. It protects against parasites and also binds to high-affinity receptors on mast cells and basophils causing allergic reactions. IgE is regarded as the most important host defense against different parasitic infections which include Strongyloides stercoralis, Trichinella spiralis, Ascaris lumbricoides, and the hookworms Necator americanus and Ancylostoma duodenale.
Option C: IgG2 forms an important host defense against bacteria that are encapsulated. IgG is the only immunoglobulin that crosses the placentae as its Fc portion binds to the receptors present on the surface of the placenta, protecting the neonate from infectious diseases. IgG is thus the most abundant antibody present in newborns.
Option D: IgMhas a molecular weight of 970 Kd and an average serum concentration of 1.5 mg/ml. It is mainly produced in the primary immune response to infectious agents or antigens. It is a pentamer and activates the classical pathway of the complement system. IgM is regarded as a potent agglutinin (e.g., anti-A and anti-B isoagglutinin present in type B and type A blood respectively) and a monomer of IgM is used as a B cell receptor (BCR).
FNDNRS-03-008
The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove:
A. Transient flora from the skin
B. Resident flora from the skin
C. All microorganisms from the skin
D. Media for bacterial growth
Correct Answer: A. Transient flora from the skin.
There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Hand washing can prevent about 30% of diarrhea-related illnesses and about 20% of respiratory infections (e.g., colds). Antibiotics often are prescribed unnecessarily for these health issues
Option B: Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing.
Option C: Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans, microbes must be able to use the body’s precise balance of food, moisture, nutrients, electrolytes, pH, temperature, and light.
Option D: Food, water, and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms, except perhaps briefly when an antiseptic agent is used for cleansing. Handwashing with soap could protect about 1 out of every 3 young children who get sick with diarrhea and almost 1 out of 5 young children with respiratory infections like pneumonia.
FNDNRS-03-009
Which of the following incidents requires the nurse to complete an occurrence report?
A. Medication given 30 minutes after scheduled dose time.
B. Patient’s dentures lost after transfer.
C. Worn electrical cord discovered on an IV infusion pump.
D. Prescription without the route of administration.
Correct Answer:B. Patient’s dentures lost after transfer
You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. An incident report also provides vital information the facility needs to decide whether restitution should be made—if personal belongings were lost or damaged, for example. Without proper documentation of the incident, there’s no way to make these important decisions effectively.
Option A: A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. An incident report invariably makes its way to risk managers and other administrators, who review it rapidly and act quickly to change any policy or procedure that appears to be a key contributing factor to the incident.
Option C: The worn electrical cord should be taken out of use and reported to the biomedical department. An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, staff member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required.
Option D: The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary. The medical record is patient focused, and facts pertinent to an unexpected incident will likely be left out. So if a claim were filed and the case proceeded to court, which sometimes occurs years after the event, you or anyone else involved might be hard-pressed to recreate the scene—especially if you consider it to be “minor” at the time. You may not be able to rely on memory alone, but you can count on the incident report to refresh your memory.
FNDNRS-03-010
The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting:
A. Separates the health record according to discipline.
B. Organizes documentation around the patient’s problems.
C. Highlights the patient’s concerns, problems, and strengths.
D. Is designed to streamline documentation.
Correct Answer: A. Separates the health record according to discipline
In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Source-oriented (SO) charting is a narrative recording by each member (source) of the health care team charts on separate records. SO charting is time-consuming and can lead to fragmented care. Effective documentation requires the use of common vocabulary; legibility and neatness; the use of only authorized abbreviations and symbols; factual and time-sequenced organization; and accuracy, including any errors that occurred. All documents related to client care are confidential and clients must sign a release to have their information released, specifying what type of information may be released and to whom it may be released.
Option B: Problem-oriented charting organizes notes around the patient’s problems. POMR is a structured, logical format of narrative charting, using “SOAP,” where S means “subjective data,” O means “objective data,” A means assessment data, and P means “plan.” Some institutions add, intervention, E, evaluation, and R, revision, to the SOAP format. POMR is sometimes altered to become a problem-oriented record (POR). The critical components of POMR/POR are the database; the problem list; the initial plan; and the progress notes, based on the SOAP, SOAPIE, or SOAPIER format.
Option C: Focus charting highlights the patient’s concerns, problems, and strengths. Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. It is a method of organizing health information in an individual’s record. Focus Charting is a systematic approach to documentation.
Option D: Charting by exception is a unique charting system designed to streamline documentation. Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.
FNDNRS-03-011
When the nurse completes the patient’s admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding?
A. NA
B. NDA
C. NKA
D. NPO
Correct Answer: C. NKA
The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NKA is the abbreviation for “no known allergies,” meaning no known allergies of any sort. By contrast, NKDA stands exclusively for “no known drug allergies.”
Option A: NA is an abbreviation for not applicable.
Option B: NDA is an abbreviation for no known drug allergies.
Option D: NPO is an abbreviation that means nothing by mouth.
FNDNRS-03-012
The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets:
A. Are comprehensive charting forms that integrate assessments and nursing actions.
B. Contain only graphic information, such as I&O, vital signs, and medication administration.
C. Are used to record routine aspects of care; they do not contain assessment data.
D. Contain vital data collected upon admission, which can be compared with newly collected data.
Correct Answer:A. Are comprehensive charting forms that integrate assessments and nursing actions
Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. A flow sheet is simply a one- or two-page form that gathers all the important data regarding a patient’s condition. The flow sheet is housed in the patient’s chart and serves as a reminder of care and a record of whether care expectations have been met.
Option B: Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. This where records of serial measurements and observations, nursing interventions, and nursing care plans are recorded.
Option C: Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance.
Option D: The admission form contains baseline information. In health care organizations, the EHR, oral reports, handoffs, conferences, and health information technologies (HIT) are intended to facilitate information flow. In particular, the JCAHO specifically conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care.
FNDNRS-03-013
At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take?
A. Complete an occurrence report before leaving.
B. Do nothing; the next nurse will document it was done.
C. Write the note of the dressing change into an earlier note.
D. Make a late entry as an addition to the narrative notes.
Correct Answer: D. Make a late entry as an addition to the narrative notes.
If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed. A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care.
Option A: An occurrence report is not necessary in this case. The issue of completeness is important; Croke cites failure to document as one of the six top reasons that nurses face malpractice suits. In terms of overall completeness, Stokke and Kalfoss found many gaps in nursing documentation in Norway. Care plans, goals, diagnoses, planned interventions, and projected outcomes were absent between 18 percent and 45 percent of the time.
Option B: If documentation is omitted, there is no legal verification that the procedure was performed. Completeness of a record may have an impact on the quality of care, but only if it reflects completeness of the right content. Echoed again here is that document focus, rather than the patient-centric nature of the medical record, does little to support shared understanding by clinicians of care and the communication needed to ensure the continuity, quality, and safety of care.
Option A: An occurrence report is not necessary in this case. The issue of completeness is important; Croke cites failure to document as one of the six top reasons that nurses face malpractice suits. In terms of overall completeness, Stokke and Kalfoss found many gaps in nursing documentation in Norway. Care plans, goals, diagnoses, planned interventions, and projected outcomes were absent between 18 percent and 45 percent of the time.
Option B: If documentation is omitted, there is no legal verification that the procedure was performed. Completeness of a record may have an impact on the quality of care, but only if it reflects completeness of the right content. Echoed again here is that document focus, rather than the patient-centric nature of the medical record, does little to support shared understanding by clinicians of care and the communication needed to ensure the continuity, quality, and safety of care.
Option C: It is illegal to add to a chart entry that was previously documented. The typical content and format of documentation—and its lack of accessibility—have also resulted in document-centric rather than patient-centric records.
FNDNRS-03-014
Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system?
A. It includes organizational reports of unusual occurrences that are not part of the client’s record.
B. This type of system consists of combined documentation and daily care plans.
C. It improves interdisciplinary collaboration that improves efficiency in procedures.
D. This type of system tracks medication administration and usage over 24 hours.
Correct Answer: C. It improves interdisciplinary collaboration that improves efficiency in procedures.
The EHR has several benefits for users, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports The EHR automates access to information and has the potential to streamline the clinician’s workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
Option A: An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. The purpose of the incident report is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident.
Option B: Integrated plans of care (IPOC) are a combined charting and care plan format. It is care that is planned with people who work together to understand the service user and their carer(s), puts them in control and coordinates and delivers services to achieve the best outcomes
Option D: A medication administration record (MAR) is used to document medications administered and their usage. A Medication Administration Record (MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a healthcare professional. The MAR is a part of a patient’s permanent record on their medical chart.
FNDNRS-03-015
In the United States, the first programs for training nurses were affiliated with:
A. The military
B. General hospitals
C. Civil service
D. Religious orders
Correct Answer:D. Religious orders
When the Civil War broke out, the Army used nurses who had already been trained in religious orders. Nursing started with religious orders. The Hindu faith was the first to write about nursing. In the United States, all training for nurses was affiliated with religious orders until after the Civil War.
Option A: Although the Army did provide some training, it occurred later than in the religious orders. Most people think of the nursing profession as beginning with the work of Florence Nightingale, an upper class British woman who captured the public imagination when she led a group of female nurses to the Crimea in October of 1854 to deliver nursing service to British soldiers.
Option B: Although nurses were trained in hospitals, the training and the hospitals were affiliated with religious orders. Upon her return to England, Nightingale successfully established nurse education programs in a number of British hospitals. These schools were organized around a specific set of ideas about how nurses should be educated, developed by Nightingale often referred to as the “Nightingale Principles.”
Option C: Civil service was not mentioned in Chapter 1 and was not a factor in the early 1800s. While Nightingale’s work was ground-breaking in that she confirmed that a corps of educated women, informed about health and the ways to promote it, could improve the care of patients based on a set of particular principles, she was not the first to put these principles into action.
FNDNRS-03-016
Which of the following is/are an example(s) of a health restoration activity? Select all that apply.
A. Administering an antibiotic every day.
B. Teaching the importance of handwashing.
C. Assessing a client’s surgical incision.
D. Advising a woman to get an annual mammogram after age 50 years.
E. Attending rehabilitation of a fractured arm.
Correct Answer: A, C, E
Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client’s surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness.
Option A: Rehabilitation or restoration is defined as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”.
Option B: Disease prevention, understood as specific, population-based, and individual-based interventions for primary and secondary (early detection) prevention, aiming to minimize the burden of diseases and associated risk factors.
Option C: Rehabilitation helps a child, adult, or older person to be as independent as possible in everyday activities and enables participation in education, work, recreation, and meaningful life roles such as taking care of a family. It does so by addressing underlying conditions (such as pain) and improving the way an individual function in everyday life, supporting them to overcome difficulties with thinking, seeing, hearing, communicating, eating, or moving around.
Option D: Secondary prevention deals with early detection when this improves the chances for positive health outcomes (this comprises activities such as evidence-based screening programs for early detection of diseases or for prevention of congenital malformations; and preventive drug therapies of proven effectiveness when administered at an early stage of the disease).
Option E: Rehabilitation is highly person-centered, meaning that the interventions and approach selected for each individual depends on their goals and preferences. Rehabilitation can be provided in many different settings, from inpatient or outpatient hospital settings to private clinics, or community settings such as an individual’s home.
FNDNRS-03-017
Which of the following aspects of nursing is essential to defining it as both a profession and a discipline?
A. Established standards of care
B. Professional organizations
C. Practice supported by scientific research
D. Activities determined by a scope of practice
Correct Answer:C. Practice supported by scientific research
A profession must have knowledge that is based on technical and scientific knowledge. The theoretical knowledge of a discipline must be based on research, so both are scientifically based. The profession of nursing consists of persons educated in the discipline according to nationally regulated, defined, and monitored standards. The standards and regulations are to preserve healthcare safety for members of society. Although the discipline and the profession of nursing have different goals, the raison d’être of nursing is the enhancement of quality of life for humankind. The discipline provides the science lived in the art of practice.
Option A: The American Nurses Association (ANA) has developed standards of care, but they are unrelated to defining nursing as a profession or discipline. Nursing is a discipline and a profession. The goal of the discipline is to expand knowledge about human experiences through creative conceptualization and research. This knowledge is the scientific guide to living the art of nursing. The discipline-specific knowledge is given birth and fostered in academic settings where research and education move the knowledge to new realms of understanding.
Option B: Having professional organizations is not included in accepted characteristics of either a profession or a discipline. The goal of the profession is to provide service to humankind through living the art of science. Members of the nursing profession are responsible for regulation of standards of practice and education based on disciplinary knowledge that reflects safe health service to society in all settings.
Option D: Having a scope of practice is not included in accepted characteristics of either a profession or a discipline. The discipline of nursing encompasses the knowledge in the extant frameworks and theories that are embedded in the totality and simultaneity paradigms (Parse, 1987). These theories and frameworks explicate the nature of nursing’s major phenomenon of concern, the human-universe-health process.
FNDNRS-03-018
The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following?
A. Team nursing
B. Case method nursing
C. Functional nursing
D. Primary nursing
Correct Answer:C. Functional nursing
This medical surgical floor is following the functional nursing model of care, in which care is partitioned and assigned to a staff member with the appropriate skills. For example, the NAP is assigned vital signs, and the LVN is assigned medication administration. Functional nursing is task-oriented in scope. Instead of one nurse performing many functions, several nurses are given one or two assignments. For example, there is a medicine nurse whose sole responsibility is administering medications.
Option A: With team nursing, an RN or LVN is paired with a NAP. The pair is then assigned to render care for a group of patients. Team nursing is a system that distributes the care of a patient amongst a team that is all working together to provide for this person. This team consists of up to 4 to 6 members that has a team leader who gives jobs and instructions to the group.
Option B: In case method nursing, one nurse cares for one patient during her entire shift. Private duty nursing is an example of this care model. The case method is a participatory, discussion-based way of learning where students gain skills in critical thinking, communication, and group dynamics. It is a type of problem-based learning.
Option D: When the primary nursing model is utilized, one nurse manages care for a group of patients 24 hours a day, even though others provide care during part of the day. A method of providing nursing services to inpatients whereby one nurse plans the care of specific patients for a period of 24 hours. The primary nurse provides direct care to those patients when working and is responsible for directing and supervising their care in collaboration with other health care team members.
FNDNRS-03-019
Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be consulted to assess the patient’s risk for aspiration?
A. Respiratory therapist
B. Occupational therapist
C. Dentist
D. Speech therapist
Correct Answer:D. Speech therapist
Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the risk. Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults.
Option A: Respiratory therapists provide care for patients with respiratory disorders. Respiratory therapists interview and examine patients with breathing or cardiopulmonary disorders. Respiratory therapists care for patients who have trouble breathing—for example, from a chronic respiratory disease, such as asthma or emphysema.
Option B: Occupational therapists help patients regain function and independence. Occupational therapists treat injured, ill, or disabled patients through the therapeutic use of everyday activities. They help these patients develop, recover, improve, as well as maintain the skills needed for daily living and working.
Option C: Dentists diagnose and treat dental disorders. Dentists remove tooth decay, fill cavities, and repair fractured teeth. Dentists diagnose and treat problems with patients’ teeth, gums, and related parts of the mouth. They provide advice and instruction on taking care of the teeth and gums and on diet choices that affect oral health.
FNDNRS-03-020
Which of the following is/are an example(s) of theoretical knowledge? Select all that apply.
A. Antibiotics are ineffective in treating viral infections.
B. When you take a patient’s blood pressure, the patient’s arm should be at heart level.
C. In Maslow’s framework, physical needs are most basic.
D. When drawing medication out of a vial, inject air into the vial first.
E. Let the patient dangle his feet first before assisting him to stand or transfer.
Correct Answer: A, C
Theoretical knowledge consists of research findings, facts (e.g., “Antibiotics are ineffective . . .” is a fact), principles, and theories (e.g., “In Maslow’s framework . . .” is a statement from a theory). Instructions for taking blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it. While practical knowledge is gained by doing things, theoretical knowledge is gained, for example, by reading a manual.
Option A: Theoretical knowledge teaches the reasoning, techniques and theory of knowledge.
Option B: Practical knowledge is the knowledge that is acquired by day-to-day hands-on experiences. In other words, practical knowledge is gained through doing things; it is very much based on real-life endeavors and tasks.
Option C: While theoretical knowledge may guarantee that you understand the fundamental concepts and have know-how about how something works and its mechanism, it will only get you so far, as, without practice, one is not able to perform the activity as well as he could.
Option D: Practical knowledge guarantees that you are able to actually do something instead of simply knowing how to do it.
Option E: Theoretical and practical knowledge are interconnected and complement each other — if one knows exactly HOW to do something, one must be able to apply these skills and therefore succeed in practical knowledge.
FNDNRS-03-021
The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?
A. The bladder distends and its capacity increases.
B. Older adults ignore the need to void.
C. Urine becomes more concentrated.
D. The amount of urine retained after voiding increases.
Correct Answer:D. The amount of urine retained after voiding increases
The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained. Muscle changes and changes in the reproductive system can affect bladder control. As the volume of urine held by the bladder increases, so too does the pressure therein. Wall pressure of 5 to 15 mm Hg creates a sensation of bladder fullness while 30 mm Hg and beyond is painful. The sensation of increasing bladder fullness is conveyed to the spinal cord via the pudendal and hypogastric nerves on both A-delta and C nerve fibers.
Option A: The bladder wall changes. The elastic tissue becomes tough and the bladder becomes less stretchy. The bladder cannot hold as much urine as before. The urethra can become blocked. In women, this can be due to weakened muscles that cause the bladder or vagina to fall out of position (prolapse). In men, the urethra can become blocked by an enlarged prostate gland.
Option B: Older adults don’t ignore the urge to void and may have difficulty getting to the toilet in time. Bladder capacity changes throughout one’s life. In children, an approximation of bladder volume can be calculated with the formula: (years of age + 2) x 30 mL. By adulthood, the average volume that a functional bladder can comfortably hold is between 300 and 400 mL.
Option C: The kidney becomes less able to concentrate urine with age. Urination or micturition primarily functions in the excretion of metabolic products and toxic wastes. The urinary tract also serves as a storage vessel of the waste filtered from the kidneys. Urine stored in the bladder is released from the bladder through the urethra upon a complex network of neurological function.
FNDNRS-03-022
During the assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
A. Perineal skin irritation
B. Fluid intake of less than 1,500 mL/d
C. History of antihistamine intake
D. Hx of UTI
E. A fecal impaction
Correct Answer:A, B, D, and E
Urinary incontinence is the involuntary leakage of urine. This medical condition is common in the elderly, especially in nursing homes, but it can affect younger adult males and females as well. Urinary incontinence can impact both patient health and quality of life. The prevalence may be underestimated as some patients do not inform health care providers of having issues with urinary incontinence for various reasons.
Option A: The perineum may become irritated by the frequent contact with urine. Approximately 13 million Americans experience urinary incontinence. The prevalence is 50% or greater among residents of nursing facilities. Caregivers report that 53% of the homebound elderly are incontinent. A random sampling of hospitalized elderly patients reports that 11% of patients have persistent urinary incontinence at admission, and 23% at discharge.
Option B: Normal fluid intake is at least 1,500 mL/d and clients often decrease their intake to try to minimize urine leakage. Functional urinary incontinence is the involuntary leakage of urine due to environmental or physical barriers to toileting. This type of incontinence is sometimes referred to as toileting difficulty.
Option C: Antihistamines can cause urinary retention rather than urinary incontinence. The urethra is the tube that takes urine from the bladder out of the body. The problem can also be caused by using drugs such as antihistamines (like Benadryl®), antispasmodics (like Detrol®), and tricyclic antidepressants (like Elavil®) that can change the way the bladder muscle works.
Option D: UTIs can contribute to incontinence. Patients should be asked about medical conditions such as chronic obstructive pulmonary disease and asthma (which can cause cough), heart failure (with related fluid overload and diuresis), neurologic conditions (which may suggest dysregulated bladder innervation), musculoskeletal conditions (which may contribute to toileting barriers), etc.
Option E: A fecal impaction can compress the urethra, which results in sm. amts of urine leakage. Overflow urinary incontinence is the involuntary leakage of urine from an overdistended bladder due to impaired detrusor contractility and/or bladder outlet obstruction. Neurologic diseases such as spinal cord injuries, multiple sclerosis, and diabetes can impair detrusor function. Bladder outlet obstruction can be caused by external compression by abdominal or pelvic masses and pelvic organ prolapse, among other causes. A common cause in men is benign prostatic hyperplasia.
FNDNRS-03-023
Which action represents the appropriate nursing management of a client wearing a condom catheter?
A. Ensure that the tip of the penis fits snugly against the end of the condom.
B. Check the penis for adequate circulation 30 min after applying.
C. Change the condom every 8 hours.
D. Tape the collecting tube to the lower abdomen.
Correct Answer:B. Check the penis for adequate circulation 30 min after applying
The penis and condom should be checked 1/2 hour after application to ensure that it’s not too tight. and the tubing is taped to the leg or attached to a leg bag. Condom catheters are external urinary catheters that are worn like a condom. They collect urine as it drains out of your bladder and send it to a collection bag strapped to your leg. They’re typically used by men who have urinary incontinence (can’t control their bladder).
Option A: A 1 in. space should be left between the penis and the end of the condom. Place the condom over the tip of the penis and slowly unroll it until it gets to the base. Leave enough room at the tip (1 to 2 inches) so it won’t rub against the condom.
Option C: The condom is changed every 24h. Condom catheters should be replaced every 24 hours. Throw away the old one unless it’s designed to be reusable. The collection bag should be emptied when it’s about half full or at least every three to four hours for a small bag and every eight hours for a large one.
Option D: An indwelling catheter is taped to the lower abdomen or upper thigh. Use a nonadhesive condom catheter to help prevent irritation from adhesive. An inflatable ring holds it in place. Keep the bag lower than the bladder to avoid backflow of urine from the bag. Securely attach the tube to the leg (below the knee, such as the calf), but leave a little slack so it doesn’t pull on the catheter.
FNDNRS-03-024
The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?
A. Leaves the catheter in place and gets a new sterile catheter.
B. Leaves the catheter in place and asks another nurse to attempt the procedure.
C. Removes the catheter and redirects it to the urinary meatus.
D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
Correct Answer:A. Leaves the catheter in place and gets a new sterile catheter.
The catheter in the vagina is contaminated and can’t be reused.If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn’t indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus. Urinary bladder catheterization is performed for both therapeutic and diagnostic purposes. Based on the dwell time, the urinary catheter can be either intermittent (short-term) or indwelling (long-term).
Option B: After exposing the urethral meatus, a lubricated catheter tip is advanced in the meatus until there is a spontaneous return of urine. The catheter balloon is then inflated as per the manufacturer’s recommendations.
Option C: In the event a catheter is inserted in the vagina, it should be left there until a new sterile catheter is successfully inserted into the meatus. Analgesia is of no proven clinical use in women. Lubrication jelly should be applied to the tip of the catheter. The application of lubricant to the urethral meatus is associated with difficulty in catheter insertion.
Option D: Urinary tract infection (UTI) is the most common complication that occurs as a result of long term catheterization. The normal urinary flow prevents the ascension of microbes from the periurethral skin avoiding the infection. Alteration of the defensive mechanism from the catheter results in an increased risk of UTIs. Escherichia coli and Klebsiella pneumonia are the most common organisms implicated in UTIs. Recurrent UTIs are associated with increased antibiotic resistance.
FNDNRS-03-025
Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter?
A. “I will keep the collecting bag below the level of the bladder at all times.”
B. “Intake of cranberry juice may help decrease the risk of infection.”
C. “Soaking in a warm tub bath may ease the irritation associated with the catheter.”
D. “I should use clean tech. when emptying the collecting bag.”
Correct Answer:C. “Soaking in a warm tub bath may ease the irritation associated with the catheter”
Soaking in a bathtub can increase the risk of exposure to bacteria. Avoid taking baths, but shower daily. For the first few days after getting a suprapubic catheter, use a waterproof bandage when showering. Once the wound heals, the client can shower as usual, but avoid scented soaps.
Option A: The bag should be below the level of the bladder to promote proper drainage. Always keep the bag below the waist. Check the tube once in a while for bends or kinks that keep pee from flowing out. Don’t use any lotions or powders around where the catheter goes into the body.
Option B: Intake of cranberry juice creates an environment nonconducive to infection. “Indwelling” means inside the body. This catheter drains urine from the bladder into a bag outside the body. Common reasons to have an indwelling catheter are urinary incontinence (leakage), urinary retention (not being able to urinate), surgery that made this catheter necessary, or another health problem.
Option D: Clean technique is appropriate for touching the exterior portions of the system. Wash hands with soap and water. Empty urine from the bag into the toilet. Pinch the catheter closed between the fingers. Remove the bag. Wipe the end of the catheter with a fresh alcohol pad. Wipe the tip of the new bag with the second alcohol pad. Connect the new bag and stop pinching the catheter now. Make sure there’s no bends or kinks in the catheter tube. Wash hands again.
FNDNRS-03-026
During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate?
A. Stress urinary incontinence
B. Reflex urinary incontinence
C. Functional urinary incontinence
D. Urge urinary incontinence
Correct Answer: D. Urge urinary incontinence
The key phrase is “the urge to void” option one occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. If one feels a strong urge to urinate even when the bladder isn’t full, the incontinence might be related to overactive bladder, sometimes called urge incontinence. This condition occurs in both men and women and involves an overwhelming urge to urinate immediately, frequently followed by loss of urine before the client can reach a bathroom. Even if one never has an accident, urgency and urinary frequency can interfere with work and a social life because of the need to keep running to the bathroom.
Option A: Stress Urinary Incontinence (SUI) is when urine leaks out with sudden pressure on the bladder and urethra, causing the sphincter muscles to open briefly. With mild SUI, pressure may be from sudden forceful activities, like exercise, sneezing, laughing, or coughing.
Option B: Reflex urinary incontinence occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Reflex incontinence occurs when the bladder muscle contracts and urine leaks (often in large amounts) without any warning or urge. This can happen as a result of damage to the nerves that normally warn the brain that the bladder is filling.
Option C: Functional urinary continence is the involuntary loss of urine related to impaired function. If the urinary tract is functioning properly but other illnesses or disabilities are preventing one from staying dry, the client might have what is known as functional incontinence. For example, if an illness rendered the client unaware or unconcerned about the need to find a toilet, the client would become incontinent. Medications, dementia, or mental illness can decrease awareness of the need to find a toilet.
FNDNRS-03-027
A female client has a urinary tract infection. Which teaching points by the nurse should be helpful to the client? Select all that apply.
A. Limit fluids to avoid the burning sensation on urination.
B. Review symptoms of UTI with the client.
C. Wipe the perineal area from back to front.
D. Wear cotton underclothes.
E. Take baths rather than showers.
Correct Answer: B, D
Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated.
Option A: Increased fluids decrease concentration and irritation. An uncomplicated UTI usually only involves the bladder. When the bacteria invade the bladder mucosal wall, cystitis is produced. The majority of organisms causing a UTI are enteric coliforms that usually inhabit the periurethral vaginal introitus. These organisms ascend into the bladder and cause a UTI.
Option B: Reviewing the symptoms of UTI with the client validates the diagnosis. Symptoms of uncomplicated UTI are pain on urination (dysuria), frequent urination (frequency), inability to start the urine stream (hesitation), sudden onset of the need to urinate (urgency), and blood in the urine (hematuria). Usually, patients with uncomplicated UTI do not have fever, chills, nausea, vomiting, or back pain, which are signs of kidney involvement or upper tract disease/pyelonephritis.
Option C: The client should wipe the perineal area from front to back to prevent the spread of bacteria from the rectal area to the urethra. Sexual intercourse is a common cause of a UTI as it promotes the migration of bacteria into the bladder. People who frequently void and empty the bladder have a much lower risk of a UTI.
Option D: Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth. Urine is an ideal medium for bacterial growth; factors that make it unfavorable for bacterial growth include a pH of less than 5, presence of organic acids, and high levels of urea. Frequent urination is also known to decrease the risk of UTI.
Option E: Showers reduce exposure of the area to bacteria. Bacteria that cause UTI have adhesins on their surface which allow the organism to attach to the mucosal surface. In addition, a short urethra also makes it easier for the uropathogen to invade the urinary tract.
FNDNRS-03-028
The nurse will need to assess the client’s performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion?
A. Ileal conduit
B. Kock pouch
C. Neobladder
D. Vesicostomy
Correct Answer: B. Kock pouch
The ileal conduit and vesicostomy are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. In this new operation, a pouch or reservoir is fashioned out of the terminal ileum with a valve mechanism at its exit to the skin surface. This allows storage of the liquid bowel contents in an expandable container with no leakage of stool or gas and therefore no skin problems. There is no need for appliances or bags, no embarrassment from the involuntary noise and smell of flatus through the ileostomy. The stoma is created flush and within the bikini line. The patient catheterizes the pouch on an average of three times a day.
Option A: An ileal conduit aims to divert urine produced from the upper urinary tracts to a newly formed reservoir created from the terminal ileum. The ureters are disconnected from the bladder and implanted into the conduit.
Option C: Clients with a neobladder can control their voiding. During neobladder surgery, the surgeon takes out the existing bladder and forms an internal pouch from part of the intestine. The pouch, called a neobladder, stores the urine.
Option D: A vesicostomy is a stoma (opening) created between the bladder and the abdomen. This allows urine to drain freely, with low pressure, to help protect and prevent harm to the kidneys. It is a surgical procedure that typically involves an overnight stay in the hospital.
FNDNRS-03-029
Which focus is the nurse most likely to teach for a client with a flaccid bladder?
A. Habit training: attempt voiding at specific time periods.
B. Bladder training: delay voiding according to a pre-schedule timetable.
C. Crede’s maneuver: apply gentle manual pressure to the lower abdomen.
D. Kegel exercises: contract the pelvic muscles.
Correct Answer:C. Crede’s maneuver: apply gentle manual pressure to the lower abdomen.
Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination, the process is initiated manually. The Credé maneuver is a technique used to void urine from the bladder of an individual who, due to disease, cannot do so without aid. The Credé maneuver is executed by exerting manual pressure on the abdomen at the location of the bladder, just below the navel. Options one, two, and four: to promote continence bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles.
Option A: One type of toilet training is habit training. Habit training is the process of teaching a child to eliminate on the toilet at routine times. Habit training involves teaching children to eliminate on the toilet by developing a toileting routine/habit.
Option B: Bladder training is an important form of behavior therapy that can be effective in treating urinary incontinence. The goals are to increase the amount of time between emptying your bladder and the amount of fluids your bladder can hold. It also can diminish leakage and the sense of urgency associated with the problem.
Option D: Kegel exercises can help make the muscles under the uterus, bladder, and bowel (large intestine) stronger. They can help both men and women who have problems with urine leakage or bowel control.
FNDNRS-03-030
Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply.
A. Voids each time there is an urge.
B. Practices slow, deep breathing until the urge decreases.
C. Uses adult diapers, for “just in case”.
D. Drinks citrus juices and carbonated beverages.
E. Performs pelvic muscle exercises.
Correct Answer:B, E
It is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Bladder training, a program of urinating on schedule, enables the client to gradually increase the amount of urine the client can comfortably hold. Bladder training is a mainstay of treatment for urinary frequency and overactive bladder in both women and men, alone or in conjunction with medications or other techniques.
Option A: Choose an interval. Based on the typical interval between urinations, select a starting interval for training that is 15 minutes longer. If the typical interval is one hour, make a starting interval one hour and 15 minutes.
Option B: When the client starts training, he should empty his bladder first thing in the morning and not again until the interval he set. If the time arrives before he can feel the urge, he should go anyway. If the urge hits first, he should remind himself that his bladder isn’t really full, and use whatever techniques he can to delay going.
Option C: Some clients may need diapers; this is not the best indicator of a successful program.
Option D: Citrus juices may irritate the bladder. Carbonated beverages increase diuresis and the risk of incontinence.
Option E: Try the pelvic floor exercises sometimes called Kegels, or simply try to wait another five minutes before walking slowly to the bathroom. Once comfortable with a set interval, increase it by 15 minutes. Over several weeks or months, the client may find that they are able to wait much longer and that they have experienced far fewer feelings of urgency or episodes of urge incontinence.
FNDNRS-03-031
A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation?
A. Coughing
B. Mobility deficits
C. Prostate enlargement
D. Urinary tract infection
Correct Answer: C. Prostate enlargement
An enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25-60mL) of urine to escape (overflow incontinence). Men who are unable to completely empty their bladder and experience unexpected urine leakage may have what is called overflow incontinence.
Option A: Coughing, which raises the intra abdominal pressure, is related to stress incontinence, not overflow incontinence. An enlarged prostate can interfere with the passage of urine through the urethra, the tube connected to the bladder.
Option B: Mobility deficits, such as spinal cord injuries, are related to reflex incontinence, not overflow incontinence. Damage to nerves near the bladder causing under-activity. This can occur with neurological injury or with diseases such as diabetes.
Option D: Urinary tract infections are related to urge incontinence, not overflow incontinence. Men with this type of urinary incontinence often do not feel that their bladders are full, which then leads to leakage as the bladder has reached its full capacity. In addition to leakage, urine left in the bladder can lead to urinary tract infections due to the growth of bacteria as well as bladder stones.
FNDNRS-03-032
A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter?
A. Urinal
B. Graduate
C. Large syringe
D. Urine collection bag
Correct Answer:B. Graduate
A graduate is a collection container with volume markings usually at 25 mL increments that promote accurate measurements of urine volume. To measure urine output in critical care units, a Foley catheter is introduced through the patient’s urethra until it reaches his/her bladder. The other end of the catheter is connected to a graduated container that collects the urine.
Option A: Although urinals have volume markings on the side, usually they occur in 100 mL increments that do not promote accurate measurements. Urine output is the best indicator of the state of the patient’s kidneys. If the kidneys are producing an adequate amount of urine it means that they are well perfused and oxygenated. Otherwise, it is a sign that the patient is suffering from some complication.
Option C: Option C is impractical. A large syringe is used to obtain a sterile specimen from a retention catheter (Foley catheter). Urine output is required for calculating the patient’s water balance, which is essential in the treatment of burn patients. Finally, it is also used in multiple therapy protocols to check whether the patient reacts properly to treatment
Option D: A urine collection bag is flexible and balloons outward as urine collects. In addition, the volume markings are at 100 mL increments that do not promote accurate measurements. In critical care units of first world countries, measurements of every patient’s urine output are taken hourly, 24 times a day, 365 days a year. In the case of emerging countries, often only burn patients—for whom urine output monitoring is of paramount importance—have this parameter recorded every hour, while the remaining critical patients have it recorded every 2 or 3 hours.
FNDNRS-03-033
A patient’s urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment?
A. Urinary retention
B. Urinary tract infection
C. Ketone bodies in the urine
D. High urinary calcium level
Correct Answer: B. Urinary tract infection
The urine appears concentrated (amber)and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria). Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnancy. Uncomplicated UTI is also known as cystitis or lower UTI.
Option A: These clinical manifestations do not reflect urinary retention. Urinary retention is evidenced by supra pubic distention and lack of voiding or small, frequent voiding (overflow incontinence). The mechanisms of acute urinary retention can include outflow obstruction, which can be mechanical such as from physical narrowing of the urethral channel. The other dynamic is from an increase in the muscle tone within and around the urethra as in benign prostatic hypertrophy and hyperplasia.
Option C: These clinical manifestations do not reflect ketone bodies in the urine. A reagent strip dipped in urine will measure the presence of Ketone bodies. If the cells don’t get enough glucose, the body burns fat for energy instead. This produces a substance called ketones, which can show up in the blood and urine.
Option D: These clinical manifestations do not reflect excessive calcium in the urine. Urine calcium levels are measured by assessing a 24-hour urine specimen. If urine calcium levels are too high or too low, it may mean that the client has a medical condition, such as kidney disease or kidney stones. Kidney stones are hard, pebble-like substances that can form in one or both kidneys when calcium or other minerals build up in the urine. Most kidney stones are formed from calcium.
FNDNRS-03-034
A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient’s needs?
A. Encouraging the use of bladder training exercises.
B. Providing assistance with toileting every four hours.
C. Positioning a bedside commode near the bed.
D. Teaching the avoidance of fluid after 5 PM.
Correct Answer: C. Positioning a bedside commode near the bed.
The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on the commode uses gravity to empty the bladder fully and thus prevent urinary stasis. Nocturia is defined as the need for a patient to get up at night on a regular basis to urinate. A period of sleep must precede and follow the urinary episode to count as a nocturnal void. This means the first-morning void is not considered when determining nocturia episodes. Use of a bedside commode or urinal can minimize the bother, if not the frequency, of nocturia and may reduce the risk of falls. Remove any obstacles, loose rugs, or furniture between the bed and the nearest commode to reduce fall risk further. Consider using nightlights to help illuminate the passage to the bathroom.
Option A: Although bladder training exercises should be done, it is not the priority. Behavioral therapy, which includes pelvic floor muscle training, urge-suppression techniques, delayed voiding, fluid management, sleep hygiene, Kegel exercises, and peripheral edema management, has been shown to be reasonably efficacious both when used alone or together with pharmacological therapy in controlling nocturia.
Option B: Assisting with toileting may be too often or not often enough for the patient. Care should be individualized for the patient. In particular, older adults with nocturia who make multiple nocturnal trips to the bathroom are at a substantially increased risk of potentially serious falls. A quarter of all the falls that occur in older individuals happen overnight. Of these, 25% are directly related to nocturia. Patients who make at least 2 or more nocturnal bathroom visits a night, have more than double the risk of fractures and fall-related traumas.
Option D: Fluids may be decreased during the last two hours before bedtime, but they should not be avoided completely after 5 PM (opt4). Some fluid intake is necessary for adequate renal perfusion. Drinking large amounts of fluids shortly before going to bed and ingesting caffeine or alcohol late in the day and before bed is likely to contribute to nocturia as well. Be aware that some elderly patients may already be somewhat dehydrated and might require extra fluid intake earlier in the day before they can safely do any evening fluid restriction before bedtime.
FNDNRS-03-035
A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen?
A. Use a sterile specimen container.
B. Collect urine from the catheter port.
C. Inflate the balloon with 10 mL of sterile water.
D. Have the patient void before collecting the specimen.
Correct Answer: A. Use a sterile specimen container.
A culture attempts to identify the microorganisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against the isolated microorganisms. A sterile specimen container is used to prevent contamination of the specimen by microorganisms outside the body (exogenous).
Option B: The urine from the straight catheter flows directly into the specimen container. Collecting a urine specimen from a catheter port is necessary when the patient has a urinary retention catheter. A straight catheter has a single lumen for draining urine from the bladder.
Option C: A straight catheter does not remain in the bladder and therefore does not have a 2nd lumen for water to be inserted into a balloon. This may result in no urine left in the bladder for the straight catheter to collect.
Option D: A minimum of 3 mL of urine is necessary for a specimen for urine culture and sensitivity. Do not urinate for at least 1 hour before the test. If the client doesn’t have the urge to urinate, he may be instructed to drink a glass of water 15 to 20 minutes before the test. Otherwise, there is no preparation for the test.
FNDNRS-03-036
A nurse in a provider’s office is assessing a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to control or eliminate the clients incontinence? Select all that apply.
A. Limit total daily fluid intake
B. Decrease or avoid caffeine
C. Increase the intake of calcium supplements
D. Avoid the intake of alcohol
E. Use Crede maneuver
Correct Answer:B and D
Caffeine and alcohol are bladder irritants and can worsen stress incontinence. Alcohol is a bladder irritant and can worsen stress incontinence. Quitting smoking, losing excess weight or treating a chronic cough will lessen the risk of stress incontinence and improve the symptoms. Stress incontinence is different from urgency incontinence and overactive bladder (OAB). If the client has urgency incontinence or OAB, the bladder muscle contracts, causing a sudden urge to urinate before he can get to the bathroom. Stress incontinence is much more common in women than in men.
Option A: Because stress incontinence results from weak pelvic muscles and other structures, limiting fluid will not resolve the problem. The doctor may recommend how much and when one should consume fluids during the day and evening. However, don’t limit what the client drinks so much that he becomes dehydrated.
Option B: Lifestyle changes should be made such as reducing caffeine intake (including green tea), stopping smoking and losing weight.
Option C: Calcium has no effect on stress incontinence. Bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course usually lasts for at least six weeks and can be combined with the Kegel exercises. Some individuals may find that timed toileting is helpful, particularly people with a learning disability or cognitive impairment.
Option D: The doctor may also suggest that the client avoid caffeinated, carbonated and alcoholic beverages, which may irritate and affect bladder function in some people. If he finds that using fluid schedules and avoiding certain beverages significantly improve leakage, the client’ll have to decide whether making these changes in the diet are worth it.
Option E: The Crede maneuver helps manage reflex incontinence, not stress incontinence. Pelvic floor muscle training is a technique that strengthens the pelvic floor muscles and is an effective treatment for stress incontinence, especially if the muscle has been damaged.
FNDNRS-03-037
A client who has an indwelling catheter reports the need to urinate. Which of the following interventions should the nurse perform?
A. Check to see whether the catheter is patent.
B. Reassure the client that it is not possible for her to urinate.
C. Re-catheterize the bladder with a larger gauge catheter.
D. Collect a urine specimen for analysis.
Correct Answer:A. Check to see whether the catheter is patent.
A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate. An indwelling urinary catheter (IUC), generally referred to as a “Foley” catheter, is a closed sterile system with a catheter and retention balloon that is inserted either through the urethra or suprapubically to allow for bladder drainage. External collecting devices (e.g. drainage tubing and bag) are connected to the catheter for urine collection.
Option B: Reassuring the client that it is not possible to urinate is a non-therapeutic response because it diminishes the client’s concern. Check the tube once in a while for bends or kinks that keep pee from flowing out. Empty the leg bag twice a day or when it’s half full. Keep the drainage bag below your bladder so it drains well.
Option C: There are less invasive approaches the nurse can take before replacing the catheter. Indwelling urinary catheters are recommended only for short-term use, defined as less than 30 days (EAUN recommends no longer than 14 days.) The catheter is inserted for continuous drainage of the bladder for two common bladder dysfunction: urinary incontinence (UI) and urinary retention.
Option D: Although it may become necessary to collect a urine specimen, there is a simpler approach the nurse can take to assess and possibly resolve the client’s problem.
FNDNRS-03-038
A provider prescribes a 24 hour urine collection for a client. Which of the following actions should the nurse take?
A. Discard the first voiding.
B. Keep all voidings in a container at room temperature.
C. Ask the client to urinate and pour the urine into a specimen container.
D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
Correct Answer:A. Discard the first voiding.
The nurse should discard the first voiding of the 24 hour urine specimen, and note the time. 24-hour urine protein measures the amount of protein released in urine over a 24-hour period. The normal value is less than 100 milligrams per day or less than 10 milligrams per deciliter of urine.
Option B: The nurse should collect all voidings after that and keep them in a refrigerated container. A 24-hour urine collection is done by collecting the urine in a special container over a full 24-hour period. The container must be kept cool until the urine is returned to the lab.
Option C: For a urinalysis, the nurse should ask the client to urinate and pour the urine into a specimen container. Urine is made up of water and dissolved chemicals, such as sodium and potassium. It also contains urea. This is made when protein breaks down. And it contains creatinine, which is formed from muscle breakdown. Normally, urine contains certain amounts of these waste products. It may be a sign of a certain disease or condition if these amounts are not within a normal range. Or if other substances are present.
Option D: For a culture, the nurse should ask the client to urinate first into the toilet, then stop midstream, and finish urinating in the specimen container. A 24-hour urine collection helps diagnose kidney problems. It is often done to see how much creatinine clears through the kidneys. It’s also done to measure protein, hormones, minerals, and other chemical compounds.
FNDNRS-03-039
A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? Select all that apply.
A. Establish a schedule of voiding prior to meal times.
B. Have the client record voiding times.
C. Gradually increase the voiding intervals.
D. Reminded client to hold urine until next scheduled voiding time.
E. Provide a sterile container for voiding.
Correct Answer:B, C, and D
Ask the client to keep track of voiding times is an appropriate nursing action. Gradually increasing the voiding interval is an appropriate nursing action. The client should be reminded to hold urine until the next scheduled voiding time. Bladder training involves voiding at scheduled in frequent intervals and gradually increasing these intervals to four hours.
Option A: Mealtimes are not regular, and the intervals may be longer than every four hours. Bladder training requires following a fixed voiding schedule, whether or not one feels the urge to urinate. If one feels an urge to urinate before the assigned interval, he should use urge suppression techniques — such as relaxation and Kegel exercises.
Option B: Keeping a diary of bladder activity is very important. This helps the health care provider determine the correct place to start the training and to monitor progress throughout the program.
Option C: Bladder training is an important form of behavior therapy that can be effective in treating urinary incontinence. The goals are to increase the amount of time between emptying the bladder and the amount of fluids the bladder can hold. It also can diminish leakage and the sense of urgency associated with the problem.
Option D: When the client feels the urge to urinate before the next designated time, he should use “urge suppression” techniques or try relaxation techniques like deep breathing. Focus on relaxing all other muscles. If possible, he must sit down until the sensation passes. If the urge is suppressed, adhere to the schedule. If the client cannot suppress the urge, wait five minutes then slowly make way to the bathroom. After urinating, re-establish the schedule. Repeat this process every time an urge is felt.
Option E: A sterile container is not used in a bladder training program. When the client has accomplished the initial goal, he should gradually increase the time between emptying the bladder by 15-minute intervals. He should try to increase the interval each week. However, he will be the best judge of how quickly he can advance to the next step. Increase the time between each urination until he reaches a three- to four-hour voiding interval.
FNDNRS-03-040
A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections with a group of assistive personnel. Which of the following should be included in the review? Select all that apply.
A. Having sexual intercourse on a frequent basis.
B. Lowering of testosterone levels.
C. Wiping from front to back.
D. The location of the vagina in relation to the anus.
E. Undergoing frequent catheterization.
Correct Answer: A, D, and E
Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. E.coli causes the majority of UTI but other organisms of importance include proteus, klebsiella, and enterococcus. The diagnosis of UTI is made from the clinical history and urinalysis, but the proper collection of the urine sample is important.
Option A: Having sexual intercourse on a frequent basis is a factor that increases the risk of UTI in both males and females. Sexual intercourse and the use of spermicide and diaphragm are also risk factors for UTI. Sexual intercourse is a common cause of a UTI as it promotes the migration of bacteria into the bladder. People who frequently void and empty the bladder have a much lower risk of a UTI.
Option B: The decrease in estrogen levels during menopause increases a woman’s susceptibility to UTIs. An uncomplicated UTI usually only involves the bladder. When the bacteria invade the bladder mucosal wall, cystitis is produced. The majority of organisms causing a UTI are enteric coliforms that usually inhabit the periurethral vaginal introitus. These organisms ascend into the bladder and cause a UTI.
Option C: Wiping from front to back decreases a woman’s risk of UTIs. After urination, women should wipe from front to back, not from the anal area forward, which seems to drag pathogenic organisms nearer to the urethra. Bacteria that cause UTI have adhesins on their surface which allow the organism to attach to the mucosal surface. In addition, a short urethra also makes it easier for the uropathogen to invade the urinary tract. Premenopausal women have large concentrations of lactobacilli in the vagina and prevent the colonization of uropathogens. However, the use of antibiotics can erase this protective effect.
Option D: The close proximity of the female urethra to the anus is a factor that increases the risk of UTIs. Pathogenic bacteria ascend from the perineum, causing UTI. Women have shorter urethras than men and therefore are more susceptible to UTI. Very few uncomplicated UTIs are caused by blood-borne bacteria. Escherichia coli is the most common organism in uncomplicated UTI by a large margin.
Option E: Undergoing frequent catheterization and the use of indwelling catheters are risk factors for UTIs. A major risk factor for UTI is the use of a catheter. In addition, manipulation of the urethra is also a risk factor. In-and-out catheterization of the bladder will cause UTI in uninfected women 1% of the time. Men should start the urine stream to clean the urethra and then obtain a midstream sample. Urine should be sent to the lab immediately or refrigerated because bacteria grow rapidly when a sample is left at room temperature, causing an overestimate of the infection’s severity.
FNDNRS-03-041
To prevent postoperative complications, Nurse Kim assists the client with coughing and deep breathing exercises. This is best accomplished by implementing which of the following?
A. Coughing exercises one hour before meals and deep breathing one hour after meals.
B. Forceful coughing as many times as tolerated.
C. Huff coughing every two hours or as needed.
D. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day.
Correct Answer: C. Huff coughing every two hours or as needed.
Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (such as postoperatively) deep breathing and coughing should be performed at the same time.
Option A: Only at mealtimes is not sufficient. Deep breathing and coughing exercises can decrease the risk of lung complications following surgery. Not only can they prevent pneumonia, deep breathing helps to get more oxygen to the body’s cells. These exercises can also be beneficial to individuals who are susceptible to pulmonary or respiratory problems. Coughing and deep breathing work to clear mucus and allow moist air to enter the airways.
Option B: Extended forceful coughing fatigues the client, especially postoperatively. If you are lying in bed and need to cough, it may be more comfortable to bend your knees up. Lean forward when you cough, if you are sitting in a chair. Place a pillow over your surgical incision and apply pressure to the area while coughing. This can help to alleviate any discomfort you feel. It’s more comfortable to sit upright if you can when doing coughing exercises.
Option D: Diaphragmatic and pursed lip breathing are techniques used for clients with obstructive airway disease. You can perform breathing exercises by relaxing your shoulders and upper chest. Take a deep breath in through your nose. Hold the breath for three seconds. Breathe out slowly through your mouth. Repeat three times. Taking too many breaths can make you dizzy or light-headed. Perform breathing exercises every hour.
FNDNRS-03-042
Nurse Trixie is preparing to perform tracheostomy care. Prior to the beginning of the procedure, the nurse performs which action?
A. Tells the client to raise two fingers to indicate pain or distress.
B. Changes twill tape holding the tracheostomy and place.
C. Cleans the incision site.
D. Check the tightness of the ties and knot.
Correct Answer:A. Tells the client to raise two fingers to indicate pain or distress.
Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. Tracheostomy is a procedure where an artificial airway is established surgically or percutaneously in the cervical trachea. The term “tracheostomy” has evolved to refer to both the procedure as well as the clinical condition of having a tracheostomy tube. With the increasing number of patients with tracheostomy, safe caring requires knowledge and competencies in dealing with routine care, weaning, decannulation, as well as tracheostomy-related emergencies.
Option B: The twill tape is not changed until after performing tracheostomy care. Remove any sutures or ties attached to the tracheostomy tube and patient. When doing this, the assistant must stabilize the flange at all times to prevent premature removal.
Option C: Cleaning the incision should be done after cleaning the inner cannula. Inspect the stoma for signs of infection, presence of granulation tissue, bleeding, wound breakdown, and adequacy of a tract. Clean the area with moist gauze (with normal saline or hydrogen peroxide) followed by dry gauze while ensuring no foreign body enters the airway. Stay sutures, if present, may be used gently to pull up the trachea to provide exposure.
Option D: Checking the tightness of the ties and knot is done after applying new twill tape. Make sure the trach ties are not too tight and should be able to pass an index finger in between the trach ties and neck.
FNDNRS-03-043
Which action by the nurse represents proper nasopharyngeal/nasotracheal suctioning technique?
A. Lubricate the suction catheter with petroleum jelly before and between insertion.
B. Apply suction intermittently while inserting the suction catheter.
C. Rotate the catheter while applying suction.
D. Hyper oxygenate with 100% oxygen for 30 minutes before and after suctioning.
Correct Answer:C. Rotate the catheter while applying suction.
Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and the side. Suction is used to clear retained or excessive lower respiratory tract secretions in patients who are unable to do so effectively for themselves. This could be due to the presence of an artificial airway, such as an endotracheal or tracheostomy tube, or in patients who have a poor cough due to an array of reasons such as excessive sedation or neurological involvement.
Option A: Suction catheters may only be lubricated with water or water-soluble lubricant and petroleum jelly such as Vaseline has an oil base. Lubricate the outside of the airway with a water-soluble/aqueous gel (e.g. KY Jelly). Initially, choose the larger nostril that is clear from other tubes (e.g. nasogastric tube). Insert the tip of the NPA into the nostril, then slightly lift the nares up and direct the airway to follow a path along the floor of the nose, parallel to the hard palate.
Option B: No suction should ever be applied while the catheters are being inserted because this can traumatize tissues. Apply a gentle partial rotation to the NPA if resistance is felt during insertion e.g. from opposition against the turbinates. If this does not relieve the resistance/obstruction then withdraw the airway and try the other nostril before selecting a smaller size.
Option D: The client should be hyper-oxygenated for only a few minutes before and after suctioning and this is generally limited to clients who are intubated or have a tracheostomy. Hyper-oxygenate the patient if able (increase mask flow rate or FiO2) delivery of 100% oxygen for > 30 secs prior to the suction event.
FNDNRS-03-044
Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?
A. “I should breathe out as fast and as hard as possible into the device.”
B. “I should inhale slowly and steadily to keep the balls up.”
C. “I should use the device three times a day, after meals.”
D. “The entire device should be washed thoroughly in sudsy water once a week.”
Correct Answer:B. “I should inhale slowly and steadily to keep the balls up.”
Proper use of an SMI requires the client to take slow, steady inhalations, every hour or two, 5 to 10 reps each time. Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation. The most important variables reported include total exhaled volume, known as the forced vital capacity (FVC), the volume exhaled in the first second, known as the forced expiratory volume in one second (FEV1), and their ratio (FEV1/FVC).
Option A: The patient must breathe in as much air as they can with a pause lasting for less than 1s at the total lung capacity. The mouthpiece is placed just inside the mouth between the teeth, soon after the deep inhalation. The lips should be sealed tightly around the mouthpiece to prevent air leakage. Exhalation should last at least 6 seconds, or as long as advised by the instructor. If only the forced expiratory volume is to be measured, the patient must insert the mouthpiece after performing step 1 and must not breathe from the tube.
Option C: The procedure is repeated in intervals separated by 1 minute until two matching, and acceptable results are acquired. Spirometry has proved to be a crucial tool in diagnosing lung disease, monitoring patients for their pulmonary function, and assessing their fitness for various procedures.
Option D: Only the mouthpiece can be successfully rinsed or wiped clean. The device should not be submerged in water. Spirometry is an apparatus used to assess pulmonary function for diagnostic or monitoring purposes. The procedure must be explained thoroughly to the subject patient by competent personnel who underwent training under supervision by a specialist mentor and will undergo periodic retraining in order to ensure that the results obtained are as accurate as possible and the complications are kept to a minimum.
FNDNRS-03-045
While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by Nurse Flora is most appropriate?
A. Assist the client to ambulate back to bed.
B. Reconnect the tube to the water seal.
C. Assess the client’s lung sounds with a stethoscope.
D. Have the client cough forcibly several times.
Correct Answer:B. Reconnect the tube to the water seal.
The tube should be reconnected to the water seal as quickly as possible. Assisting the client back to bed and assessing the client’s lung are possible actions after the system is reconnected. Or place the end of the tube in a bottle of sterile water, creating a water seal. Instruct a colleague to prepare a new sterile chest-drainage collection device, or retrieve a new sterile connector while safely returning the patient to bed. Observe the patient for signs and symptoms of respiratory decline. Then reconnect the chest tube to the new drain and unclamp it.
Option A: If walking with the patient and the chest tube becomes dislodged where it connects to the drainage tubing, immediately close off the tubing to air with a gloved hand by crimping it or using a clamp, if readily available.
Option C: Whether chest-tube removal was planned or unplanned, monitor the patient closely for signs and symptoms of respiratory compromise, using such techniques as pulse oximetry (Spo2), end-tidal carbon dioxide (ETco2) monitoring, and breath sound auscultation.
Option D: Monitor the patient’s respiratory rate and effort. A repeat chest X-ray (if indicated) may be done to compare to previous films and evaluate for presence or return of a pneumothorax, an effusion, or other problem.
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FNDNRS-03-046
Nurse Peter makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has:
A. Anemia
B. An infection
C. A fractured rib
D. A tumor of the medulla
Correct Answer:A. Anemia
Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. Anemia is described as a reduction in the proportion of the red blood cells. Anemia is not a diagnosis, but a presentation of an underlying condition. Whether or not a patient becomes symptomatic depends on the etiology of anemia, the acuity of onset, and the presence of other comorbidities, especially the presence of cardiovascular disease.
Option B: An infection would depend on its location. Infections can be caused by a variety of different organisms, including viruses, bacteria, fungi, and parasites. The different ways that you can get an infection can be just as diverse as the organisms that cause them.
Option C: A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. Broken ribs are most commonly caused by direct impacts — such as those from motor vehicle accidents, falls, child abuse or contact sports. Ribs also can be fractured by repetitive trauma from sports like golf and rowing or from severe and prolonged coughing.
Option D: Damage to the medulla would interfere with neural stimulation of the respiratory system. Tumors of the medulla cause swallowing problems and limb weakness.
FNDNRS-03-047
Which term does the nurse document to best describe a client experiencing shortness of breath while lying down who must assume an upright or sitting position to breathe more comfortably and effectively?
A. Dyspnea
B. Hyperpnea
C. Orthopnea
D. Apnea
Correct Answer: C. Orthopnea
Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea. Orthopnea is the sensation of breathlessness in the recumbent position, relieved by sitting or standing. Orthopnea is caused by pulmonary congestion during recumbency. In the horizontal position there is redistribution of blood volume from the lower extremities and splanchnic beds to the lungs.
Option A: Dyspnea is the medical term for shortness of breath, sometimes described as “air hunger.” It is an uncomfortable feeling. Shortness of breath can range from mild and temporary to serious and long-lasting. It is sometimes difficult to diagnose and treat dyspnea because there can be many different causes.
Option B: Hyperpnea is breathing more deeply and sometimes faster than usual. It’s normal during exercise or exertion. Hyperpnea is breathing deeply, a normal response to exertion requiring more oxygen. This is when you’re breathing in more air but not necessarily breathing faster. It can happen during exercise or because of a medical condition that makes it harder for your body to get oxygen, like heart failure or sepsis (a serious overreaction by your immune system).
Option D: Apnea is breathing that stops briefly during sleep. Oxygen to the brain is decreased. It requires treatment. Apnea is the medical term used to describe slowed or stopped breathing. Apnea can affect people of all ages, and the cause depends on the type of apnea one has. Apnea usually occurs while sleeping. For this reason, it’s often called sleep apnea.
FNDNRS-03-048
A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responded by saying that the corticosteroids will do which of the following?
A. Promote bronchodilation
B. Help the client to cough
C. Prevent respiratory infection
D. Decrease inflammation in the airways
Correct Answer:D. Decrease inflammation in the airways
Glucocorticoids are prescribed because of their anti-inflammatory effect. Options 1, 2, and 4 are not achieved with glucocorticoids. Corticosteroids produce their effect through multiple pathways. In general, they produce anti-inflammatory and immunosuppressive effects, protein and carbohydrate metabolic effects, water and electrolyte effects, central nervous system effects, and blood cell effects.
Option A: The glucocorticoid receptor is located intracellularly within the cytoplasm and upon binding trans-locates rapidly into the nucleus where it affects gene transcription and causes inhibition of gene expression and translation for inflammatory leukocytes and structural cells such as epithelium. This action leads to a reduction in proinflammatory cytokines, chemokines, and cell adhesion molecules, as well as other enzymes involved in the inflammatory response.
Option B: The non-genomic mechanism occurs more rapidly and is mediated through interactions between the intracellular glucocorticoid receptor or a membrane-bound glucocorticoid receptor. Within seconds to minutes of receptor activation, a cascade of effects is set off, including inhibition of phospholipase A2, which is critical for the production of inflammatory cytokines, impaired release of arachidonic acid, and regulation of apoptosis in thymocytes.
Option C: Their nonendocrine role regularly takes advantage of their potent anti-inflammatory and immunosuppressive effects to treat patients with a wide range of immunologic and inflammatory disorders. Corticosteroids are used at physiologic doses as replacement therapy in cases of adrenal insufficiency and supraphysiologic doses in treatments for anti-inflammatory and immunosuppressive effects.
FNDNRS-03-049
Nurse Aleli is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients’ care?
A. Percussion and postural drainage should be done before lunch.
B. The order should be coughing, percussion, positioning, and then suctioning.
C. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.
D. Percussion and postural drainage should always be preceded by three minutes of 100% oxygen.
Correct Answer: A. Percussion and postural drainage should be done before lunch.
Postural drainage results in expectoration of large amounts of mucus. Clients sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort.
Option B: PD & P involves a combination of techniques, including multiple positions to drain the lungs, percussion, vibration, deep breathing and coughing. When the person with CF is in one of the positions, the caregiver can clap on the person’s chest wall. This is usually done for three to five minutes and is sometimes followed by vibration over the same area for approximately 15 seconds (or during five exhalations). The person is then encouraged to cough or huff forcefully to get the mucus out of the lungs.
Option C: Generally, each treatment session can last for 20 to 40 minutes. PD & P is best done before meals or one and a half to two hours after eating, to decrease the chance of vomiting. Early morning and bedtimes are usually recommended. The length of PD & P and the number of times of day it is done may need to be increased if the person is more congested or getting sick.
Option D: When the person with CF is in one of the positions, the caregiver can clap on the person’s chest wall. This is usually done for three to five minutes and is sometimes followed by vibration over the same area for approximately 15 seconds (or during five exhalations). The person is then encouraged to cough or huff forcefully to get the mucus out of the lungs.
FNDNRS-03-050
Nurse Winona teaches a patient how to use an incentive spirometer. What patient outcome will support the conclusion that the use of the incentives spirometer was effective?
A. Supplemental oxygen use will be reduced.
B. Inspiratory volume will be increased.
C. Sputum will be expectorated.
D. Coughing will be stimulated.
Correct Answer:B. Inspiratory volume will be increased.
An incentive spirometry or provides a visual goal for and measurement of inspiration. It encourages the patient to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis. Spirometry is one of the most readily available and useful tests for pulmonary function. It measures the volume of air exhaled at specific time points during complete exhalation by force, which is preceded by a maximal inhalation.
Option A: Patients who use an incentive spirometer may or may not be receiving oxygen. All patients must be informed that they must abstain from smoking, physical exercise in the hours before the procedure. Any bronchodilator therapy must also be stopped beforehand.
Option C: Although sputum may be expectorated after the use of an incentive spirometer, this is not the primary reason for its use. Recent evidence also supports the use of spirometry in non thoracic surgeries. A recent retrospective observational study found that lower preoperative spirometry FVC may predict postoperative pulmonary complications in high-risk patients undergoing abdominal surgery.
Option D: Although the deep breathing associated with the use of an incentive barometer may stimulate coughing, this is not the primary reason for its use. Complete spirometry exams will identify FEV1, forced vital capacity (FVC), vital capacity (VC), residual lung volume (RV), maximum voluntary minute ventilation (MMV), and total lung capacity (TLC). One parametric that is highly indicative of postoperative complications is predicted postoperative FEV 1(ppo FEV 1). Predicted postoperative FEV1 <30% are at a higher risk of postoperative pulmonary complications after thoracic surgery.
FNDNRS-03-051
Nurse AJ is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold?
A. Minimizes muscle spasms
B. Prevents hemorrhage
C. Increases circulation
D. Reduces discomfort
Correct Answer:C. Increases circulation.
Heat increases the skin surface temperature, promoting vasodilation, which increases blood flow to the area. Cold has the opposite effect: it promotes vasoconstriction, which decreases blood flow to the area. In general, heat therapy is also recommended prior to exercise for those who have chronic injuries. Heat warms the muscles and helps increase flexibility. The only time one should ever consider using cold to treat a chronic injury is after finishing exercising when inflammation may reappear. Applying cold at this time helps reduce any residual swelling.
Option A: Both heat and cold relax muscles and thus minimize muscle spasms. It reduces joint stiffness and muscle spasm, which makes it useful when muscles are tight. There is no advantage to using heat over cold. When muscles work, chemical byproducts are made that need to be eliminated. When exercise is very intense, there may not be enough blood flow to eliminate all the chemicals. It is the buildup of chemicals (for example, lactic acid) that cause muscle ache. Because the blood supply helps eliminate these chemicals, use heat to help sore muscles after exercise.
Option B: Heat does not prevent hemorrhage; heat causes vasodilation, which promotes hemorrhage. Apply an ice compress to the injury as soon as possible. This will cool down the tissues, lower their metabolic rate and nerve conduction velocity, resulting in vasoconstriction of the surrounding blood vessels and reduced inflammation.
Option D: Both heat and cold can reduce discomfort. Cold reduces discomfort by numbing the area, slowing the transmission of pain impulses, and increasing the pain threshold. Heat reduces the discomfort by relaxing the muscles. When an injury or inflammation, such as tendonitis or bursitis occurs, tissues are damaged. Cold numbs the affected area, which can reduce pain and tenderness. Cold can also reduce swelling and inflammation.
FNDNRS-03-052
A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioner’s order?
A. Emphysema
B. Osteoporosis
C. Cystic fibrosis
D. Chronic bronchitis
Correct Answer: B. Osteoporosis
Implementing the practitioner’s order may compromise patient safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength. Chest physiotherapy is a group of physical techniques that improve lung function and help you breathe better. Chest PT, or CPT expands the lungs, strengthens breathing muscles, and loosens and improves drainage of thick lung secretions.
Option A: These are appropriate interventions for a patient with emphysema. Emphysema is a chronic pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls. Chest percussion and vibration to help loosen lung secretions. Some patients wear a special CPT vest hooked up to a machine. The machine makes the vest vibrate at a high frequency to break up the secretions.
Option C: These are appropriate interventions for a patient with cystic fibrosis causes widespread dysfunction of the exocrine glands. It is characterized by thick, tenacious secretions in the respiratory system that block the bronchioles, creating breathing difficulties. Chest PT helps treat such diseases as cystic fibrosis and COPD (chronic obstructive pulmonary disease). It also keeps the lungs clear to prevent pneumonia after surgery and during periods of immobility.
Option D: These are appropriate interventions for a patient with chronic bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial airways. The doctor may recommend chest PT to help loosen and cough up thick or excessive lung secretions from such conditions as lung infections, which include pneumonia, acute bronchitis, and lung abscess.
FNDNRS-03-053
Nurse Sue teaches a patient about pursed lip breathing. The nurse identifies that the teaching is affected when the patient says its purpose is to:
A. Precipitate coughing
B. Help maintain open airways
C. Decrease intrathoracic pressure
D. Facilitate expectoration of mucus
Correct Answer: B. Help maintain open airways
Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse. Pursed lip breathing is beneficial for people with chronic lung disease. It can help strengthen the lungs and make them more efficient.
Option A: Deep breathing and huff coughing, not pursed-lip breathing, stimulate effective coughing. Deep breathing prevents air from getting trapped in the lungs, which can cause the client to feel short of breath. As a result, the client can breathe in a more fresh air.
Option C: Pursed lip breathing increases, not decreased intrathoracic pressure. Pursed lip breathing is a simple technique for slowing down a person’s breathing and getting more air into their lungs. With regular practice, it can help strengthen the lungs and make them work more efficiently. The technique involves breathing in through the nose and breathing out slowly through the mouth.
Option D: The huff coughing stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word huff with short forceful exhalations keeps the glottis open, mobilizes sputum, and stimulates a cough. When one has COPD, mucus can build up more easily in the lungs. The huff cough is a breathing exercise designed to help one cough up mucus effectively without making one feel too tired. A huff cough should be less tiring than a traditional cough, and it can keep one from feeling worn out when coughing up mucus.
FNDNRS-03-054
What should Nurse Mavie do first if a patient is choking on food?
A. Apply sharp for thrusts over the patient’s xiphoid process.
B. Determine if the patient can make any verbal sounds.
C. Hit the middle of the patients back firmly.
D. Sweep the patient’s mouth with a finger.
Correct Answer:B. Determine if the patient can make any verbal sounds.
When a person is choking on food, the first intervention is to determine if the person can speak because the next intervention will depend on if it is a partial or total airway obstruction. With a partial airway obstruction, the person will be able to make sounds because some air can pass from the lungs through the vocal cords. In this situation the person’s own efforts open parentheses gagging and coughing) should be allowed to clear the airway. With a total airway obstruction, the person will not be able to make a sound because the airway is blocked and the nurse should immediately initiate the abdominal thrust maneuver (Heimlich maneuver).
Option A: Thrusts to the xiphoid process may cause a fracture that may result in a pneumothorax. The foreign body lodged in the larynx or trachea is most dangerous as this causes complete airway obstruction. Alternatively, foreign bodies such as small beads or small pieces of food may pass below the vocal cords and become lodged at the carina or within a mainstem bronchus. In adults, due to differences in right versus left pulmonary anatomy, foreign bodies are more commonly retrieved from the right main bronchus. However, children will have equal likelihood in either bronchus, due to equal growth until the age of 16.
Option C: All adults can and should receive the Heimlich maneuver while they are conscious. If the Heimlich cannot be performed due to body habitus or pregnancy, the American Heart Association recommends a supine patient with force again applied just above the umbilicus in a cephalad posterior vector. If the adult loses consciousness, it is imperative to check for a pulse and begin cardiopulmonary resuscitation if a pulse is not detected. Advanced airway techniques are now indicated, and you may be able to visualize the foreign body under direct laryngoscopy.
Option D: Never sweep a choking patient’s mouth with a finger. It might further dislodge the food. The commonly known abdominal thrust maneuver, known as the Heimlich maneuver, is performed by a bystander on a person who appears to be choking. The bystander stands behind the subject and wraps his/her arms around the upper abdominal region, about two inches above the belly button. Making a fist with one hand and wrapping the other hand tightly over the fist and delivering five sharp midline thrusts inward and upward.
FNDNRS-03-055
Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply.
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Cyanosis
Correct Answer: A, B, & E
Restlessness, tachypnea, and pallor are early manifestations of hypoxemia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. Bradycardia and confusion are late manifestations of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias. Hypoxemia is defined as a decrease in the partial pressure of oxygen in the blood whereas hypoxia is defined by reduced level of tissue oxygenation. It can be due to either defective delivery or defective utilization of oxygen by the tissues.
Option A: When oxygen delivery is severely compromised, organ function will start to deteriorate. Neurologic manifestations include restlessness, headache, and confusion with moderate hypoxia. In severe cases, altered mentation and coma can occur, and if not corrected quickly may lead to death.
Option B: The chronic presentation is usually less dramatic, with dyspnea on exertion as the most common complaint. Symptoms of the underlying condition that induced the hypoxia can help in narrowing the differential diagnosis. The physical exam may show tachypnea, and low oxygen saturation. Fever may point to infection as the cause of hypoxia.
Option C: Bradycardia is a late manifestation of hypoxemia. Increase in cardiac output with exercise results in accelerated blood flow through alveoli, reducing the time available for gas exchange. In case of the abnormal pulmonary interstitium, gas exchange time becomes insufficient, and hypoxemia ensues.
Option D: Both confusion and somnolence may occur in respiratory failure. Myoclonus and seizures may occur with severe hypoxemia. Polycythemia is a complication of long-standing hypoxemia.
Option E: Cyanosis, a bluish color of skin and mucous membranes, indicates hypoxemia. Visible cyanosis typically is present when the concentration of deoxygenated hemoglobin in the capillaries of tissues is at least 5 g/dL.
FNDNRS-03-056
Nurse CJ is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?
A. Increase the oxygen flow.
B. Assist the client to Fowler’s position.
C. Promote removal of pulmonary secretions.
D. Attain a specimen for arterial blood gases.
Correct Answer:B. Assist the client to Fowler’s position.
The priority action the nurse should take when using the airway, breathing, circulation approach to care delivery is to relieve the clients dyspnea. Fowler’s position facilitates maximal long expansion and thus optimizing breathing. With the client in this position, the nurse can better assess and determine the cause of the clients dyspnea.
Option A: The client may need more oxygen, as hypoxemia may be the cause of his difficulty breathing. However, administering oxygen and adjusting the fraction of inspired oxygen requires the provider’s prescription after a careful assessment of the clients oxygenation status, there is a higher priority given the nature of the client’s distress.
Option C: The client may need suction or expectoration, as pulmonary secretions may be the cause of his difficulty breathing. However, there is a higher priority given the nature of the client’s distress.
Option D: It is important to check the clients oxygenation status, and in many nursing situations, assessment precedes action, but there is a higher priority given the nature of the client’s distress.
FNDNRS-03-057
Nurse Aldrin is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all that apply.
A. Apply suction while withdrawing the catheter.
B. Perform suctioning on a routine basis, every 2 to 3 hours.
C. Maintain medical asepsis during suctioning.
D. Use a new catheter for each suctioning attempt.
E. Limit suctioning to 2 to 3 attempts.
Correct Answer:A, D, & E
Within intensive care units (ICUs), one such common procedure is the suctioning of respiratory secretions in patients who have been intubated or who have undergone tracheostomy. The traditional goal of suctioning is to aid in maintaining airway patency and prevent complications related to retention of secretions
Option A: The nurse should apply suction pressure only while withdrawing the catheter, not while inserting it. One interesting thing to note about ETS is that negative pressure is created inside of the lungs only while air flows out of the suction catheter. As soon as secretions are aspirated into the catheter, the intrapulmonary pressure returns to that of the atmospheric level, and lung volume loss stops.
Option B: The nurse should not suction routinely because suctioning is not without risk. It can cause mucosal damage, bleeding, and bronchospasm. Although there has been a very limited number of studies regarding a scheduled frequency of performing ETS every 1, 3, 4, 6, 8, or even 12 hours, the overall recommendation is to suction only as indicated (as needed).
Option C: Endotracheal suctioning requires surgical asepsis. The second method of suctioning is the shallow (premeasured) technique, which is also considered minimally invasive.1-3 With shallow ETS, the catheter is inserted only to the tip of the ETT, thereby avoiding injury to the airway.
Option D: The nurse should not reuse the suction catheter unless an in-line suctioning system is in place. If a suction catheter is too large for the ETT, and/or there is too much vacuum pressure, massive atelectasis may occur. Therefore, the general recommendation is to use a suction catheter that has an external diameter less than 50% of the size of the ETT inner diameter.
Option E: To prevent hypoxemia, the nurse should limit each section in session to 2 to 3 attempts and allow at least one minute between passes for ventilation and oxygenation. The reason for this is because there is considerable risk with using “routine” suctioning. It has been suggested by Pedersen et al3 that ETS should be performed at least every 8 hours to slow the formation of the secretion biofilm within the lumen of the endotracheal tube (ETT). Clifton-Koeppel1 made a good general recommendation that ETS should be performed as infrequently as possible—yet as much as needed.
FNDNRS-03-058
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides a tracheostomy care? Select all that apply.
A. Apply the oxygen source loosely if the SPO2 increases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
Correct Answer:A, B, & C
A tracheostomy is an opening (made by an incision) through the neck into the trachea (windpipe). A tracheostomy opens the airway and aids breathing. A tracheostomy may be required in an emergent setting to bypass an obstructed airway, or (more commonly) may be placed electively to facilitate mechanical ventilation, to wean from a ventilator, or to allow more efficient management of secretions (referred to as pulmonary toilet), among other reasons.
Option A: The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygenation saturation while performing tracheostomy care. Nurses need to understand all aspects of tracheostomy care, including routine and emergency airway management, safe decannulation, weaning and safe discharge into the community. The patient’s airway requires close monitoring 24 hours a day using a tracheostomy care chart to record care.
Option B: The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. The NTSP (2013) recommends that all patients with a tracheostomy have a bed-head label with information regarding their tube and airway, including whether it is surgical or percutaneous, the tube type, size and suction-catheter size, patency of the upper airway and whether the tracheostomy is temporary, permanent or involves a laryngectomy (removal of the larynx).
Option C: Option 3 helps move mucus and contaminated material away from the stoma for easy removal. The stoma site should be checked at least once a day, or more frequently if required, and this requires two nurses: one to hold the tube and one to clean the stoma site. The site should be cleaned using a tracheostomy wipe or with 0.9% sodium chloride solution, and dried thoroughly.
Option D: To help keep the skin clean and dry, the nurse should replace the tracheostomy ties if they are wet or soiled. There is a risk of two dislodgements replacing the ties, so he should not replace them routinely. Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the tracheostomy tube. Securing tapes in this manner avoids the use of knots, which can come untied or cause pressure and irritation.
Option E: The nurse should use a commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or cause fibers the client could aspirate. Use a commercially prepared tracheostomy dressing of non-raveling material or open and refold a 4-in. X 4-in. Gauze dressing into a V shape. Avoid using cotton-filled gauze squares or cutting the 4×4 gauze. Cotton lint or gauze fibers can be aspirated by the client, potentially creating a tracheal abscess.
FNDNRS-03-059
An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment findings?
A. Increase blood pressure
B. Weak, rapid pulse
C. Moist mucous membranes
D. Jugular vein distention
Correct Answer: B. Week, rapid pulse
All other options are indicated by fluid volume excess. A client who has not eaten or drunk anything for several days would be experiencing a fluid volume deficit. The primary control of water homeostasis is through osmoreceptors in the brain. Dehydration, as perceived by these osmoreceptors, stimulates the thirst center in the hypothalamus, which leads to water consumption. These osmoreceptors can also cause conservation of water by the kidney. When the hypothalamus detects lower water concentration, it causes the posterior pituitary to release antidiuretic hormone (ADH), which stimulates the kidneys to reabsorb more water.
Option A: Decreased blood pressure, which often accompanies dehydration triggers renin secretion from the kidney. Renin converts angiotensin I to angiotensin II, which increases aldosterone release from the adrenals. Aldosterone increases the absorption of sodium and water from the kidney. Using these mechanisms, the body regulates body volume and sodium and water concentration.
Option C: Some of the most common presenting symptoms of dehydration include but are not limited to fatigue, thirst, dry skin and lips, dark urine or decreased urine output, headaches, muscle cramps, lightheadedness, dizziness, syncope, orthostatic hypotension, and palpitations. The physical examination could show dry mucosa, skin tenting, delayed capillary refill, or cracked lips.
Option D: A 2015 Cochrane review evaluated predictors of dehydration in the elderly. Historical and physical findings tested were dry axilla, mucous membranes, tongue, increased capillary refill time, poor skin turgor, sunken eyes, orthostatic blood pressure drop, dizziness, thirst, urine color, weakness, blue lips, altered mentation, tiredness, and appetite. Of all these factors only fatigue and missed drinks between meals predicted the diagnosis of dehydration.
FNDNRS-03-060
A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past two days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?
A. Start an IV.
B. Review the results of serum electrolytes.
C. Offer the woman foods that are high in sodium and potassium content.
D. Administer an antiemetic.
Correct Answer: B. Review the results of serum electrolytes.
Further assessment is needed to determine appropriate action. While the nurse may perform some of the interventions in options one, three, and four, assessment is needed initially. Electrolyte abnormalities may be addressed on an individual level, although often these are caused by an overall fluid volume depletion which, when corrected, will also cause electrolytes to normalize. Both saline and lactated Ringer’s solutions appear to be effective for the treatment of dehydration due to viral gastroenteritis.
Option A: The most important goal of treatment is to maintain hydration status and effectively counter fluid and electrolyte losses. Fluid therapy is a fundamental part of treatment. Intravenous fluids may be administered to those individuals who appear dehydrated or to those unable to tolerate oral fluids.
Option C: No specific nutritional recommendations are universal for patients with viral gastroenteritis. A diet of banana, rice, apples, tea, and toast is often advised, but several studies have failed to show any significant outcome difference when compared to regular diets.
Option D: Antiemetic medications such as ondansetron or metoclopramide may be used to assist with controlling nausea and vomiting symptoms. Patients demonstrating severe dehydration or intractable vomiting may require hospital admission for continued intravenous fluids and careful monitoring of electrolyte status.
FNDNRS-03-061
Which of the following is the appropriate meaning of CBR?
A. Cardiac Board Room
B. Complete Bathroom
C. Complete Bed Rest
D. Complete Board Room
Correct Answer:C. Complete Bed Rest
CBR means complete bed rest. For more abbreviations, please see this post. Standardization and uniform use of codes, symbols, and abbreviations can improve communication and understanding between health care practitioners, leading to safer and more effective care for patients.
Option A: When developing lists, hospitals need to ensure that abbreviations on the approved list are not also on the do-not-use list, and vice versa. In addition, abbreviations can have only one meaning within the entire organization—for example, the abbreviation NKDA could mean “no known drug allergies,” or it could mean “nonketotic diabetic acidosis,” but it cannot have both meanings in an organization.
Option B: Appropriate use of abbreviations is particularly important. Numerous studies have focused on health care practitioners’ understanding and interpretation of abbreviations in medical documents, such as medical records, discharge summaries, and medication orders. Findings indicate that it is not uncommon for practitioners to have difficulty understanding the abbreviations used in their hospitals.
Option D: To prevent misunderstandings and potential risks to patient safety, MOI.4 requires hospitals to establish lists for approved and do-not-use abbreviations and monitor for appropriate abbreviation use. There are resources for identifying abbreviations for the do-not-use list, such as the Institute for Safe Medication Practices (ISMP), which publishes a list of dangerous abbreviations not to be used due to frequent misinterpretation and associated medication errors.
FNDNRS-03-062
One (1) tsp is equal to how many drops?
A. 15
B. 60
C. 10
D. 30
Correct Answer: B. 60
One teaspoon (tsp) is equal to 60 drops (gtts). When the nurse has an order for an IV infusion, it is her responsibility to make sure the fluid will infuse at the prescribed rate. IV fluids may be infused by gravity using a manual roller clamp or dial-a-flow, or infused using an infusion pump. Regardless of the method, it is important to know how to calculate the correct IV flow rate.
Option A: When calculating the flow rate, determine which IV tubing will be used, microdrip or macrodrip, so the nurse can use the proper drop factor in her calculations. The drop factor is the number of drops in one mL of solution, and is printed on the IV tubing package. Macrodrip and microdrip refers to the diameter of the needle where the drop enters the drip chamber.
Option C: Macrodrip tubing delivers 10 to 20 gtts/mL and is used to infuse large volumes or to infuse fluids quickly. Microdrip tubing delivers 60 gtts/mL and is used for small or very precise amounts of fluid, as with neonates or pediatric patients.
Option D: To calculate the drops per minute, the drop factor is needed. The formula for calculating the IV flow rate (drip rate) is… total volume (in mL) divided by time (in min), multiplied by the drop factor (in gtts/mL), which equals the IV flow rate in gtts/min.
FNDNRS-03-063
20 cc is equal to how many ml?
A. 2
B. 20
C. 2000
D. 20000
Correct Answer:B. 20
One cubic centimeter is equal to one milliliter. When clinicians are prepared and know the key conversion factors, they will be less anxious about the calculation involved. This is vital to accuracy, regardless of which formula or method employed.
Option A: Drug calculations require the use of conversion factors, for example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows clinicians to work with various units of measurement, converting factors to find the answer. These methods are useful in checking the accuracy of the other methods of calculation, thus acting as a double or triple check.
Option C: Units of measurement must match, for example, milliliters and milliliters, or one needs to convert to like units of measurement. In the example above, the ordered dose was in milligrams, and the have dose was in milligrams, both of which cancel out leaving milliliters (answer called for milliliters), so no further conversion is required.
Option D: All members of the interprofessional team are responsible for dose calculations. Physicians, nurses, and pharmacists all must be conversant in the desired overall formula. This technique is invaluable in properly treating patients.
FNDNRS-03-064
1 cup is equal to how many ounces?
A. 8
B. 80
C. 800
D. 8000
Correct Answer:A. 8
One cup is equal to 8 ounces. Weight conversion is also utilized daily in health care. There are two systems calculating weight used in all healthcare settings for health management, such as medication dosing per patient body weight. First, the metric system is in common use in health care in the US. It is also the only system universally used in many countries on all continents of the globe. It has the advantage of a decimal system in increments or the power of tenths. Second, the US weight system customarily uses the ounce or pound. It derives from the British colonial era. This non-metric system is still being used nowadays among laypersons in the US for products sold to the public.
Option B: The metric system is essential in all health care settings. Patients are weighed at each clinical encounter. Scales used in the US have double marking indicators: metric and non-metric markings. Metric weight values are used in medication calculation, radiation dosing, and weight compliance in equipment use, such as the maximum weight of a CAT-SCAN unit or a surgical table that may hold a person.
Option C: Nowadays, all medications are based on weight for dose calculations for all populations but very specifically in children and infants. Adults have their weight recorded mainly by their doctors at each physical patient-clinician encounter. Commonly, most adults monitor their weight for weight management. Clinicians record it in the electronic health records in both kilograms and pounds.
Option D: Commonly in healthcare and medical practices, the metric system is used for weighing mass. In the metric system, there are increments at the power of the tenth for calculations. This weight conversion is used daily among scientists and health care providers.
FNDNRS-03-065
The nurse must verify the client’s identity before administration of medication. Which of the following is the safest way to identify the client?
A. Ask the client his name.
B. Check the client’s identification band.
C. State the client’s name aloud and have the client repeat it.
D. Check the room number.
Correct Answer: B. Check the client’s identification band
The identification band is the safest way to know the identity of a patient whether he is conscious or unconscious. Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.
Option A: Ask the client his name only after you have checked his ID band. Right patient’ – ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. This is best practiced by nurses directly asking a patient to provide his or her full name aloud, checking medical wristbands if appropriate for matching name and ID number as on a chart.
Option C: It is advisable not to address patients by first name or surname alone, in the event, there are two or more patients with identical or similar names in a unit. Depending on the unit that a patient may be in, some patients, such as psychiatric patients, may not wear wristbands or may have altered mentation to the point where they are unable to identify themselves correctly. In these instances, nurses are advised to confirm a patient’s identity through alternative means with appropriate due diligence.
Option D: The medical literature states that the value of nurses’ critical thinking, the role of patient advocacy, and clinical judgment are not accounted for by the five rights framework that is commonly observed in modern practice to deliver patient-centered care. Research has shown a clear benefit in the value of nursing experience as it relates to decision-making capability; however, it states that further studies are necessary to achieve an improved understanding of how nurses apply intuition, the context of the situation, and interpretation.
FNDNRS-03-066
The nurse prepares to administer buccal medication. The medicine should be placed in what area?
A. On the client’s skin.
B. Between the client’s cheeks and gums.
C. Under the client’s tongue.
D. On the client’s conjunctiva.
Correct Answer: B. Between the client’s cheeks and gums
Buccal administration involves placing a drug between the gums and cheek, where it also dissolves and is absorbed into the blood. Because the medication absorbs quickly, these types of administration can be important during emergencies when you need the drug to work right away, such as during a heart attack.
Option A: An advantage of a transdermal drug delivery route over other types of medication delivery such as oral, topical, intravenous, intramuscular, etc. is that the patch provides a controlled release of the medication into the patient, usually through either a porous membrane covering a reservoir of medication or through body heat melting thin layers of medication embedded in the adhesive.
Option C: Sublingual administration involves placing a drug under the tongue to dissolve and absorb into the blood through the tissue there. These drugs do not go through the digestive system, so they aren’t metabolized through the liver. This means you may be able to take a lower dose and still get the same results.
Option D: The three primary methods of delivery of ocular medications to the eye are topical, local ocular (ie, subconjunctival, intravitreal, retrobulbar, intracameral), and systemic. The most appropriate method of administration depends on the area of the eye to be medicated. The conjunctiva, cornea, anterior chamber, and iris usually respond well to topical therapy. The eyelids can be treated with topical therapy but more frequently require systemic therapy. The posterior segment always requires systemic therapy, because most topical medications do not penetrate to the posterior segment. Retrobulbar and orbital tissues are treated systemically.
FNDNRS-03-067
The nurse administers cleansing enema. The common position for this procedure is:
A. Sims left lateral
B. Dorsal Recumbent
C. Supine
D. Prone
Correct Answer: A. Sims left lateral
This position provides comfort to the patient and an easy access to the natural curvature of the rectum. Enemas are rectal injections of fluid intended to cleanse or stimulate the emptying of the bowel. Enemas may also be prescribed to flush out the colon before certain diagnostic tests or surgeries. The bowel needs to be empty before these procedures to reduce infection risk and prevent stool from getting in the way.
Option B: Position the patient on the left side, lying with the knees drawn to the abdomen. This eases the passage and flow of fluid into the rectum. Gravity and the anatomical structure of the sigmoid colon also suggest that this will aid enema distribution and retention. Dorsal recumbent is a position in which the patient lies on the back with the lower extremities moderately flexed and rotated outward. It is employed in the application of obstetrical forceps, repair of lesions following parturition, vaginal examination, and bimanual palpation.
Option C: The supine position means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the head, neck and extremities.
Option D: Prone position is a body position in which the person lies flat with the chest down and the back up. In anatomical terms of location, the dorsal side is up, and the ventral side is down. The supine position is the 180° contrast.
FNDNRS-03-068
A client complains of difficulty swallowing when the nurse tries to administer capsule medication. Which of the following measures should the nurse do?
A. Dissolve the capsule in a glass of water.
B. Break the capsule and give the content with applesauce.
C. Check the availability of a liquid preparation.
D. Crush the capsule and place it under the tongue.
Correct Answer: C. Check the availability of a liquid preparation.
The nurse should check first if the medication is available in liquid form before doing Choice A. The swallowing of capsules can be particularly difficult. This is because capsules are lighter than water and float due to air trapped inside the gelatine shell. In comparison, tablets are heavier than water and do not float.
Option A: The physical properties of capsules predispose them to float in the mouth when taken with water. As a result, the swallowing of capsules can be problematic. In patients who experience such difficulty, it is suggested that they try leaning forward when swallowing, as this has been found to assist. It may be necessary to reassure patients about this technique as they may initially find it unnatural to execute.
Option B: Some tablets, pills, and capsules don’t work properly or may be harmful if they’re crushed or opened. Most capsules are intended to be swallowed whole so patients should be encouraged to trial the ‘lean-forward’ technique. If swallowing difficulties remain other options, such as a liquid or tablet form of the medicine, can be considered.
Option D: Placing it under the tongue is not the intended way of administering oral medication. Crushing the medication may alter the medicine’s effects. You shouldn’t chew, crush or break tablets or pills, or open and empty powder out of capsules unless your GP or another healthcare professional has told you to do so. Some tablets, pills, and capsules don’t work properly or may be harmful if they’re crushed or opened.
FNDNRS-03-069
Which of the following is the appropriate route of administration for insulin?
A. Intramuscular
B. Intradermal
C. Subcutaneous
D. Intravenous
Correct Answer: C. Subcutaneous
The subcutaneous tissue of the abdomen is preferred because the absorption of the insulin is more consistent from this location than subcutaneous tissues in other locations. Insulin may be injected into the subcutaneous tissue of the upper arm and the anterior and lateral aspects of the thigh, buttocks, and abdomen (with the exception of a circle with a 2-inch radius around the navel).
Option A: Intramuscular injection is not recommended for routine injections. Rotation of the injection site is important to prevent lipohypertrophy or lipoatrophy. Rotating within one area is recommended (e.g., rotating injections systematically within the abdomen) rather than rotating to a different area with each injection. This practice may decrease variability in absorption from day to day.
Option B: Site selection should take into consideration the variable absorption between sites. The abdomen has the fastest rate of absorption, followed by the arms, thighs, and buttocks. Exercise increases the rate of absorption from injection sites, probably by increasing blood flow to the skin and perhaps also by local actions.
Option D: Administration of mixtures of rapid- or short- and intermediate- or long-acting insulins will produce a more normal glycemia in some patients than the use of single insulin. The formulations and particle size distributions of insulin products vary. On mixing, physicochemical changes in the mixture may occur (either immediately or over time). As a result, the physiological response to the insulin mixture may differ from that of the injection of the insulins separately.
FNDNRS-03-070
The nurse is ordered to administer ampicillin capsule TID p.o. The nurse should give the medication by which frequency?
A. Three times a day orally
B. Three times a day after meals
C. Two times a day by mouth
D. Two times a day before meals
Correct Answer:A. Three times a day orally
TID is the Latin for “ter in die” which means three times a day. P.O. means per orem or through mouth. The “time” of administration of medication is valuable information to consider during patient counselling and is a typical query by patients especially when filling a prescription for the first time.
Option B: The timing of doses isn’t the only question people may have when it comes to deciphering prescriptions or oral communication from the doctor. Other abbreviations include the number of refills allowed and whether one is receiving a brand name or generic drug. Medical errors are a significant cause of death in the United States. Fortunately, most of these errors are preventable when patients are active advocates for their health and ask plenty of questions.
Option C: Two times a day by mouth is BID P.O. Seen on a prescription, b.i.d. means twice (two times) a day. It is an abbreviation for “bis in die” which in Latin means twice a day. The abbreviation b.i.d. is sometimes written without a period either in lower-case letters as “bid” or in capital letters as “BID”.
Option D: However it is written, it is one of a number of hallowed abbreviations of Latin terms that have been traditionally used in prescriptions to specify the frequency with which medicines should be taken.
FNDNRS-03-071
Back Care is best described as:
A. Caring for the back by means of massage.
B. Washing of the back.
C. Application of cold compress at the back.
D. Application of hot compress at the back.
Correct Answer: A. Caring for the back by means of massage
Back care or massage is usually given in conjunction with the activities of bathing the client. It can also be done on other occasions when a client seems to have a risk of developing skin irritation due to bed rest. The goal when performing this procedure is to enhance relaxation, reduce muscle tension and stimulate circulation.
Option B: Help the patient to turn on his abdomen or on his side with his back toward the nurse and his body near the edge of the bed so that he is as near the operator as possible. If the supine position is used and the patient is a woman, a pillow under the abdomen removes pressure from the breasts and favors relaxation. Apply to back rubbing lotion or talcum powder to reduce friction. In rubbing the back use firm long strokes and kneading motions. The amount of pressure to exert depends upon the patient’s condition. Begin from the neck and shoulders then proceed over the entire back.
Option C: Massage with both hands working with a strong stroke. In upward then in downward motions. Give particular attention to pressure areas in rubbing (Alcohol 25%) to 50% is generally used for its refreshing effect, but rubbing lotion may be used. Powder again the area at the completion of the rubbing process which should consume from 3-5 minutes.
Option D: Effleurage (stroking) is a long sweeping movement with the palm of hand conforming to the contour of the surface treated, over a small surface (on the neck) the thumb and fingers are used. Strokes should be slow, rhythmical and gentle with pressure constant and in the direction of venous stream. Kneading is performed with the ulnar side palm resting on the surface and the fingers, and thumb grasping the skin and subcutaneous tissues which move with the hand of the operator.
FNDNRS-03-072
It refers to the preparation of the bed with a new set of linens
A. Bed bath
B. Bed making
C. Bed shampoo
D. Bed lining
Correct Answer: B. Bed making
Bed making is one of the important nursing techniques to prepare various types of bed for patients or clients to guarantee comfort and beneficial position for a specific condition. The bed is particularly important for patients who are sick. The nurse plays an inevitable role to ensure comfort and cleanliness for ill patients. It should be adaptable to various positions as per patient’s need because they spend a varying amount of the day in bed.
Option A: Bed bathing is not as effective as showering or bathing and should only be undertaken when there is no alternative (Dougherty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity.
Option C: The condition of their hair and how it is styled is an important part of patients’ identity and wellbeing, so assisting them with hair care is a fundamental aspect of nursing care
Option D: The purpose of a well-made hospital bed, as well as an appropriately chosen mattress, is to provide a safe, comfortable place for the patient, where repositioning is more easily achieved, and pressure ulcers are prevented.
FNDNRS-03-073
Which of the following is the most important purpose of handwashing?
A. To promote hand circulation.
B. To prevent the transfer of microorganisms.
C. To avoid touching the client with a dirty hand.
D. To provide comfort.
Correct Answer: B. To prevent the transfer of microorganism
Hand washing is the single most effective infection control measure. Handwashing practices in the patient care setting began in the early 19th century. The practice evolved over the years with evidential proof of its vast importance and coupled with other hand-hygienic practices, decreased pathogens responsible for nosocomial or hospital-acquired infections (HAI).
Option A: According to the Centers for Disease Control and Prevention (CDC), hand hygiene is the single most important practice in the reduction of the transmission of infection in the healthcare setting Transient microorganisms are often acquired by healthcare workers through direct, close contact with patients or contaminated inanimate objects or environmental surfaces. Transient flora colonizes the superficial skin layers. It can be removed by routine hand washing more easily than resident flora. These organisms vary in number depending upon body location. Healthcare-associated infections are a result of these transient organisms.
Option C: Contaminated hands of healthcare providers are a primary source of pathogenic spread. Proper hand hygiene decreases the proliferation of microorganisms, thus reducing infection risk and overall healthcare costs, length of stays, and ultimately, reimbursement. According to the CDC, hand hygiene encompasses the cleansing of your hands with soap and water, antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers, foams or gels, or surgical hand antisepsis.
Option D: Indications for handwashing include when hands are visibly soiled, contaminated with blood or other bodily fluids, before eating, and after restroom use. Hands should be washed if there was potential exposure to Clostridium difficile, Norovirus, or Bacillus anthracis. Alcohol-based hand sanitizers are the recommended product for hand hygiene when hands are not visibly soiled. Apply alcohol-based products per manufacturer guidelines on dispensing of the product. Typically, 3 mL to 5 mL in the palm, rubbing vigorously, ensuring all surfaces on both hands get covered, about 20 seconds is required for all surfaces to dry completely.
FNDNRS-03-074
What should be done in order to prevent contaminating the environment in bed making?
A. Avoid fanning soiled linens
B. Strip all linens at the same time
C. Finished both sides at the time
D. Embrace soiled linen
Correct Answer: A. Avoid fanning soiled linens
Fanning soiled linens would scatter the lodged microorganisms and dead skin cells on the linens. Healthcare linens are known to harbor a number of microorganisms. Most notably, there is an increased concern that methicillin-resistant Staphylococcus aureus (MRSA)and vancomycin-resistant Enterococcus (VRE) can survive for days on linens. There is further concern that these contaminated linens then become a potential source of cross-contamination.
Option B: There is now a common understanding that linens, once in use, are usually contaminated and could be harboring microorganisms such as MRSA and VRE. Further, the Centers for Disease Control and Prevention (CDC) cautions that healthcare professionals should handle contaminated textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons. Even one of the leading nursing textbooks, Fundamentals of Nursing, Soiled linen is never shaken in the air because shaking can disseminate secretions and excretions and the microorganisms they contain. This text also states linens that have been soiled with excretions and secretions harbor microorganisms that can be transmitted to others.
Option C: Healthcare laundry protocols have long relied on chlorine-based sanitizers to kill bacteria in bed linens and other fabrics. While chlorine is known as one of the best antimicrobial agents in the world, its power has been limited because it evaporates from untreated fabric soon after laundering. But with this new patented technology in HaloShield ® linens, the chlorine keeps killing bacteria right up until the next laundering.
Option D: The environment in which linens are used in healthcare is often ideal for the proliferation and spread of bacteria and viruses. Often the patient, in a weakened or compromised state, is lying on a sheet. That sheet under the patient’s body is warm, dark, and sometimes damp. Most would agree that those conditions are considered ideal for bacteria and viruses to thrive.
FNDNRS-03-075
The most important purpose of cleansing bed bath is:
A. To cleanse, refresh and give comfort to the client who must remain in bed.
B. To expose the necessary parts of the body.
C. To develop skills in bed bath.
D. To check the body temperature of the client in bed.
Correct Answer:A. To cleanse, refresh and give comfort to the client who must remain in bed.
The nurse provides a bed bath for patients who must remain in bed and depend on someone else for their care. It is an important part of the patient’s daily care. Not only does it remove sweat, oil, and micro-organisms from the patient’s skin, but it also stimulates circulation and promotes a feeling of self-worth by improving the patient’s appearance. For patients who are on bedrest, bathing can also be a time for socialization.
Option B: During bed bath, the patient is always given privacy so as not to expose their intimate parts of the body. Some patients cannot safely leave their beds to bathe. For these people, daily bed baths can help keep their skin healthy, control odor, and increase comfort. If moving the patient causes pain, plan to give the patient a bed bath after the person has received pain medicine and it has taken effect.
Option C: The nurse may develop her skills in bed bath, but it is not the main purpose. A bed bath is a good time to inspect a patient’s skin for redness and sores. Pay special attention to skin folds and bony areas when checking. Encourage the patient to be involved as possible in bathing themselves.
Option D: A bed bath may give a relaxation effect on the patient. It may also stimulate blood circulation to the skin, respirations, and elimination; maintain joint mobility; and improve the patient’s self-image and emotional and mental well-being. It provides the nurse with an opportunity for health teaching and assessment; gives the patient psychological support; and the process of building rapport may begin during the initial bath.
