Answers and Rationale –Test I Foundation of Professional Nursing Practice part 1

Answers and Rationale –Test I Foundation of Professional Nursing Practice part 1

1. Answer: (D) The actions of a reasonably

prudent nurse with similar education and

experience.

Rationale: The standard of care is determined

by the average degree of skill, care, and

diligence by nurses in similar circumstances.

2. Answer: (B) I.M

Rationale: With a platelet count of 22,000/μl,

the clients tends to bleed easily. Therefore,

the nurse should avoid using the I.M. route

because the area is a highly vascular and can

bleed readily when penetrated by a needle.

The bleeding can be difficult to stop.

3. Answer: (C) “Digoxin 0.125 mg P.O. once daily”

Rationale: The nurse should always place a

zero before a decimal point so that no one

misreads the figure, which could result in a

dosage error. The nurse should never insert a

zero at the end of a dosage that includes a

decimal point because this could be misread,

possibly leading to a tenfold increase in the

dosage.

4. Answer: (A) Ineffective peripheral tissue

perfusion related to venous congestion.

Rationale: Ineffective peripheral tissue

perfusion related to venous congestion takes

the highest priority because venous

inflammation and clot formation impede blood

flow in a client with deep vein thrombosis.

5. Answer: (B) A 44 year-old myocardial

infarction (MI) client who is complaining of

nausea.

Rationale: Nausea is a symptom of impending

myocardial infarction (MI) and should be

assessed immediately so that treatment can

be instituted and further damage to the heart

is avoided.

6. Answer: (C) Check circulation every 15-30

minutes.

Rationale: Restraints encircle the limbs, which

place the client at risk for circulation being

restricted to the distal areas of the

extremities. Checking the client’s circulation

every 15-30 minutes will allow the nurse to

adjust the restraints before injury from

decreased blood flow occurs.

7. Answer: (A) Prevent stress ulcer

Rationale: Curling’s ulcer occurs as a

generalized stress response in burn patients.

This results in a decreased production of

mucus and increased secretion of gastric acid.

The best treatment for this prophylactic use of

antacids and H2 receptor blockers.

8. Answer: (D) Continue to monitor and record

hourly urine output

Rationale: Normal urine output for an adult is

approximately 1 ml/minute (60 ml/hour).

Therefore, this client's output is normal.

Beyond continued evaluation, no nursing

action is warranted.

9. Answer: (B) “My ankle feels warm”.

Rationale: Ice application decreases pain and

swelling. Continued or increased pain, redness,

and increased warmth are signs of

inflammation that shouldn't occur after ice

application

10. Answer: (B) Hyperkalemia

Rationale: A loop diuretic removes water and,

along with it, sodium and potassium. This may

result in hypokalemia, hypovolemia, and

hyponatremia.

11. Answer:(A) Have condescending trust and

confidence in their subordinates

Rationale: Benevolent-authoritative managers

pretentiously show their trust and confidence

to their followers.

12. Answer: (A) Provides continuous, coordinated

and comprehensive nursing services.

Rationale: Functional nursing is focused on

tasks and activities and not on the care of the

patients.

13. Answer: (B) Standard written order

Rationale: This is a standard written order.

Prescribers write a single order for

medications given only once. A stat order is

written for medications given immediately for

an urgent client problem. A standing order,

also known as a protocol, establishes

guidelines for treating a particular disease or

set of symptoms in special care areas such as

the coronary care unit. Facilities also may

institute medication protocols that specifically

designate drugs that a nurse may not give.

14. Answer: (D) Liquid or semi-liquid stools

Rationale: Passage of liquid or semi-liquid

stools results from seepage of unformed

bowel contents around the impacted stool in

the rectum. Clients with fecal impaction don't

pass hard, brown, formed stools because the

feces can't move past the impaction. These

clients typically report the urge to defecate

(although they can't pass stool) and a

decreased appetite.

15. Answer: (C) Pulling the helix up and back

Rationale: To perform an otoscopic

examination on an adult, the nurse grasps the

helix of the ear and pulls it up and back to

straighten the ear canal. For a child, the nurse

grasps the helix and pulls it down to straighten

the ear canal. Pulling the lobule in any

direction wouldn't straighten the ear canal for

visualization.

16. Answer: (A) Protect the irritated skin from

sunlight.

Rationale: Irradiated skin is very sensitive and

must be protected with clothing or sunblock.

The priority approach is the avoidance of

strong sunlight.

17. Answer: (C) Assist the client in removing

dentures and nail polish.

Rationale: Dentures, hairpins, and combs must

be removed. Nail polish must be removed so

that cyanosis can be easily monitored by

observing the nail beds.

18. Answer: (D) Sudden onset of continuous

epigastric and back pain.

Rationale: The autodigestion of tissue by the

pancreatic enzymes results in pain from

inflammation, edema, and possible

hemorrhage. Continuous, unrelieved epigastric

or back pain reflects the inflammatory process

in the pancreas.

19. Answer: (B) Provide high-protein, highcarbohydrate

diet.

Rationale: A positive nitrogen balance is

important for meeting metabolic needs, tissue

repair, and resistance to infection. Caloric

goals may be as high as 5000 calories per day.

20. Answer: (A) Blood pressure and pulse rate.

Rationale: The baseline must be established to

recognize the signs of an anaphylactic or

hemolytic reaction to the transfusion.

21. Answer: (D) Immobilize the leg before moving

the client.

Rationale: If the nurse suspects a fracture,

splinting the area before moving the client is

imperative. The nurse should call for

emergency help if the client is not hospitalized

and call for a physician for the hospitalized

client.

22. Answer: (B) Admit the client into a private

room.

Rationale: The client who has a radiation

implant is placed in a private room and has a

limited number of visitors. This reduces the

exposure of others to the radiation.

23. Answer: (C) Risk for infection

Rationale: Agranulocytosis is characterized by

a reduced number of leukocytes (leucopenia)

and neutrophils (neutropenia) in the blood.

The client is at high risk for infection because

of the decreased body defenses against

microorganisms. Deficient knowledge related

to the nature of the disorder may be

appropriate diagnosis but is not the priority.

24. Answer: (B) Place the client on the left side in

the Trendelenburg position.

Rationale: Lying on the left side may prevent

air from flowing into the pulmonary veins. The

Trendelenburg position increases intrathoracic

pressure, which decreases the amount of

blood pulled into the vena cava during

aspiration.

25. Answer: (A) Autocratic.

Rationale: The autocratic style of leadership is

a task-oriented and directive.

26. Answer: (D) 2.5 cc

Rationale: 2.5 cc is to be added, because only a

500 cc bag of solution is being medicated

instead of a 1 liter.

27. Answer: (A) 50 cc/ hour

Rationale: A rate of 50 cc/hr. The child is to

receive 400 cc over a period of 8 hours = 50

cc/hr.

28. Answer: (B) Assess the client for presence of

pain. Rationale: Assessing the client for pain is a

very important measure. Postoperative pain is

an indication of complication. The nurse

should also assess the client for pain to

provide for the client’s comfort.

29. Answer: (A) BP – 80/60, Pulse – 110 irregular

Rationale: The classic signs of cardiogenic

shock are low blood pressure, rapid and weak

irregular pulse, cold, clammy skin, decreased

urinary output, and cerebral hypoxia.

30. Answer: (A) Take the proper equipment, place

the client in a comfortable position, and

record the appropriate information in the

client’s chart.

Rationale: It is a general or comprehensive

statement about the correct procedure, and it

includes the basic ideas which are found in the

other options

31. Answer: (B) Evaluation

Rationale: Evaluation includes observing the

person, asking questions, and comparing the

patient’s behavioral responses with the

expected outcomes.

32. Answer: (C) History of present illness

Rationale: The history of present illness is the

single most important factor in assisting the

health professional in arriving at a diagnosis or

determining the person’s needs.

33. Answer: (A) Trochanter roll extending from the

crest of the ileum to the mid-thigh.

Rationale: A trochanter roll, properly placed,

provides resistance to the external rotation of

the hip.

34. Answer: (C) Stage III

Rationale: Clinically, a deep crater or without

undermining of adjacent tissue is noted.

35. Answer: (A) Second intention healing

Rationale: When wounds dehisce, they will

allowed to heal by secondary Intention

36. Answer: (D) Tachycardia

Rationale: With an extracellular fluid or plasma

volume deficit, compensatory mechanisms

stimulate the heart, causing an increase in

heart rate.

37. Answer: (A) 0.75

Rationale: To determine the number of

milliliters the client should receive, the nurse

uses the fraction method in the following

equation.

75 mg/X ml = 100 mg/1 ml

To solve for X, cross-multiply:

75 mg x 1 ml = X ml x 100 mg

75 = 100X

75/100 = X

0.75 ml (or ¾ ml) = X

38. Answer: (D) it’s a measure of effect, not a

standard measure of weight or quantity.

Rationale: An insulin unit is a measure of

effect, not a standard measure of weight or

quantity. Different drugs measured in units

may have no relationship to one another in

quality or quantity.

39. Answer: (B) 38.9 °C

Rationale: To convert Fahrenheit degreed to

Centigrade, use this formula

°C = (°F – 32) ÷ 1.8

°C = (102 – 32) ÷ 1.8

°C = 70 ÷ 1.8

°C = 38.9

40. Answer: (C) Failing eyesight, especially close

vision.

Rationale: Failing eyesight, especially close

vision, is one of the first signs of aging in

middle life (ages 46 to 64). More frequent

aches and pains begin in the early late years

(ages 65 to 79). Increase in loss of muscle tone

occurs in later years (age 80 and older).

41. Answer: (A) Checking and taping all

connections

Rationale: Air leaks commonly occur if the

system isn’t secure. Checking all connections

and taping them will prevent air leaks. The

chest drainage system is kept lower to

promote drainage – not to prevent leaks.

42. Answer: (A) Check the client’s identification

band.

Rationale: Checking the client’s identification

band is the safest way to verify a client’s

identity because the band is assigned on

admission and isn’t be removed at any time. (If

it is removed, it must be replaced). Asking the

client’s name or having the client repeated his

name would be appropriate only for a client

who’s alert, oriented, and able to understand

what is being said, but isn’t the safe standard

of practice. Names on bed aren’t always

reliable

43. Answer: (B) 32 drops/minute

Rationale: Giving 1,000 ml over 8 hours is the

same as giving 125 ml over 1 hour (60

minutes). Find the number of milliliters per

minute as follows:

125/60 minutes = X/1 minute

60X = 125 = 2.1 ml/minute

To find the number of drops per minute:

2.1 ml/X gtt = 1 ml/ 15 gtt

X = 32 gtt/minute, or 32 drops/minute

44. Answer: (A) Clamp the catheter

Rationale: If a central venous catheter

becomes disconnected, the nurse should

immediately apply a catheter clamp, if

available. If a clamp isn’t available, the nurse

can place a sterile syringe or catheter plug in

the catheter hub. After cleaning the hub with

alcohol or povidone-iodine solution, the nurse

must replace the I.V. extension and restart the

infusion.

45. Answer: (D) Auscultation, percussion, and

palpation.

Rationale: The correct order of assessment for

examining the abdomen is inspection,

auscultation, percussion, and palpation. The

reason for this approach is that the less

intrusive techniques should be performed

before the more intrusive techniques.

Percussion and palpation can alter natural

findings during auscultation.

46. Answer: (D) Ulnar surface of the hand

Rationale: The nurse uses the ulnar surface, or

ball, of the hand to assess tactile fremitus,

thrills, and vocal vibrations through the chest

wall. The fingertips and finger pads best

distinguish texture and shape. The dorsal

surface best feels warmth.

47. Answer: (C) Formative

Rationale: Formative (or concurrent)

evaluation occurs continuously throughout the

teaching and learning process. One benefit is

that the nurse can adjust teaching strategies

as necessary to enhance learning. Summative,

or retrospective, evaluation occurs at the

conclusion of the teaching and learning

session. Informative is not a type of

evaluation.

48. Answer: (B) Once per year

Rationale: Yearly mammograms should begin

at age 40 and continue for as long as the

woman is in good health. If health risks, such

as family history, genetic tendency, or past

breast cancer, exist, more frequent

examinations may be necessary.

49. Answer: (A) Respiratory acidosis

Rationale: The client has a below-normal

(acidic) blood pH value and an above-normal

partial pressure of arterial carbon dioxide

(Paco2) value, indicating respiratory acidosis.

In respiratory alkalosis, the pH value is above

normal and in the Paco2 value is below

normal. In metabolic acidosis, the pH and

bicarbonate (Hco3) values are below normal.

In metabolic alkalosis, the pH and Hco3 values

are above normal.

50. Answer: (B) To provide support for the client

and family in coping with terminal illness.

Rationale: Hospices provide supportive care

for terminally ill clients and their families.

Hospice care doesn’t focus on counseling

regarding health care costs. Most client

referred to hospices have been treated for

their disease without success and will receive

only palliative care in the hospice.