Answers and Rationale –Test I Foundation of Professional Nursing Practice part 2

Answers and Rationale –Test I Foundation of Professional Nursing Practice part 2

51. Answer: (C) Using normal saline solution to

clean the ulcer and applying a protective

dressing as necessary.

Rationale: Washing the area with normal

saline solution and applying a protective

dressing are within the nurse’s realm of

interventions and will protect the area. Using a

povidone-iodine wash and an antibiotic cream

require a physician’s order. Massaging with an

astringent can further damage the skin.

52. Answer: (D) Foot

Rationale: An elastic bandage should be

applied form the distal area to the proximal

area. This method promotes venous return. In

this case, the nurse should begin applying the

bandage at the client’s foot. Beginning at the

ankle, lower thigh, or knee does not promote

venous return.

53. Answer: (B) Hypokalemia

Rationale: Insulin administration causes

glucose and potassium to move into the cells,

causing hypokalemia.

54. Answer: (A) Throbbing headache or dizziness

Rationale: Headache and dizziness often occur

when nitroglycerin is taken at the beginning of

therapy. However, the client usually develops

tolerance

55. Answer: (D) Check the client’s level of

consciousness

Rationale: Determining unresponsiveness is

the first step assessment action to take. When

a client is in ventricular tachycardia, there is a

significant decrease in cardiac output.

However, checking the unresponsiveness

ensures whether the client is affected by the

decreased cardiac output.

56. Answer: (B) On the affected side of the client.

Rationale: When walking with clients, the

nurse should stand on the affected side and

grasp the security belt in the midspine area of

the small of the back. The nurse should

position the free hand at the shoulder area so

that the client can be pulled toward the nurse

in the event that there is a forward fall. The

client is instructed to look up and outward

rather than at his or her feet.

57. Answer: (A) Urine output: 45 ml/hr

Rationale: Adequate perfusion must be

maintained to all vital organs in order for the

client to remain visible as an organ donor. A

urine output of 45 ml per hour indicates

adequate renal perfusion. Low blood pressure

and delayed capillary refill time are circulatory

system indicators of inadequate perfusion. A

serum pH of 7.32 is acidotic, which adversely

affects all body tissues.

58. Answer: (D ) Obtaining the specimen from the

urinary drainage bag.

Rationale: A urine specimen is not taken from

the urinary drainage bag. Urine undergoes

chemical changes while sitting in the bag and

does not necessarily reflect the current client

status. In addition, it may become

contaminated with bacteria from opening the

system.

59. Answer: (B) Cover the client, place the call

light within reach, and answer the phone call.

Rationale: Because telephone call is an

emergency, the nurse may need to answer it.

The other appropriate action is to ask another

nurse to accept the call. However, is not one of

the options. To maintain privacy and safety,

the nurse covers the client and places the call

light within the client’s reach. Additionally, the

client’s door should be closed or the room

curtains pulled around the bathing area.

60. Answer: (C) Use a sterile plastic container for

obtaining the specimen.

Rationale: Sputum specimens for culture and

sensitivity testing need to be obtained using

sterile techniques because the test is done to

determine the presence of organisms. If the

procedure for obtaining the specimen is not

sterile, then the specimen is not sterile, then

the specimen would be contaminated and the

results of the test would be invalid.

61. Answer: (A) Puts all the four points of the

walker flat on the floor, puts weight on the

hand pieces, and then walks into it.

Rationale: When the client uses a walker, the

nurse stands adjacent to the affected side. The

client is instructed to put all four points of the

walker 2 feet forward flat on the floor before

putting weight on hand pieces. This will ensure

client safety and prevent stress cracks in the

walker. The client is then instructed to move

the walker forward and walk into it.

62. Answer: (C) Draws one line to cross out the

incorrect information and then initials the

change.

Rationale: To correct an error documented in a

medical record, the nurse draws one line

through the incorrect information and then

initials the error. An error is never erased and

correction fluid is never used in the medical

record.

63. Answer: (C) Secures the client safety belts

after transferring to the stretcher.

Rationale: During the transfer of the client

after the surgical procedure is complete, the

nurse should avoid exposure of the client

because of the risk for potential heat loss.

Hurried movements and rapid changes in the

position should be avoided because these

predispose the client to hypotension. At the

time of the transfer from the surgery table to

the stretcher, the client is still affected by the

effects of the anesthesia; therefore, the client

should not move self. Safety belts can prevent

the client from falling off the stretcher.

64. Answer: (B) Gown and gloves

Rationale: Contact precautions require the use

of gloves and a gown if direct client contact is

anticipated. Goggles are not necessary unless

the nurse anticipates the splashes of blood,

body fluids, secretions, or excretions may

occur. Shoe protectors are not necessary.

65. Answer: (C) Quad cane

Rationale: Crutches and a walker can be

difficult to maneuver for a client with

weakness on one side. A cane is better suited

for client with weakness of the arm and leg on

one side. However, the quad cane would

provide the most stability because of the

structure of the cane and because a quad cane

has four legs.                                                   

66. Answer: (D) Left side-lying with the head of

the bed elevated 45 degrees.

Rationale: To facilitate removal of fluid from

the chest wall, the client is positioned sitting at

the edge of the bed leaning over the bedside

table with the feet supported on a stool. If the

client is unable to sit up, the client is

positioned lying in bed on the unaffected side

with the head of the bed elevated 30 to 45

degrees.

67. Answer: (D) Reliability

Rationale: Reliability is consistency of the

research instrument. It refers to the

repeatability of the instrument in extracting

the same responses upon its repeated

administration.

68. Answer: (A) Keep the identities of the subject

secret

Rationale: Keeping the identities of the

research subject secret will ensure anonymity

because this will hinder providing link between

the information given to whoever is its source.

69. Answer: (A) Descriptive- correlational

Rationale: Descriptive- correlational study is

the most appropriate for this study because it

studies the variables that could be the

antecedents of the increased incidence of

nosocomial infection.

70. Answer: (C) Use of laboratory data

Rationale: Incidence of nosocomial infection is

best collected through the use of

biophysiologic measures, particularly in vitro

measurements, hence laboratory data is

essential.

71. Answer: (B) Quasi-experiment

Rationale: Quasi-experiment is done when

randomization and control of the variables are

not possible.

72. Answer: (C) Primary source

Rationale: This refers to a primary source

which is a direct account of the investigation

done by the investigator. In contrast to this is a

secondary source, which is written by

someone other than the original researcher.             

73. Answer: (A) Non-maleficence

Rationale: Non-maleficence means do not

cause harm or do any action that will cause

any harm to the patient/client. To do good is

referred as beneficence.         

74. Answer: (C) Res ipsa loquitor

Rationale: Res ipsa loquitor literally means the

thing speaks for itself. This means in

operational terms that the injury caused is the

proof that there was a negligent act.       

75. Answer: (B) The Board can investigate

violations of the nursing law and code of ethics

Rationale: Quasi-judicial power means that the

Board of Nursing has the authority to

investigate violations of the nursing law and

can issue summons, subpoena or subpoena

duces tecum as needed.

76. Answer: (C) May apply for re-issuance of

his/her license based on certain conditions

stipulated in RA 9173

Rationale: RA 9173 sec. 24 states that for

equity and justice, a revoked license maybe reissued

provided that the following conditions

are met: a) the cause for revocation of license

has already been corrected or removed; and,

b) at least four years has elapsed since the

license has been revoked.         

77. Answer: (B) Review related literature

Rationale: After formulating and delimiting the

research problem, the researcher conducts a

review of related literature to determine the

extent of what has been done on the study by

previous researchers.

78. Answer: (B) Hawthorne effect

Rationale: Hawthorne effect is based on the

study of Elton Mayo and company about the

effect of an intervention done to improve the

working conditions of the workers on their

productivity. It resulted to an increased

productivity but not due to the intervention

but due to the psychological effects of being

observed. They performed differently because

they were under observation.

79. Answer: (B) Determines the different

nationality of patients frequently admitted and

decides to get representations samples from

each.

Rationale: Judgment sampling involves

including samples according to the knowledge

of the investigator about the participants in

the study.

80. Answer: (B) Madeleine Leininger

Rationale: Madeleine Leininger developed the

theory on transcultural theory based on her

observations on the behavior of selected

people within a culture.

81. Answer: (A) Random

Rationale: Random sampling gives equal

chance for all the elements in the population

to be picked as part of the sample.

82. Answer: (A) Degree of agreement and

disagreement

Rationale: Likert scale is a 5-point summated

scale used to determine the degree of

agreement or disagreement of the

respondents to a statement in a study       

83. Answer: (B) Sr. Callista Roy

Rationale: Sr. Callista Roy developed the

Adaptation Model which involves the

physiologic mode, self-concept mode, role

function mode and dependence mode.

84. Answer: (A) Span of control

Rationale: Span of control refers to the

number of workers who report directly to a

manager.

85. Answer: (B) Autonomy

Rationale: Informed consent means that the

patient fully understands about the surgery,

including the risks involved and the alternative

solutions. In giving consent it is done with full

knowledge and is given freely. The action of

allowing the patient to decide whether a

surgery is to be done or not exemplifies the

bioethical principle of autonomy.

86. Answer: (C) Avoid wearing canvas shoes.

Rationale: The client should be instructed to

avoid wearing canvas shoes. Canvas shoes

cause the feet to perspire, which may, in turn,

cause skin irritation and breakdown. Both

cotton and cornstarch absorb perspiration.

The client should be instructed to cut toenails

straight across with nail clippers.

87. Answer: (D) Ground beef patties

Rationale: Meat is an excellent source of

complete protein, which this client needs to

repair the tissue breakdown caused by

pressure ulcers. Oranges and broccoli supply

vitamin C but not protein. Ice cream supplies

only some incomplete protein, making it less

helpful in tissue repair.                                           

88. Answer: (D) Sims’ left lateral

Rationale: The Sims' left lateral position is the

most common position used to administer a

cleansing enema because it allows gravity to

aid the flow of fluid along the curve of the

sigmoid colon. If the client can't assume this

position nor has poor sphincter control, the

dorsal recumbent or right lateral position may

be used. The supine and prone positions are

inappropriate and uncomfortable for the

client.                                    

89. Answer: (A) Arrange for typing and cross

matching of the client’s blood.

Rationale: The nurse first arranges for typing

and cross matching of the client's blood to

ensure compatibility with donor blood. The

other options, although appropriate when

preparing to administer a blood transfusion,

come later.

90. Answer: (A) Independent

Rationale: Nursing interventions are classified

as independent, interdependent, or

dependent. Altering the drug schedule to

coincide with the client's daily routine

represents an independent intervention,

whereas consulting with the physician and

pharmacist to change a client's medication

because of adverse reactions represents an

interdependent intervention. Administering an

already-prescribed drug on time is a

dependent intervention. An intradependent

nursing intervention doesn't exist.              

91. Answer: (D) Evaluation

Rationale: The nursing actions described

constitute evaluation of the expected

outcomes. The findings show that the

expected outcomes have been achieved.

Assessment consists of the client's history,

physical examination, and laboratory studies.

Analysis consists of considering assessment

information to derive the appropriate nursing

diagnosis. Implementation is the phase of the

nursing process where the nurse puts the plan

of care into action.                   

92. Answer: (B) To observe the lower extremities

Rationale: Elastic stockings are used to

promote venous return. The nurse needs to

remove them once per day to observe the

condition of the skin underneath the stockings.

Applying the stockings increases blood flow to

the heart. When the stockings are in place, the

leg muscles can still stretch and relax, and the

veins can fill with blood.                 

93. Answer :(A) Instructing the client to report any

itching, swelling, or dyspnea.

Rationale: Because administration of blood or

blood products may cause serious adverse

effects such as allergic reactions, the nurse

must monitor the client for these effects. Signs

and symptoms of life-threatening allergic

reactions include itching, swelling, and

dyspnea. Although the nurse should inform

the client of the duration of the transfusion

and should document its administration, these

actions are less critical to the client's

immediate health. The nurse should assess

vital signs at least hourly during the

transfusion.                    

94. Answer: (B) Decrease the rate of feedings and

the concentration of the formula.

Rationale: Complaints of abdominal

discomfort and nausea are common in clients

receiving tube feedings. Decreasing the rate of

the feeding and the concentration of the

formula should decrease the client's

discomfort. Feedings are normally given at

room temperature to minimize abdominal

cramping. To prevent aspiration during

feeding, the head of the client's bed should be

elevated at least 30 degrees. Also, to prevent

bacterial growth, feeding containers should be

routinely changed every 8 to 12 hours.

95. Answer: (D) Roll the vial gently between the

palms.

Rationale: Rolling the vial gently between the

palms produces heat, which helps dissolve the

medication. Doing nothing or inverting the vial

wouldn't help dissolve the medication. Shaking

the vial vigorously could cause the medication

to break down, altering its action.         

96. Answer: (B) Assist the client to the semi-

Fowler position if possible.

Rationale: By assisting the client to the semi-

Fowler position, the nurse promotes easier

chest expansion, breathing, and oxygen intake.

The nurse should secure the elastic band so

that the face mask fits comfortably and snugly

rather than tightly, which could lead to

irritation. The nurse should apply the face

mask from the client's nose down to the chin

— not vice versa. The nurse should check the

connectors between the oxygen equipment

and humidifier to ensure that they're airtight;

loosened connectors can cause loss of oxygen.

97. Answer: (B) 4 hours

Rationale: A unit of packed RBCs may be given

over a period of between 1 and 4 hours. It

shouldn't infuse for longer than 4 hours

because the risk of contamination and sepsis

increases after that time. Discard or return to

the blood bank any blood not given within this

time, according to facility policy.

98. Answer: (B) Immediately before administering

the next dose.

Rationale: Measuring the blood drug

concentration helps determine whether the

dosing has achieved the therapeutic goal. For

measurement of the trough, or lowest, blood

level of a drug, the nurse draws a blood

sample immediately before administering the

next dose. Depending on the drug's duration

of action and half-life, peak blood drug levels

typically are drawn after administering the

next dose.

99. Answer: (A) The nurse can implement

medication orders quickly.

Rationale: A floor stock system enables the

nurse to implement medication orders quickly.

It doesn't allow for pharmacist input, nor does

it minimize transcription errors or reinforce

accurate calculations.

100. Answer: (C) Shifting dullness over the

abdomen.

Rationale: Shifting dullness over the abdomen

indicates ascites, an abnormal finding. The

other options are normal abdominal findings.