ANSWERS AND RATIONALE –PRACTICE TEST 1 FOUNDATION OF NURSING

ANSWERS AND RATIONALE –PRACTICE TEST 1  FOUNDATION OF

NURSING

1. D. In the circular chain of infection, pathogens

must be able to leave their reservoir and be

transmitted to a susceptible host through a

portal of entry, such as broken skin.

2. C. Respiratory isolation, like strict isolation,

requires that the door to the door patient’s

room remain closed. However, the patient’s

room should be well ventilated, so opening the

window or turning on the ventricular is

desirable. The nurse does not need to wear

gloves for respiratory isolation, but good hand

washing is important for all types of isolation.

3. A. Leukopenia is a decreased number of

leukocytes (white blood cells), which are

important in resisting infection. None of the

other situations would put the patient at risk for

contracting an infection; taking broad- spectrum

antibiotics might actually reduce the infection

risk.

4. A. Soaps and detergents are used to help

remove bacteria because of their ability to lower

the surface tension of water and act as

emulsifying agents. Hot water may lead to skin

irritation or burns.

5. A. Depending on the degree of exposure to

pathogens, hand washing may last from 10

seconds to 4 minutes. After routine patient

contact, hand washing for 30 seconds effectively

minimizes the risk of pathogen transmission.

6. B. The urinary system is normally free of

microorganisms except at the urinary meatus.

Any procedure that involves entering this system

must use surgically aseptic measures to maintain

a bacteria-free state.

7. C. All invasive procedures, including surgery,

catheter insertion, and administration of

parenteral therapy, require sterile technique to

maintain a sterile environment. All equipment

must be sterile, and the nurse and the physician

must wear sterile gloves and maintain surgical

asepsis. In the operating room, the nurse and

physician are required to wear sterile gowns,

gloves, masks, hair covers, and shoe covers for

all invasive procedures. Strict isolation requires

the use of clean gloves, masks, gowns and

equipment to prevent the transmission of highly

communicable diseases by contact or by

airborne routes. Terminal disinfection is the

disinfection of all contaminated supplies and

equipment after a patient has been discharged

to prepare them for reuse by another patient.

The purpose of protective (reverse) isolation is

to prevent a person with seriously impaired

resistance from coming into contact who

potentially pathogenic organisms.

8. C. The edges of a sterile field are considered

contaminated. When sterile items are allowed to

come in contact with the edges of the field, the

sterile items also become contaminated.

9. B. Hair on or within body areas, such as the

nose, traps and holds particles that contain

microorganisms. Yawning and hiccupping do not

prevent microorganisms from entering or

leaving the body. Rapid eye movement marks

the stage of sleep during which dreaming occurs.

10. D. The inside of the glove is always considered to

be clean, but not sterile.

11. A. The back of the gown is considered clean, the

front is contaminated. So, after removing gloves

and washing hands, the nurse should untie the

back of the gown; slowly move backward away

from the gown, holding the inside of the gown

and keeping the edges off the floor; turn and

fold the gown inside out; discard it in a

contaminated linen container; then wash her

hands again.

12. B. According to the Centers for Disease Control

(CDC), blood-to-blood contact occurs most

commonly when a health care worker attempts

to cap a used needle. Therefore, used needles

should never be recapped; instead they should

be inserted in a specially designed puncture

resistant, labeled container. Wearing gloves is

not always necessary when administering an I.M.

injection. Enteric precautions prevent the

transfer of pathogens via feces.

13. A. Nurses and other health care professionals

previously believed that massaging a reddened

area with lotion would promote venous return

and reduce edema to the area. However,

research has shown that massage only increases

the likelihood of cellular ischemia and necrosis

to the area.

14. B. Before a blood transfusion is performed, the

blood of the donor and recipient must be

checked for compatibility. This is done by blood

typing (a test that determines a person’s blood

type) and cross-matching (a procedure that

determines the compatibility of the donor’s and

recipient’s blood after the blood types has been

matched). If the blood specimens are

incompatible, hemolysis and antigen-antibody

reactions will occur.

15. A. Platelets are disk-shaped cells that are

essential for blood coagulation. A platelet count

determines the number of thrombocytes in

blood available for promoting hemostasis and

assisting with blood coagulation after injury. It

also is used to evaluate the patient’s potential

for bleeding; however, this is not its primary

purpose. The normal count ranges from 150,000

to 350,000/mm3. A count of 100,000/mm3 or

less indicates a potential for bleeding; count of

less than 20,000/mm3 is associated with

spontaneous bleeding.

16. D. Leukocytosis is any transient increase in the

number of white blood cells (leukocytes) in the

blood. Normal WBC counts range from 5,000 to

100,000/mm3. Thus, a count of 25,000/mm3

indicates leukocytosis.

17. A. Fatigue, muscle cramping, and muscle

weaknesses are symptoms of hypokalemia (an

inadequate potassium level), which is a potential

side effect of diuretic therapy. The physician

usually orders supplemental potassium to

prevent hypokalemia in patients receiving

diuretics. Anorexia is another symptom of

hypokalemia. Dysphagia means difficulty

swallowing.

18. A. Pregnancy or suspected pregnancy is the only

contraindication for a chest X-ray. However, if a

chest X-ray is necessary, the patient can wear a

lead apron to protect the pelvic region from

radiation. Jewelry, metallic objects, and buttons

would interfere with the X-ray and thus should

not be worn above the waist. A signed consent is

not required because a chest X-ray is not an

invasive examination. Eating, drinking and

medications are allowed because the X-ray is of

the chest, not the abdominal region.

19. A. Obtaining a sputum specimen early in this

morning ensures an adequate supply of bacteria

for culturing and decreases the risk of

contamination from food or medication.

20. A. Initial sensitivity to penicillin is commonly

manifested by a skin rash, even in individuals

who have not been allergic to it previously.

Because of the danger of anaphylactic shock, he

nurse should withhold the drug and notify the

physician, who may choose to substitute

another drug. Administering an antihistamine is

a dependent nursing intervention that requires a

written physician’s order. Although applying

corn starch to the rash may relieve discomfort, it

is not the nurse’s top priority in such a

potentially life-threatening situation.

21. D. The Z-track method is an I.M. injection

technique in which the patient’s skin is pulled in

such a way that the needle track is sealed off

after the injection. This procedure seals

medication deep into the muscle, thereby

minimizing skin staining and irritation. Rubbing

the injection site is contraindicated because it

may cause the medication to extravasate into

the skin.

22. D. The vastus lateralis, a long, thick muscle that

extends the full length of the thigh, is viewed by

many clinicians as the site of choice for I.M.

injections because it has relatively few major

nerves and blood vessels. The middle third of the

muscle is recommended as the injection site.

The patient can be in a supine or sitting position

for an injection into this site.

23. A. The mid-deltoid injection site can

accommodate only 1 ml or less of medication

because of its size and location (on the deltoid

muscle of the arm, close to the brachial artery

and radial nerve).

24. D. A 25G, 5/8” needle is the recommended size

for insulin injection because insulin is

administered by the subcutaneous route. An

18G, 1 ½” needle is usually used for I.M.

injections in children, typically in the vastus

lateralis. A 22G, 1 ½” needle is usually used for

adult I.M. injections, which are typically

administered in the vastus lateralis or

ventrogluteal site.

25. D. Because an intradermal injection does not

penetrate deeply into the skin, a small-bore 25G

needle is recommended. This type of injection is

used primarily to administer antigens to

evaluate reactions for allergy or sensitivity

studies. A 20G needle is usually used for I.M.

injections of oil- based medications; a 22G

needle for I.M. injections; and a 25G needle, for

I.M. injections; and a 25G needle, for

subcutaneous insulin injections.

26. A. Parenteral penicillin can be administered I.M.

or added to a solution and given I.V. It cannot be

administered subcutaneously or intradermally.

27. D. gr 10 x 60mg/gr 1 = 600 mg

28. C. 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

29. A. Hemoglobinuria, the abnormal presence of

hemoglobin in the urine, indicates a hemolytic

reaction (incompatibility of the donor’s and

recipient’s blood). In this reaction, antibodies in

the recipient’s plasma combine rapidly with

donor RBC’s; the cells are hemolyzed in either

circulatory or reticuloendothelial system.

Hemolysis occurs more rapidly in ABO

incompatibilities than in Rh incompatibilities.

Chest pain and urticarial may be symptoms of

impending anaphylaxis. Distended neck veins are

an indication of hypervolemia.

30. C. In real failure, the kidney loses their ability to

effectively eliminate wastes and fluids. Because

of this, limiting the patient’s intake of oral and

I.V. fluids may be necessary. Fever, chronic

obstructive pulmonary disease, and dehydration

are conditions for which fluids should be

encouraged.

31. D. Phlebitis, the inflammation of a vein, can be

caused by chemical irritants (I.V. solutions or

medications), mechanical irritants (the needle or

catheter used during venipuncture or

cannulation), or a localized allergic reaction to

the needle or catheter. Signs and symptoms of

phlebitis include pain or discomfort, edema and

heat at the I.V. insertion site, and a red streak

going up the arm or leg from the I.V. insertion

site.

32. D. Return demonstration provides the most

certain evidence for evaluating the effectiveness

of patient teaching.

33. D. Capsules, enteric-coated tablets, and most

extended duration or sustained release products

should not be dissolved for use in a gastrostomy

tube. They are pharmaceutically manufactured

in these forms for valid reasons, and altering

them destroys their purpose. The nurse should

seek an alternate physician’s order when an

ordered medication is inappropriate for delivery

by tube.

34. D. A drug-allergy is an adverse reaction resulting

from an immunologic response following a

previous sensitizing exposure to the drug. The

reaction can range from a rash or hives to

anaphylactic shock. Tolerance to a drug means

that the patient experiences a decreasing

physiologic response to repeated administration

of the drug in the same dosage. Idiosyncrasy is

an individual’s unique hypersensitivity to a drug,

food, or other substance; it appears to be

genetically determined. Synergism, is a drug

interaction in which the sum of the drug’s

combined effects is greater than that of their

separate effects.

35. D. A hemoglobin and hematocrit count would be

ordered by the physician if bleeding were

suspected. The other answers are appropriate

nursing interventions for a patient who has

undergone femoral arteriography.

36. A. Coughing, a protective response that clears

the respiratory tract of irritants, usually is

involuntary; however it can be voluntary, as

when a patient is taught to perform coughing

exercises. An antitussive drug inhibits coughing.

Splinting the abdomen supports the abdominal

muscles when a patient coughs.

37. C. In an infected patient, shivering results from

the body’s attempt to increase heat production

and the production of neutrophils and

phagocytotic action through increased skeletal

muscle tension and contractions. Initial

vasoconstriction may cause skin to feel cold to

the touch. Applying additional bed clothes helps

to equalize the body temperature and stop the

chills. Attempts to cool the body result in further

shivering, increased metabloism, and thus

increased heat production.

38. D. A clinical nurse specialist must have

completed a master’s degree in a clinical

specialty and be a registered professional nurse.

The National League of Nursing accredits

educational programs in nursing and provides a

testing service to evaluate student nursing

competence but it does not certify nurses. The

American Nurses Association identifies

requirements for certification and offers

examinations for certification in many areas of

nursing, such as medical surgical nursing. These

certification (credentialing) demonstrates that

the nurse has the knowledge and the ability to

provide high quality nursing care in the area of

her certification. A graduate of an associate

degree program is not a clinical nurse specialist:

however, she is prepared to provide bed side

nursing with a high degree of knowledge and

skill. She must successfully complete the

licensing examination to become a registered

professional nurse.

39. D. Microorganisms usually do not grow in an

acidic environment.

40. D. Bile colors the stool brown. Any inflammation

or obstruction that impairs bile flow will affect

the stool pigment, yielding light, clay-colored

stool. Upper GI bleeding results in black or tarry

stool. Constipation is characterized by small,

hard masses. Many medications and foods will

discolor stool – for example, drugs containing

iron turn stool black.; beets turn stool red.

41. D. In the evaluation step of the nursing process,

the nurse must decide whether the patient has

achieved the expected outcome that was

identified in the planning phase.

42. A. The main sources of vitamin A are yellow and

green vegetables (such as carrots, sweet

potatoes, squash, spinach, collard greens,

broccoli, and cabbage) and yellow fruits (such as

apricots, and cantaloupe). Animal sources

include liver, kidneys, cream, butter, and egg

yolks.

43. D. Maintaing the drainage tubing and collection

bag level with the patient’s bladder could result

in reflux of urine into the kidney. Irrigating the

bladder with Neosporin and clamping the

catheter for 1 hour every 4 hours must be

prescribed by a physician.

44. D. The ELISA test of venous blood is used to

assess blood and potential blood donors to

human immunodeficiency virus (HIV). A positive

ELISA test combined with various signs and

symptoms helps to diagnose acquired

immunodeficiency syndrome (AIDS)

45. D. Tachypnea (an abnormally rapid rate of

breathing) would indicate that the patient was

still hypoxic (deficient in oxygen).The partial

pressures of arterial oxygen and carbon dioxide

listed are within the normal range. Eupnea refers

to normal respiration.

46. D. Studies have shown that showering with an

antiseptic soap before surgery is the most

effective method of removing microorganisms

from the skin. Shaving the site of the intended

surgery might cause breaks in the skin, thereby

increasing the risk of infection; however, if

indicated, shaving, should be done immediately

before surgery, not the day before. A topical

antiseptic would not remove microorganisms

and would be beneficial only after proper

cleaning and rinsing. Tub bathing might transfer

organisms to another body site rather than rinse

them away.

47. C. The leg muscles are the strongest muscles in

the body and should bear the greatest stress

when lifting. Muscles of the abdomen, back, and

upper arms may be easily injured.

48. C. The factors, known as Virchow’s triad,

collectively predispose a patient to

thromboplebitis; impaired venous return to the

heart, blood hypercoagulability, and injury to a

blood vessel wall. Increased partial

thromboplastin time indicates a prolonged

bleeding time during fibrin clot formation,

commonly the result of anticoagulant (heparin)

therapy. Arterial blood disorders (such as pulsus

paradoxus) and lung diseases (such as COPD) do

not necessarily impede venous return of injure

vessel walls.

49. A. Because of restricted respiratory movement, a

recumbent, immobilize patient is at particular

risk for respiratory acidosis from poor gas

exchange; atelectasis from reduced surfactant

and accumulated mucus in the bronchioles, and

hypostatic pneumonia from bacterial growth

caused by stasis of mucus secretions.

50. B. The immobilized patient commonly suffers

from urine retention caused by decreased

muscle tone in the perineum. This leads to

bladder distention and urine stagnation, which

provide an excellent medium for bacterial

growth leading to infection. Immobility also

results in more alkaline urine with excessive

amounts of calcium, sodium and phosphate, a

gradual decrease in urine production, and an

increased specific gravity.