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Sunday, October 26, 2014

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.

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