Foundation Of Nursing Comprehensive Test Part 1- Rnpedia

The most important purpose of handwashing is to prevent the transfer of microorganisms. Handwashing helps to remove bacteria, viruses, and other harmful germs from the hands, reducing the risk of spreading infection to oneself or others. Proper hand hygiene is crucial in healthcare settings, food preparation, and everyday life to maintain good health and prevent the transmission of diseases.

The purpose of a cleansing bed bath is to cleanse, refresh, and provide comfort to a client who is unable to leave their bed. This type of bath helps maintain hygiene, removes dirt and sweat, and promotes a sense of well-being for the client. It is an essential aspect of care for individuals who are bedridden or have limited mobility.

The correct answer is immunity because it refers to the body's ability to defend itself against invading agents such as bacteria, toxins, viruses, and foreign bodies. Immunity is a complex system involving various cells, tissues, and organs that work together to protect the body from harmful pathogens. This includes the production of antibodies, activation of immune cells, and the ability to recognize and destroy foreign substances. Immunity is crucial for maintaining overall health and preventing infections and diseases.

The correct answer is Lungs. The lungs are responsible for the exchange of gases, specifically oxygen and carbon dioxide, in the respiratory system. Oxygen is taken in through inhalation and transported to the bloodstream, while carbon dioxide, a waste product, is removed from the bloodstream and exhaled through exhalation. This gas exchange occurs in the alveoli, tiny air sacs within the lungs, where the thin walls allow for efficient diffusion of gases between the air and blood.

The correct answer is stethoscope. A stethoscope is a medical instrument used for auscultation, which is the process of listening to internal sounds of the body, such as the heartbeat, lung sounds, or bowel sounds. It consists of a chestpiece, which is placed on the patient's body to capture the sounds, and a pair of earpieces for the healthcare professional to listen to the amplified sounds. The stethoscope is an essential tool for doctors, nurses, and other healthcare providers to assess and diagnose various medical conditions.

CBR stands for Complete Bed Rest, which means a patient is advised to stay in bed and avoid any physical activity. This is usually recommended for individuals who are recovering from an illness or injury and need to rest and allow their body to heal. The other options, such as Cardiac Board Room, Complete Bathroom, and Complete Board Room, do not accurately represent the meaning of CBR in a medical context.

Inspection involves the sense of sight. It is a technique where the healthcare professional visually examines the patient's body or specific body parts to gather information about their physical appearance, color, shape, symmetry, movement, and any abnormalities or changes. This technique is commonly used in physical examinations to assess the overall health and identify any visible signs or symptoms of illness or injury.

The stomach is a muscular organ that is located slightly to the left in the abdominal cavity. It serves as a temporary storage site for food that has been ingested. The stomach secretes gastric juices and enzymes that help break down the food into smaller particles, allowing for better digestion and absorption of nutrients. It also has muscular contractions that help mix and propel the food through the digestive system. Therefore, the stomach is the correct answer as it fits the description given in the question.

1800 ml is equal to 1.8 liters because there are 1000 milliliters in 1 liter. Therefore, to convert milliliters to liters, we divide the number of milliliters by 1000. In this case, dividing 1800 by 1000 gives us 1.8 liters.

Bed making refers to the process of preparing a bed with a new set of linens. This typically involves removing the old sheets and pillowcases, and replacing them with fresh ones. It may also include fluffing pillows, arranging the bedspread or duvet, and tucking in the sheets to create a neat and comfortable sleeping surface.

The nurse is implementing the assessment phase of the nursing process. This involves gathering information about the client's chief complaint, abdominal pain and diarrhea, as well as taking vital signs. The assessment phase is crucial in identifying the client's health needs and determining the appropriate course of action.

The correct answer is "All of the above" because Maslow's hierarchy of needs includes all the mentioned clusters of data. Maslow's theory suggests that individuals have different levels of needs, starting from physiological needs (such as food, water, and shelter) to love and belonging (such as social relationships and friendships) and finally to self-actualization (fulfilling one's potential and achieving personal growth). Therefore, all the mentioned clusters of data align with Maslow's hierarchy of needs.

PRN is an abbreviation commonly used in medical contexts, standing for "pro re nata" in Latin, which translates to "when necessary" in English. This term is often used in prescription instructions to indicate that a medication should be taken as needed or when the patient's symptoms require it. Therefore, "when necessary" is the correct meaning of PRN in this context.

The nurse would wear gloves when providing oral hygiene because it involves direct contact with the client's mouth, which can potentially contain bodily fluids or pathogens. Gloves are used as a protective barrier to prevent the transmission of microorganisms from the client to the nurse and vice versa.

The nurse asked the client to read the Snellen chart, which is used to test visual acuity. The Snellen chart measures the client's ability to see and identify letters or symbols at a distance. The optic nerve is responsible for transmitting visual information from the eye to the brain, so testing the client's ability to read the chart would assess the function of the optic nerve. The olfactory nerve is responsible for the sense of smell, the oculomotor nerve controls eye movements, and the trochlear nerve controls certain eye muscles. However, these nerves are not directly involved in reading the Snellen chart.

The correct answer is Sims left lateral. This position is commonly used for administering a cleansing enema. In the Sims left lateral position, the patient lies on their left side with the right knee flexed towards the chest. This position helps to facilitate the flow of the enema solution into the rectum and colon, allowing for effective cleansing. It also helps to minimize discomfort for the patient during the procedure.

Gait refers to the manner in which a person walks. It includes the pattern, rhythm, and characteristics of a person's walking style. Gait analysis is often used in medical and biomechanical studies to assess and diagnose walking abnormalities or conditions. It involves observing and measuring various aspects of the walking pattern, such as stride length, step width, and foot placement. By analyzing gait, healthcare professionals can gain insights into a person's overall musculoskeletal health and identify any abnormalities or issues that may need to be addressed.

Axillary temperature measurement is the best method to assess the client's temperature in this scenario. The client is alert, which means they can cooperate with the nurse during the assessment. Additionally, the client is admitted to the hospital with dehydration, which can affect the accuracy of oral temperature measurement. Axillary temperature measurement is a non-invasive method that involves placing the thermometer in the armpit, making it suitable for this client. Radial temperature measurement is not a commonly used method, and heat sensitive tape is not a reliable method for assessing temperature.

The nursing process is a systematic, rational method of planning and providing nursing care for individuals, families, groups, and communities. It involves several steps, including assessment, diagnosis, implementation, and evaluation. Assessment involves gathering information about the patient's health status, while diagnosis involves identifying the patient's health problems. Implementation involves carrying out the planned interventions, and evaluation involves determining the effectiveness of the interventions. The nursing process helps nurses provide comprehensive and individualized care to their patients.

The nurse documented the client's pulse rate as "Tachycardia" because the term refers to a heart rate that is above normal. Tachycardia is typically defined as a heart rate greater than 100 beats per minute in adults. This finding indicates that the client's heart is beating faster than the normal range, which could be a sign of various underlying conditions or physiological responses.

Insulin is typically administered subcutaneously, which means it is injected into the layer of fat just below the skin. This route of administration allows for a slower and more controlled absorption of insulin into the bloodstream. Intramuscular administration would be inappropriate as it may result in faster absorption and potentially dangerous fluctuations in blood sugar levels. Intradermal administration is used for diagnostic purposes, such as skin testing for allergies, and would not be appropriate for insulin delivery. Intravenous administration would deliver insulin directly into the bloodstream, bypassing the subcutaneous tissue and potentially causing rapid and unpredictable effects on blood sugar levels.

Acute illness refers to a condition that is characterized by severe symptoms that occur suddenly and last for a relatively short duration. Unlike chronic illnesses, which persist over a long period of time, acute illnesses have a rapid onset and typically resolve within a few days or weeks. This distinction is important in understanding the nature and treatment of different medical conditions.

20 cc is equal to 20 ml. The abbreviation "cc" stands for cubic centimeter, which is a unit of volume commonly used in the medical field. One cubic centimeter is equal to one milliliter, so 20 cc is equivalent to 20 ml.

Auscultation is a technique in physical examination that involves listening to the sounds produced by the body, particularly the lungs and airways. By using a stethoscope, the healthcare provider can assess the movement of air through the tracheobronchial tree by listening to the breath sounds. This technique helps in identifying any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can indicate respiratory conditions or diseases. Palpation involves using touch to assess the body, inspection involves visual examination, and percussion involves tapping the body to assess underlying structures. However, for assessing the movement of air through the tracheobronchial tree, auscultation is the most appropriate technique.

The Z-track technique is the best action to prevent tracking of the medication. This technique involves pulling the skin to the side before administering the injection and then releasing it after the medication has been injected. This creates a zigzag path for the medication, preventing it from leaking or tracking along the subcutaneous tissue. Using a small gauge needle may help reduce pain, but it will not prevent tracking. Applying ice on the injection site may help numb the area, but it will not prevent tracking either. Administering at a 45° angle is a common technique for IM injections, but it does not specifically address the issue of preventing tracking.

Insulin is secreted by the Islets of Langerhans in the pancreas. It plays a crucial role in regulating blood glucose levels by promoting the uptake of glucose from the bloodstream into cells. Insulin also helps in the storage of excess glucose as glycogen in the liver and muscles. Deficiency or resistance to insulin leads to diabetes, a condition characterized by high blood sugar levels. Therefore, insulin is an important hormone involved in maintaining normal blood sugar levels in the body.

1 cup is equal to 8 ounces. This is a standard conversion in the United States and is commonly used in cooking and baking recipes.

The correct abbreviation for drops is "Gtts." This abbreviation is derived from the Latin word "guttae," which means drops. The double "t" in "Gtts." represents the plural form of the abbreviation, indicating multiple drops. This abbreviation is commonly used in medical and pharmaceutical contexts to indicate the number of drops to be administered in a medication or solution.

One teaspoon is equivalent to 5 milliliters (ml). Therefore, five teaspoons would be equal to 5 x 5 = 25 ml.

Buccal medication refers to medication that is placed between the client's cheeks and gums. This route of administration allows for direct absorption of the medication into the bloodstream through the oral mucosa. Placing the medication in this area ensures that it is in close proximity to the blood vessels, allowing for efficient absorption. It is important for the nurse to properly place the medication in this location to ensure its effectiveness.

The correct answer is three times a day orally. This means that the nurse should administer the ampicillin capsule three times a day, using the oral route of administration. This is the most appropriate and effective way to ensure that the medication is taken as prescribed and absorbed by the body.

Back care is best described as caring for the back by means of massage. This involves providing therapeutic touch and manipulation of the muscles and tissues in the back to promote relaxation, relieve tension, and improve circulation. Massage can help alleviate back pain, improve flexibility, and enhance overall back health. It is an effective way to prevent and treat various back conditions, such as muscle strains, spasms, and stiffness. Regular massage can also promote a sense of well-being and reduce stress, contributing to overall physical and mental health.

The nurse should use the axillary method to take the client's body temperature. This method involves placing the thermometer under the client's armpit. Given that the client had oral surgery, using the oral method may not be possible or comfortable for the client. The arterial line method is invasive and typically used in critical care settings. The rectal method is not necessary in this situation and may not be appropriate for the client. Therefore, the axillary method is the best option to obtain an accurate body temperature reading.

A community is a group of individuals who share common characteristics or interests and interact with one another. In this context, the given statement describes a community as a collection of people who share some attributes of their lives. This suggests that individuals within a community have certain aspects of their lives in common, such as living in the same area, sharing similar values or beliefs, or participating in similar activities. The concept of a community emphasizes the importance of social connections and mutual support among its members.

The correct answer is µgtt. The abbreviation for micro drop is represented by the symbol µ, which stands for micro, followed by the letters gtt, which stand for drop. Therefore, the correct abbreviation for micro drop is µgtt.

Keeping the side rails up at all times ensures the safety of the client by preventing them from falling out of bed or getting out of bed without assistance. This is especially important for a client who is hospitalized for the first time, as they may be disoriented or unfamiliar with their surroundings. By keeping the side rails up, the client's risk of injury is minimized, and they are less likely to wander or fall.

Inspection is the first technique used to examine the abdomen of a client because it involves visually observing and assessing the appearance of the abdomen. This can provide important information about any visible abnormalities, such as scars, rashes, or distension. Palpation, auscultation, and percussion are typically performed after inspection to gather further information about the abdomen's texture, sounds, and underlying structures. However, inspection is the initial step as it allows the healthcare provider to gain a general overview and identify any obvious abnormalities before proceeding with more detailed examinations.

To prevent contaminating the environment in bed making, it is important to avoid running soiled linens. This means not shaking or handling dirty linens in a way that can spread any contaminants or pathogens into the air or onto other surfaces. By avoiding this action, the risk of spreading contaminants and potentially harming the environment is minimized.

When performing mouth care on an unconscious client, the best position is side lying. This position allows for proper drainage of saliva and prevents aspiration. It also helps to maintain the airway and prevent choking. Fowler's position, supine position, and Trendelenburg position are not ideal for mouth care as they may cause complications such as choking or aspiration.

The client's difficulty swallowing may be due to the size or texture of the capsule. By checking the availability of a liquid preparation, the nurse can provide an alternative form of medication that the client can easily swallow without any difficulty. This ensures that the client receives the necessary medication in a safe and effective manner. Dissolving the capsule in water or breaking it and mixing it with applesauce may not be suitable options as they may still pose a challenge for the client to swallow. Placing the capsule under the tongue may not be appropriate as it may not be absorbed properly.

Resonance is best described as sounds created by air-filled lungs. This means that when air passes through the lungs, it produces certain sounds. This explanation suggests that resonance is related to the production of sound by the lungs, indicating that it is a physiological process.

The nurse's role in health promotion includes educating and empowering clients to make informed decisions about their health. By teaching clients to be effective health consumers, the nurse helps them understand the importance of preventive care, making healthy lifestyle choices, and seeking appropriate healthcare services. This role involves providing information on available resources, promoting self-care practices, and encouraging active participation in healthcare decision-making. Through this education, the nurse aims to improve the client's overall health outcomes and promote a sense of ownership and responsibility for their own well-being.

To use a wide base support when assisting a client to get up in a chair, the nurse should face the client, bend their knees, and place their hands on the client's forearm to provide support and lift. This position allows the nurse to have a stable and balanced stance, distributing their weight evenly and reducing the risk of injury to both the nurse and the client. By bending the knees, the nurse can use the strength of their leg muscles to lift the client, rather than relying solely on their back or arm strength. Placing hands on the client's forearm provides a secure grip and helps maintain control during the transfer.

The left atrium of the heart receives oxygenated blood from the lungs. This is because after the blood is oxygenated in the lungs, it is returned to the heart via the pulmonary veins. The pulmonary veins carry the oxygenated blood to the left atrium, which then pumps it into the left ventricle to be circulated to the rest of the body.

The safest way to identify the client before administering medication is to ask the client his name. This ensures that the medication is being given to the correct person and helps prevent any potential errors or mix-ups. Checking the client's identification band and stating the client's name aloud and having the client repeat it can also be helpful, but asking the client directly is the most reliable method. Checking the room number alone is not sufficient for verifying the client's identity.

The correct answer is "Genu-pectoral." The knee-chest position is a medical position where the patient is positioned on their knees with their chest resting on the examination table. In this position, the hips are flexed, and the thighs are perpendicular to the table. The term "genu-pectoral" is derived from Latin, where "genu" means knee and "pectoral" refers to the chest. Therefore, "genu-pectoral" accurately describes the knee-chest position.

The knee-chest position is the best position for examining the rectum. In this position, the patient kneels on the examination table with their chest and knees touching the surface. This position allows for optimal access and visualization of the rectum, as it helps to relax the pelvic muscles and open up the rectal area. It also allows for better manipulation and insertion of instruments if necessary. The prone position, Sim's position, and lithotomy position may also be used for rectal examinations, but the knee-chest position is considered the most effective.

The cornea is a transparent membrane that is responsible for focusing the light that enters the eyes onto the retina. It acts as a protective covering for the front of the eye and helps to refract light, allowing it to pass through the pupil and reach the retina. The cornea plays a crucial role in clear vision and is essential for proper eye function.

Orem's theory of self-care deficit focuses on the individual's ability to meet their own self-care needs. This includes the maintenance of a sufficient intake of air, which is essential for sustaining life. Orem emphasizes the importance of individuals being able to independently meet their physiological needs, such as breathing, in order to maintain their overall health and well-being. Therefore, the inclusion of "Maintenance of a sufficient intake of air" aligns with Orem's theory.

One teaspoon is equal to 60 drops.