Foundation Of Nursing Test I - Set A

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 recognize and eliminate harmful substances. It includes both innate immunity, which provides immediate but non-specific defense, and adaptive immunity, which develops over time and provides specific defense against particular pathogens. Hormones, secretion, and glands are not directly related to the body's defense mechanisms against invading agents.

The exchange of gases takes place in the lungs. The lungs are responsible for the intake of oxygen and the removal of carbon dioxide from the body. Oxygen from the air we breathe enters the lungs and is transferred to the bloodstream, while carbon dioxide, a waste product, is removed from the bloodstream and exhaled out of the body. This process of gas exchange occurs in the tiny air sacs called alveoli, which are present in the lungs.

In this scenario, the nurse is implementing the assessment phase of the nursing process. Assessment involves gathering information about the client's health status, including their chief complaint, vital signs, and any other relevant data. By taking the client's vital signs, the nurse is collecting objective data that will help in further evaluation and decision-making. The assessment phase is crucial in identifying the client's needs and formulating an appropriate plan of care.

1800 ml is equal to 1.8 liters because there are 1000 milliliters in a liter. To convert milliliters to liters, we divide the given value by 1000. Therefore, 1800 divided by 1000 equals 1.8.

Maslow's hierarchy of needs is a theory that suggests that individuals have different levels of needs that must be fulfilled in order to achieve self-actualization. The hierarchy includes physiological needs (such as food, water, and shelter), love and belonging needs (such as social relationships and friendships), and self-actualization needs (such as personal growth and fulfillment). Therefore, all of the given options, including love and belonging, physiological needs, and self-actualization, belong to Maslow's hierarchy of needs.

The given correct answer is "Nursing Process." The nursing process is a systematic and rational method used by nurses to plan and provide care for individuals, families, groups, and communities. It involves several steps, including assessment (collecting data about the patient's health status), diagnosis (identifying the patient's health problems and needs), planning (setting goals and developing a care plan), implementation (carrying out the planned interventions), and evaluation (assessing the effectiveness of the interventions). The nursing process helps nurses to provide holistic and individualized care to their patients.

When providing oral hygiene, the nurse would wear gloves to protect both the nurse and the client from potential transmission of microorganisms through contact with saliva, blood, or other body fluids. This is in line with the principles of standard precautions, which aim to prevent the spread of infection and ensure the safety of healthcare workers and patients. Wearing gloves during oral hygiene procedures helps to minimize the risk of cross-contamination and maintain proper infection control practices.

The nurse should use the axillary method to take the client's body temperature. This method involves placing the thermometer in the client's armpit and is a reliable and non-invasive way to measure body temperature. It is particularly suitable for clients who have undergone oral surgery, as using the oral method may be uncomfortable or not possible due to pain or swelling in the mouth. The flushed and warm skin may indicate an elevated body temperature, and using the axillary method can provide an accurate measurement to assess the client's condition.

Axillary temperature measurement is the best method to assess the client's temperature in this scenario. The client is admitted with dehydration secondary to vomiting and diarrhea, which can cause fluctuations in body temperature. Axillary temperature measurement involves placing the thermometer in the armpit, which provides a close approximation of core body temperature. This method is non-invasive, easy to perform, and suitable for alert clients. It is a reliable option for assessing temperature in this situation.

The correct answer is the stomach because it is a muscular sac located slightly to the left in the abdominal cavity. It is responsible for temporarily storing food and breaking it down through the process of digestion. The stomach secretes digestive enzymes and acids to further break down the food before it moves on to the small intestine for absorption.

Five teaspoons is equivalent to 25 milliliters (ml). This conversion is based on the fact that one teaspoon is equal to 5 milliliters. Therefore, if we have five teaspoons, we can multiply 5 by 5 to get the equivalent amount in milliliters, which is 25 ml.

The correct answer for the meaning of PRN is "When necessary." This acronym is commonly used in medical settings to indicate that a medication or treatment should be administered as needed or when the patient requires it. It implies that the action should be taken based on the specific circumstances or condition of the individual.

An acute illness refers to a condition that has severe symptoms but lasts for a relatively short duration. Unlike chronic illnesses, which are long-lasting and often require ongoing management, acute illnesses typically resolve on their own or with treatment within a short period of time. This answer accurately describes the characteristic of severe symptoms and short duration that are associated with acute illnesses.

The correct abbreviation for micro drop is µgtt. This abbreviation is derived from the symbol for micro, which is represented by the Greek letter mu (µ), and the abbreviation for drop, which is gtt. Therefore, the correct answer is µgtt.

A community is a group of people who share common characteristics or interests. They come together to support and interact with one another, creating a sense of belonging and connection. In this context, the attributes of their lives refer to the shared experiences, values, and goals that bind them together. A community can be based on geographical location, shared interests, or a common purpose. It provides individuals with a support network, resources, and a sense of identity.

Tachycardia refers to a heart rate that is above the normal range. In this scenario, the nurse obtained the client's pulse and found it to be above normal, indicating a rapid heart rate. Therefore, the nurse correctly documents this finding as tachycardia.

Insulin is the correct answer because it is a hormone secreted by the Islets of Langerhans in the pancreas. Insulin plays a crucial role in regulating blood sugar levels by facilitating the uptake of glucose from the bloodstream into cells for energy production or storage. It also helps in the storage of excess glucose as glycogen in the liver and muscles. Insufficient insulin secretion or reduced sensitivity to insulin can lead to diabetes mellitus, a condition characterized by high blood sugar levels.

The nurse's role in health promotion includes teaching the client to be an effective health consumer. This means providing education and guidance on how to make informed decisions about their health, such as understanding medical information, navigating the healthcare system, and advocating for their own well-being. By empowering the client to take an active role in their health, the nurse helps promote a sense of ownership and responsibility for their own well-being.

Keeping side rails up at all times ensures the safety of the client. Side rails help prevent the client from accidentally falling out of bed, especially if they are disoriented or have mobility issues. By keeping the side rails up, the client is protected from potential injuries and falls. It is important to note that side rails should only be used when necessary and in accordance with the client's care plan, as prolonged use can have negative effects such as entrapment or feelings of confinement.

When a client is unconscious, the best position for performing mouth care is side lying. This position allows for proper drainage of saliva and fluids from the mouth, preventing aspiration. It also helps to maintain the client's airway and reduces the risk of choking. Additionally, side lying facilitates easy access to the client's mouth for the caregiver, ensuring thorough and effective mouth care.

The abbreviation "Gtts." is the correct answer because it stands for "drops." This abbreviation is commonly used in medical and pharmaceutical contexts to indicate the dosage of liquid medication that should be administered in the form of drops.

The left atrium is the chamber of the heart that receives oxygenated blood from the lungs. After the blood is oxygenated in the lungs, it is returned to the heart through the pulmonary veins and enters the left atrium. From there, it is pumped into the left ventricle and then circulated to the rest of the body. The right atrium, on the other hand, receives deoxygenated blood from the body and pumps it into the right ventricle to be sent to the lungs for oxygenation.

The nurse should face the client, bend their knees, and place their hands on the client's forearm before lifting them. This position allows the nurse to maintain a wide base of support, which provides stability and reduces the risk of injury to both the nurse and the client. Bending at the waist and placing arms under the client's arms may put strain on the nurse's back and increase the risk of injury. Tightening pelvic muscles is unrelated to using a wide base support when assisting a client to get up in a chair.

The cornea is a transparent membrane located at the front of the eye. Its main function is to focus the light that enters the eye onto the retina, which is responsible for converting light into neural signals that can be interpreted by the brain. The cornea plays a crucial role in the process of vision, as it helps to refract or bend the incoming light, allowing it to be properly focused on the retina. This explanation aligns with the given correct answer, which is "Cornea".

Orem's theory of self-care includes the concept of maintenance of a sufficient intake of air. This refers to the individual's ability to meet their own respiratory needs, such as breathing properly and ensuring an adequate supply of oxygen to the body. This aspect of Orem's theory emphasizes the importance of self-care and self-management in maintaining one's health and well-being. It recognizes the role of the individual in taking responsibility for their own physiological needs and promoting their own health through appropriate self-care practices.