Foundation Of Nursing Comprehensive Test Part 1 (Practice Mode)- Rnpedia

Handwashing is important to prevent the transfer of microorganisms because our hands come into contact with numerous surfaces throughout the day, picking up bacteria and viruses. By washing our hands with soap and water, we can effectively remove these microorganisms and reduce the risk of spreading infections. Regular handwashing is especially crucial in healthcare settings, where healthcare professionals can come into contact with vulnerable patients and transmit harmful pathogens.

The most important purpose of cleansing bed bath is to cleanse, refresh, and give comfort to the client who must remain in bed. This activity helps maintain the client's hygiene and promotes their overall well-being. It also helps prevent skin breakdown and infections.

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 involves the action of various components of the immune system, including white blood cells, antibodies, and specialized cells and tissues. This defense mechanism helps to protect the body from infections and diseases.

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 inhaled air enters the bloodstream through the tiny air sacs called alveoli in the lungs, while carbon dioxide is eliminated from the bloodstream and exhaled. This process is essential for respiration and maintaining the body's oxygen levels.

CBR stands for Complete Bed Rest, which means a patient is required to stay in bed and avoid any physical activity. This is often prescribed by doctors to promote healing and recovery in certain medical conditions or after surgery. The other options, such as Cardiac Board Room, Complete Bathroom, and Complete Board Room, do not have any relevance to the medical term CBR.

Bed making refers to the process of preparing the bed with a new set of linens. This involves removing the old sheets and pillowcases, and replacing them with fresh ones. It may also involve fluffing the pillows, arranging the blankets, and tucking in the sheets. Bed making is an important task in maintaining cleanliness and hygiene in a bed, ensuring a comfortable and inviting sleeping environment.

Inspection involves the sense of sight as it refers to visually examining the body or a specific area for any abnormalities, changes, or signs of disease or injury. It involves observing the color, shape, size, texture, movement, and symmetry of body parts or organs. This technique allows healthcare professionals to gather important visual information about a patient's condition and make initial assessments.

The stomach is a muscular pouch that lies slightly to the left and is responsible for the temporary storage of food. It is a part of the digestive system and plays a crucial role in breaking down food through the secretion of gastric juices and churning motions. The food is then gradually released into the small intestine for further digestion and absorption of nutrients. The other options, such as the gallbladder, urinary bladder, and lungs, do not fit the description of a muscular pouch used for temporary food storage.

The correct answer is stethoscope. Auscultation is the process of listening to the internal sounds of the body, particularly the heart, lungs, and abdomen, using a medical instrument called a stethoscope. It consists of a chest piece with a diaphragm and a set of earpieces connected by tubing. The diaphragm is placed on the patient's body, and the sound waves produced by internal organs are transmitted through the tubing to the physician's ears, allowing them to listen and diagnose any abnormalities.

The nurse is implementing the assessment phase of the nursing process. This involves gathering information about the client's chief complaint, as well as taking vital signs to assess their current health status. Assessment is the first step in the nursing process and is crucial in identifying the client's needs and formulating a plan of care.

The nurse would wear gloves when providing oral hygiene because it involves direct contact with the client's mouth and saliva, which may contain microorganisms. Wearing gloves helps to prevent the transmission of any potential pathogens from the client to the nurse and vice versa. This is in line with the principle of standard precautions, which aims to protect healthcare workers and clients from infection by assuming that all bodily fluids and substances are potentially infectious.

The correct answer is "All of the above" because Maslow's hierarchy of needs includes all of these clusters of data. Maslow's theory suggests that individuals have a hierarchy of needs that must be fulfilled in a specific order, starting with physiologic needs such as food and shelter, then moving up to love and belonging, and finally self-actualization, which refers to fulfilling one's potential and achieving personal growth. Therefore, all three clusters mentioned in the question align with Maslow's hierarchy of needs.

PRN stands for "pro re nata," which is a Latin phrase commonly used in medical contexts. It means "when necessary" or "as needed." This term is often used in prescriptions to indicate that a medication should be taken only when the symptoms require it, rather than on a regular schedule. Therefore, the correct answer is "When necessary."

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

The nursing process is a systematic and rational method used to plan and provide nursing care for individuals, families, groups, and communities. It involves several steps, including assessment, diagnosis, and implementation. Assessment involves gathering information about the patient's health status. Diagnosis involves identifying the patient's health problems and needs. Implementation involves carrying out the planned interventions and providing care to the patient. The nursing process helps nurses to provide efficient and effective care, ensuring that all aspects of the patient's health are addressed.

The nurse asked the client to read the Snellen chart to test their visual acuity, which is determined by the function of the optic nerve. The optic nerve is responsible for transmitting visual information from the eyes to the brain. By asking the client to read the Snellen chart, the nurse can assess the client's ability to see and distinguish letters or symbols at a distance, thus evaluating the function of their optic nerve.

The nurse documented the findings as "Tachycardia" because a pulse rate that is above normal is indicative of tachycardia. Tachycardia refers to a heart rate that exceeds the normal range, which is typically around 60-100 beats per minute. This can be caused by various factors such as stress, exercise, fever, or certain medical conditions. Tachycardia can be a sign of an underlying health issue and should be monitored and addressed accordingly.

Axillary temperature measurement is the best method to assess the client's temperature in this scenario. This method involves placing the thermometer in the client's armpit, which provides a reliable and accurate measurement of body temperature. It is particularly suitable for clients who are alert and cooperative, like the one in this case. Oral temperature measurement may not be ideal due to the client's dehydration, which can affect oral mucous membranes. Radial temperature measurement is not a common method and may not provide an accurate reading. Heat sensitive tape is not a recognized method for assessing body temperature.

Acute illness refers to a condition that has severe symptoms but lasts for a relatively short duration. This means that the illness develops quickly and the symptoms are intense, but they do not persist for a long period of time. Unlike chronic illnesses that may last for months or even years, acute illnesses resolve within a shorter timeframe. Therefore, the given answer "Acute Illness" accurately describes the condition characterized by severe symptoms of short duration.

The correct answer is Sims left lateral. In this position, the patient lies on their left side with the right knee bent towards the chest. This position allows for better visualization and access to the rectum during the administration of a cleansing enema. It also helps to promote the flow of the enema solution and the evacuation of fecal matter.

Insulin is typically administered via the subcutaneous route. This is because subcutaneous injections allow for a slow and steady absorption of the medication into the bloodstream, mimicking the natural release of insulin by the pancreas. Intramuscular administration would result in a faster absorption and potentially erratic blood sugar levels. Intradermal administration is used for skin testing and not for insulin delivery. Intravenous administration would deliver insulin directly into the bloodstream, causing an immediate and potentially dangerous drop in blood sugar levels.

Auscultation is a technique in physical examination that involves listening to the sounds produced by the body. In this context, it is used to assess the movement of air through the tracheobronchial tree, specifically listening for abnormal breath sounds such as wheezing or crackles. Palpation involves using touch to assess the body, inspection involves visual examination, and percussion involves tapping on the body to assess underlying structures. However, in this case, auscultation is the most appropriate technique for assessing air movement in the tracheobronchial tree.

Gait refers to the manner in which a person walks. It includes the coordination and movement of the limbs, trunk, and pelvis during walking. Gait analysis is often used in medical and rehabilitation settings to assess and diagnose various conditions affecting a person's ability to walk. It involves observing and analyzing factors such as stride length, step width, cadence, and symmetry of movement. By studying a person's gait, healthcare professionals can gain valuable insights into their overall mobility and identify any abnormalities or issues that may need to be addressed.

Insulin is secreted by the Islets of Langerhans in the pancreas. It plays a crucial role in regulating blood sugar levels by allowing cells to take in glucose from the bloodstream and use it for energy. Insulin also helps store excess glucose in the liver for later use. Without sufficient insulin, the body cannot effectively regulate blood sugar levels, leading to conditions like diabetes. Therefore, insulin is an important hormone secreted by the Islets of Langerhans.

The Z-track technique is the best action to prevent tracking of the medication. This technique involves pulling the skin to one side before administering the injection, creating a zigzag path for the medication. This helps to seal the medication in the muscle and prevents it from leaking into the subcutaneous tissue. Using a small gauge needle may help minimize tissue damage, but it does not prevent tracking of the medication. Applying ice on the injection site may help reduce pain and swelling, but it does not prevent tracking. Administering at a 45° angle does not prevent tracking either.

A community is a group of individuals who have common characteristics or interests and interact with one another. They may live in the same geographical area or share similar values, beliefs, or goals. In this context, the description provided aligns with the concept of a community, as it refers to a collection of people who share some attributes of their lives. This suggests that the correct answer is "Community."

20 cc is equal to 20 ml. The abbreviation "cc" stands for cubic centimeter, which is a unit of volume in the metric system. The milliliter (ml) is also a unit of volume in the metric system, and 1 cc is equal to 1 ml. Therefore, 20 cc is equal to 20 ml.

Axillary temperature measurement is the best method to take the client's body temperature in this case because the client had oral surgery, which may make it difficult or uncomfortable for them to use the oral method. Additionally, the client's skin is flushed and warm, which could indicate inflammation or increased blood flow in the oral cavity, potentially affecting the accuracy of oral temperature measurement. Axillary temperature measurement is a non-invasive method that can provide a reliable estimate of the client's body temperature.

The correct answer is 25 ml because one teaspoon is equivalent to 5 ml. Therefore, if we have five teaspoons, it would be 5 multiplied by 5 ml which equals 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 rich blood supply in the oral mucosa. Placing the medication in this location ensures that it is not swallowed immediately and allows for optimal absorption. This method is commonly used for medications such as sublingual nitroglycerin tablets.

Back care is best described as caring for the back by means of massage. This involves using massage techniques to alleviate tension, improve circulation, and promote relaxation in the muscles and tissues of the back. Massage can help reduce pain, improve flexibility, and promote overall back health. It is an effective way to relieve stress and promote a sense of well-being.

The correct answer is µgtt. The abbreviation for micro drop is commonly represented as µgtt. The symbol "µ" denotes micro, and "gtt" stands for drop. This abbreviation is used in medical and pharmaceutical contexts to indicate a very small unit of liquid volume.

One cup is equal to 8 ounces.

The correct answer is three times a day orally. This means that the nurse should administer the ampicillin capsule by mouth three times a day. This route of administration is chosen because ampicillin is intended to be absorbed through the gastrointestinal tract. By giving it orally, the medication can be easily and efficiently absorbed into the bloodstream. Additionally, administering it three times a day ensures that the therapeutic levels of the medication are maintained in the body throughout the day.

Keeping the side rails up at all times ensures the safety of the client because it prevents them from accidentally falling out of bed. This is especially important for a client who is hospitalized for the first time and may be disoriented or unfamiliar with their surroundings. The side rails provide a physical barrier and help to keep the client secure in their bed, reducing the risk of injury.

The correct abbreviation for drops is "Gtts." This abbreviation is derived from the Latin word "guttae," which means drops. It is commonly used in medical and pharmaceutical contexts to indicate the number of drops to be administered or prescribed.

The correct answer is Inspection because it is the first technique used to examine the abdomen of a client. Inspection involves visually examining the abdomen for any abnormalities, such as swelling, discoloration, or scars. This initial assessment allows the healthcare provider to gather important information about the client's condition before proceeding with other examination techniques like palpation, auscultation, and percussion.

When a client is unconscious, the best position for performing mouth care is side lying. This position allows for easy access to the client's mouth and prevents aspiration of any fluids or debris. It also helps to maintain the client's airway and prevent choking. Fowler's position, supine position, and Trendelenburg position are not ideal for mouth care in an unconscious client as they may increase the risk of aspiration or cause discomfort.

To prevent contaminating the environment in bed making, it is important to avoid running soiled linens. This means not shaking or flapping the linens, as it can release dust and particles into the air, potentially spreading contaminants. Instead, linens should be handled carefully and folded or rolled up to minimize the release of any dirt or debris. By avoiding the act of running soiled linens, the risk of contaminating the environment can be significantly reduced.

The client's difficulty in swallowing the capsule medication suggests that they may have a swallowing disorder or dysphagia. Checking the availability of a liquid preparation would be the most appropriate measure for the nurse to take in this situation. Liquid medications are easier to swallow and can be a suitable alternative for clients with difficulty swallowing solid forms of medication. Dissolving the capsule in water or breaking it and mixing it with applesauce may not fully address the client's swallowing difficulty. Placing the crushed capsule under the tongue is not a recommended method of administration for this medication.

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 how to access and evaluate health information, make appropriate choices for their well-being, and actively participate in their own healthcare. This role is crucial in promoting health and preventing illness by enabling clients to take control of their health and make informed decisions about their healthcare.

Resonance refers to the sound produced by air-filled lungs. This is because when air passes through the vocal cords, it causes them to vibrate, producing sound. This sound is then modified and amplified by the resonating chambers in the throat, mouth, and nose, resulting in the characteristic quality of the voice. Therefore, resonance can be described as the sounds created by air-filled lungs.

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 lift. This position allows the nurse to maintain a stable and balanced stance, distributing their weight evenly and providing support to the client. By bending the knees, the nurse can use their leg muscles to generate the necessary force for lifting, reducing strain on their back. Placing hands on the client's forearm also ensures a secure grip and prevents slipping or loss of control during the transfer.

The left atrium is the chamber of the heart that receives oxygenated blood from the lungs.

The nurse must verify the client's identity before administering medication to ensure that the medication is given to the correct person. Asking the client his name is the safest way to identify the client because it directly involves the client and allows for confirmation of their identity. Checking the client's identification band can also be helpful, but it is not foolproof as bands can be misplaced or switched. Stating the client's name aloud and having them repeat it can be unreliable as the client may not be able to hear or understand properly. Checking the room number is not a reliable method as it does not directly confirm the client's identity.

The correct answer is Genu-pectoral. The knee-chest position is a medical position in which the patient rests on their knees and chest, with the buttocks elevated. This position is also known as the Genu-pectoral position, as it involves flexion at the knees (genu) and the chest (pectoral). It is commonly used in medical procedures such as rectal examinations, sigmoidoscopies, and certain types of surgeries.

The knee-chest position is the best position for examining the rectum because it allows for optimal visualization and access to the rectal area. In this position, the patient kneels on the examination table and rests their chest and head on the table, while their buttocks are elevated. This position helps to relax the pelvic muscles and allows for easier insertion of instruments for examination or procedures. It also allows for better visualization of the rectal area, making it easier to identify any abnormalities or perform necessary interventions.

The cornea is a transparent membrane located at the front of the eye. It plays a crucial role in focusing the light that enters the eyes onto the retina, which is responsible for converting light into electrical signals that the brain can interpret. The cornea acts as a protective covering for the eye and helps to refract or bend the incoming light, allowing it to pass through the pupil and lens before reaching the retina.

Orem's theory of self-care deficit focuses on the individual's ability to meet their own self-care needs. This includes maintaining a sufficient intake of air, which is essential for sustaining life and overall well-being. By including this aspect in her theory, Orem recognizes the importance of respiratory health and the role it plays in self-care. This aligns with her broader concept of self-care, which emphasizes the individual's responsibility for meeting their own physiological needs.

The correct answer is 60. One teaspoon is equal to 60 drops. This conversion is commonly used in cooking and medical measurements.