This Is A Quiz About Fundamentals Of Nursing

1. The most important nursing intervention to correct skin dryness is:

Avoid bathing the patient until the condition is remedied, and notify the physician

Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear

Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection

The correct answer is to encourage the patient to increase their fluid intake, use non-irritating soap when bathing, and apply lotion to the affected areas. This intervention addresses the underlying cause of skin dryness, which is dehydration. Increasing fluid intake helps to hydrate the body from within, while using non-irritating soap and applying lotion helps to moisturize the skin externally. This comprehensive approach can help to improve skin dryness and prevent further complications such as infection.

Explanation

The correct answer is to encourage the patient to increase their fluid intake, use non-irritating soap when bathing, and apply lotion to the affected areas. This intervention addresses the underlying cause of skin dryness, which is dehydration. Increasing fluid intake helps to hydrate the body from within, while using non-irritating soap and applying lotion helps to moisturize the skin externally. This comprehensive approach can help to improve skin dryness and prevent further complications such as infection.

2. To institute appropriate isolation precautions, the nurse must first know the:

Organism’s mode of transmission

Organism’s Gram-staining characteristics

Organism’s susceptibility to antibiotics

Patient’s susceptibility to the organism

To institute appropriate isolation precautions, the nurse must first know the organism's mode of transmission. This is because different organisms can be transmitted through different routes such as direct contact, droplet transmission, airborne transmission, or through contaminated surfaces. By understanding the mode of transmission, the nurse can implement the necessary precautions to prevent the spread of the organism to other individuals. This may include measures such as wearing gloves, masks, or gowns, practicing proper hand hygiene, and implementing isolation protocols specific to the mode of transmission.

Explanation

To institute appropriate isolation precautions, the nurse must first know the organism's mode of transmission. This is because different organisms can be transmitted through different routes such as direct contact, droplet transmission, airborne transmission, or through contaminated surfaces. By understanding the mode of transmission, the nurse can implement the necessary precautions to prevent the spread of the organism to other individuals. This may include measures such as wearing gloves, masks, or gowns, practicing proper hand hygiene, and implementing isolation protocols specific to the mode of transmission.

3. Which of the following is the nurse's legal responsibility when applying restraints?

Document the patient’s behavior

Document the type of restraint used

All of the above

The nurse's legal responsibility when applying restraints includes documenting the patient's behavior, documenting the type of restraint used, and obtaining a written order from the physician except in an emergency. These actions are necessary to ensure proper documentation, accountability, and patient safety.

Explanation

The nurse's legal responsibility when applying restraints includes documenting the patient's behavior, documenting the type of restraint used, and obtaining a written order from the physician except in an emergency. These actions are necessary to ensure proper documentation, accountability, and patient safety.

4. To ensure homogenization when diluting powdered medication in a vial, the nurse should:

Shake the vial vigorously

Roll the vial gently between the palms

Invert the vial and let it stand for 1 minute

Do nothing after adding the solution to the vial

Rolling the vial gently between the palms is the correct answer because it helps to ensure homogenization when diluting powdered medication. This action helps to mix the powder and the solution evenly, ensuring that the medication is properly dissolved and distributed throughout the vial. Vigorous shaking may cause foaming and may not be suitable for all medications. Inverting the vial and letting it stand for 1 minute may not be enough to achieve homogenization. Doing nothing after adding the solution to the vial would not promote proper mixing.

Explanation

Rolling the vial gently between the palms is the correct answer because it helps to ensure homogenization when diluting powdered medication. This action helps to mix the powder and the solution evenly, ensuring that the medication is properly dissolved and distributed throughout the vial. Vigorous shaking may cause foaming and may not be suitable for all medications. Inverting the vial and letting it stand for 1 minute may not be enough to achieve homogenization. Doing nothing after adding the solution to the vial would not promote proper mixing.

5. A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?

0.5 ml

0.75 ml

1 ml

2 ml

The label states that 100 units of insulin is equal to 1 ml. Since the patient needs 50 units of insulin, the nurse should administer half of the volume stated on the label, which is 0.5 ml.

Explanation

The label states that 100 units of insulin is equal to 1 ml. Since the patient needs 50 units of insulin, the nurse should administer half of the volume stated on the label, which is 0.5 ml.

6. A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:

National League for Nursing (NLN)

Centers for Disease Control (CDC)

American Medical Association (AMA)

American Nurses Association (ANA)

The Centers for Disease Control (CDC) is the appropriate organization to refer to for guidelines on caring for a patient with an infectious disease who requires isolation. The CDC is a government agency that specializes in public health and provides evidence-based guidelines and recommendations for healthcare professionals. They have expertise in infectious diseases and are responsible for monitoring and controlling the spread of diseases in the United States. The CDC guidelines are widely recognized and followed by healthcare professionals to ensure the safety of both patients and healthcare workers.

Explanation

The Centers for Disease Control (CDC) is the appropriate organization to refer to for guidelines on caring for a patient with an infectious disease who requires isolation. The CDC is a government agency that specializes in public health and provides evidence-based guidelines and recommendations for healthcare professionals. They have expertise in infectious diseases and are responsible for monitoring and controlling the spread of diseases in the United States. The CDC guidelines are widely recognized and followed by healthcare professionals to ensure the safety of both patients and healthcare workers.

7. Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?

Have the patient place the specimen in a container and enclose the container in a plastic bag

Have the patient expectorate the sputum while the nurse holds the container

Have the patient expectorate the sputum into a sterile container

Offer the patient an antiseptic mouthwash just before he expectorate the sputum

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Explanation

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8. The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:

Wash the gloves before removing them

Gently pull on the fingers of the gloves when removing them

Gently pull just below the cuff and invert the gloves when removing them

Remove the gloves and then turn them inside out

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Explanation

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9. After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:

Infectiom

Infiltration

Phlebitis

Bleeding

Phlebitis is the inflammation of a vein, which can occur as a result of prolonged use of an I.V. line. The patient's complaint of tenderness, burning, and swelling, along with the assessment findings of warmth and erythema at the I.V. site, are consistent with phlebitis. This inflammation is typically caused by irritation or infection at the site, leading to redness, pain, and swelling. It is important to monitor and address phlebitis promptly to prevent further complications.

Explanation

Phlebitis is the inflammation of a vein, which can occur as a result of prolonged use of an I.V. line. The patient's complaint of tenderness, burning, and swelling, along with the assessment findings of warmth and erythema at the I.V. site, are consistent with phlebitis. This inflammation is typically caused by irritation or infection at the site, leading to redness, pain, and swelling. It is important to monitor and address phlebitis promptly to prevent further complications.

10. The physician's order reads "Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes." What is the flow rate if the drop factor is 10 gtt = 1 ml?

25 gtt/minute

37 gtt/minute

50 gtt/minute

60 gtt/minute

The flow rate can be calculated by dividing the total volume (150 ml) by the time (60 minutes). Since the drop factor is 10 gtt = 1 ml, the flow rate will be 150 ml / 60 minutes = 2.5 ml/minute. To convert this to drops per minute, we multiply by the drop factor: 2.5 ml/minute * 10 gtt/ml = 25 gtt/minute. Therefore, the correct answer is 25 gtt/minute.

Explanation

The flow rate can be calculated by dividing the total volume (150 ml) by the time (60 minutes). Since the drop factor is 10 gtt = 1 ml, the flow rate will be 150 ml / 60 minutes = 2.5 ml/minute. To convert this to drops per minute, we multiply by the drop factor: 2.5 ml/minute * 10 gtt/ml = 25 gtt/minute. Therefore, the correct answer is 25 gtt/minute.

11. Vivid dreaming occurs in which stage of sleep?

Stage I non-REM

Rapid eye movement (REM) stage

Stage II non-REM

Delta stage

During the REM stage of sleep, vivid dreaming occurs. This is the stage where the brain is highly active and the eyes move rapidly. It is characterized by increased brain activity, irregular breathing, and muscle paralysis. REM sleep is essential for memory consolidation, learning, and emotional regulation.

Explanation

During the REM stage of sleep, vivid dreaming occurs. This is the stage where the brain is highly active and the eyes move rapidly. It is characterized by increased brain activity, irregular breathing, and muscle paralysis. REM sleep is essential for memory consolidation, learning, and emotional regulation.

12. An autoclave is used to sterilize hospital supplies because:

More articles can be sterilized at a time

Steam causes less damage to the materials

A lower temperature can be obtained

Pressurized steam penetrates the supplies better

Pressurized steam is the correct answer because it allows for better penetration of the supplies, ensuring that all areas are sterilized effectively. The high pressure helps the steam reach into small crevices and hard-to-reach areas, ensuring thorough sterilization. This is important in a hospital setting where cleanliness and preventing the spread of infections are crucial. The other options do not provide a sufficient explanation for why an autoclave is used for sterilization.

Explanation

Pressurized steam is the correct answer because it allows for better penetration of the supplies, ensuring that all areas are sterilized effectively. The high pressure helps the steam reach into small crevices and hard-to-reach areas, ensuring thorough sterilization. This is important in a hospital setting where cleanliness and preventing the spread of infections are crucial. The other options do not provide a sufficient explanation for why an autoclave is used for sterilization.

13. Kubler-Ross's five successive stages of death and dying are:

Anger, bargaining, denial, depression, acceptance

Denial, anger, depression, bargaining, acceptance

Denial, anger, bargaining, depression acceptance

Bargaining, denial, anger, depression, acceptance

Kubler-Ross's five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. This means that when faced with the reality of death, individuals initially deny it, then experience feelings of anger, followed by attempts to negotiate or bargain with the situation. Subsequently, they may go through a period of depression before finally reaching a state of acceptance.

Explanation

Kubler-Ross's five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. This means that when faced with the reality of death, individuals initially deny it, then experience feelings of anger, followed by attempts to negotiate or bargain with the situation. Subsequently, they may go through a period of depression before finally reaching a state of acceptance.

14. A terminally ill patient usually experiences all of the following feelings during the anger stage except:

Rage

Envy

Numbness

Resentment

During the anger stage of terminal illness, patients commonly experience feelings of rage, envy, and resentment. However, numbness is not typically associated with this stage. Numbness refers to a lack of emotion or feeling, which is not commonly reported during the anger stage. Instead, patients may feel intense emotions such as anger, frustration, or bitterness towards their situation.

Explanation

During the anger stage of terminal illness, patients commonly experience feelings of rage, envy, and resentment. However, numbness is not typically associated with this stage. Numbness refers to a lack of emotion or feeling, which is not commonly reported during the anger stage. Instead, patients may feel intense emotions such as anger, frustration, or bitterness towards their situation.

15. A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?

Call the physician

Remedicate the patient

Observe the emesis

Explain to the patient that she can do nothing to help him

The nurse should observe the emesis first because vomiting shortly after taking medication may indicate that the medication was not absorbed properly or may need to be administered in a different form. By observing the emesis, the nurse can assess the amount and appearance of the vomit and determine if any further actions, such as contacting the physician or remedicating the patient, are necessary.

Explanation

The nurse should observe the emesis first because vomiting shortly after taking medication may indicate that the medication was not absorbed properly or may need to be administered in a different form. By observing the emesis, the nurse can assess the amount and appearance of the vomit and determine if any further actions, such as contacting the physician or remedicating the patient, are necessary.

16. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:

Flurazepam

Temazepam

Tryptophan

Methotrimeprazine

Tryptophan is the correct answer because it is an essential amino acid found in many protein-rich foods, including meat and milk products. Tryptophan is a precursor to serotonin, a neurotransmitter that helps regulate sleep. When consumed, tryptophan is converted into serotonin, which can then be converted into melatonin, a hormone that helps regulate sleep-wake cycles. Therefore, consuming foods high in tryptophan, such as warm milk, can help induce sleep due to its natural sedative effects.

Explanation

Tryptophan is the correct answer because it is an essential amino acid found in many protein-rich foods, including meat and milk products. Tryptophan is a precursor to serotonin, a neurotransmitter that helps regulate sleep. When consumed, tryptophan is converted into serotonin, which can then be converted into melatonin, a hormone that helps regulate sleep-wake cycles. Therefore, consuming foods high in tryptophan, such as warm milk, can help induce sleep due to its natural sedative effects.

17. When bathing a patient's extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:

Provides an opportunity for skin assessment

Avoids undue strain on the nurse

Increases venous blood return

Causes vasoconstriction and increases circulation

When the nurse uses long, firm strokes from the distal to the proximal areas while bathing a patient's extremities, it helps to increase venous blood return. This is because the pressure applied by the strokes helps to push the blood in the veins towards the heart, enhancing circulation. This technique is beneficial for patients who have impaired circulation or are at risk for developing blood clots. Additionally, it allows the nurse to assess the skin for any abnormalities or changes while providing care.

Explanation

When the nurse uses long, firm strokes from the distal to the proximal areas while bathing a patient's extremities, it helps to increase venous blood return. This is because the pressure applied by the strokes helps to push the blood in the veins towards the heart, enhancing circulation. This technique is beneficial for patients who have impaired circulation or are at risk for developing blood clots. Additionally, it allows the nurse to assess the skin for any abnormalities or changes while providing care.

18. A patient is characterized with a #16 indwelling urinary (Foley) catheter to determine if:

Trauma has occurred

His 24-hour output is adequate

He has a urinary tract infection

Residual urine remains in the bladder after voiding

The patient is characterized with an indwelling urinary catheter (#16 Foley catheter) to determine if his 24-hour output is adequate. This means that the purpose of the catheter is to measure the amount of urine the patient is producing over a 24-hour period. By monitoring the output, healthcare professionals can assess the patient's kidney function and hydration status. This information is important in evaluating the patient's overall health and determining if any interventions are needed.

Explanation

The patient is characterized with an indwelling urinary catheter (#16 Foley catheter) to determine if his 24-hour output is adequate. This means that the purpose of the catheter is to measure the amount of urine the patient is producing over a 24-hour period. By monitoring the output, healthcare professionals can assess the patient's kidney function and hydration status. This information is important in evaluating the patient's overall health and determining if any interventions are needed.

19. Which of the following symptoms is the best indicator of imminent death?

A weak, slow pulse

Increased muscle tone

Fixed, dilated pupils

Slow, shallow respirations

Fixed, dilated pupils are the best indicator of imminent death because they suggest that the brain is no longer receiving oxygen and blood flow is severely compromised. Pupils normally constrict in response to light, but when they become fixed and dilated, it indicates a loss of brain function. This can occur in critical conditions such as severe head trauma, drug overdose, or cardiac arrest, and is a sign that the body is shutting down and death is imminent.

Explanation

Fixed, dilated pupils are the best indicator of imminent death because they suggest that the brain is no longer receiving oxygen and blood flow is severely compromised. Pupils normally constrict in response to light, but when they become fixed and dilated, it indicates a loss of brain function. This can occur in critical conditions such as severe head trauma, drug overdose, or cardiac arrest, and is a sign that the body is shutting down and death is imminent.

20. Restraints can be used for all of the following purposes except to:

Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters

Prevent a patient from falling out of bed or a chair

Discourage a patient from attempting to ambulate alone when he requires assistance for his safety

Prevent a patient from becoming confused or disoriented

Restraints are used in healthcare settings to ensure patient safety and prevent harm. They are commonly used to prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. Restraints can also be used to prevent a patient from falling out of bed or a chair, as well as to discourage a patient from attempting to ambulate alone when they require assistance for their safety. However, restraints are not used to prevent a patient from becoming confused or disoriented. Confusion or disorientation is a symptom or condition that may require appropriate medical intervention or treatment, but the use of restraints is not typically indicated for this purpose.

Explanation

Restraints are used in healthcare settings to ensure patient safety and prevent harm. They are commonly used to prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. Restraints can also be used to prevent a patient from falling out of bed or a chair, as well as to discourage a patient from attempting to ambulate alone when they require assistance for their safety. However, restraints are not used to prevent a patient from becoming confused or disoriented. Confusion or disorientation is a symptom or condition that may require appropriate medical intervention or treatment, but the use of restraints is not typically indicated for this purpose.

21. How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?

Draw up the NPH insulin, then the regular insulin, in the same syringe

Draw up the regular insulin, then the NPH insulin, in the same syringe

Use two separate syringe

Check with the physician

Drawing up the regular insulin first and then the NPH insulin in the same syringe is the correct way to prepare an injection for a patient who takes both regular and NPH insulin. This is because regular insulin is a clear solution and NPH insulin is a cloudy suspension. By drawing up the regular insulin first, any contamination from the NPH insulin will not affect the clarity of the regular insulin. Additionally, by using the same syringe, it reduces the number of injections the patient needs to receive.

Explanation

Drawing up the regular insulin first and then the NPH insulin in the same syringe is the correct way to prepare an injection for a patient who takes both regular and NPH insulin. This is because regular insulin is a clear solution and NPH insulin is a cloudy suspension. By drawing up the regular insulin first, any contamination from the NPH insulin will not affect the clarity of the regular insulin. Additionally, by using the same syringe, it reduces the number of injections the patient needs to receive.

22. A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:

Writing down all assignments

Making changes after evaluating the situation and having discussions with the staff.

Telling the staff nurses that she is making changes to benefit their performance

Evaluating the clinical performance of each staff nurse in a private conference

The best way for the newly promoted assistant nurse manager to decrease her discomfort when supervising her former peers is by making changes after evaluating the situation and having discussions with the staff. This approach allows her to gather input from her team, address any concerns or issues, and make informed decisions based on a collaborative effort. It promotes open communication, teamwork, and a sense of ownership among the staff, ultimately leading to a smoother transition and a more comfortable working environment for everyone involved.

Explanation

The best way for the newly promoted assistant nurse manager to decrease her discomfort when supervising her former peers is by making changes after evaluating the situation and having discussions with the staff. This approach allows her to gather input from her team, address any concerns or issues, and make informed decisions based on a collaborative effort. It promotes open communication, teamwork, and a sense of ownership among the staff, ultimately leading to a smoother transition and a more comfortable working environment for everyone involved.

23. Nurses and other health care provides often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?

Taking psychology courses related to gerontology

Reading books and other literature on the subject of thanatology

Reflecting on the significance of death

Reviewing varying cultural beliefs and practices related to death

Reflecting on the significance of death can be the most helpful strategy for nurses in assisting terminally ill patients with accepting death. By reflecting on the significance of death, nurses can develop a deeper understanding and empathy towards the patient's emotions and fears. This self-reflection can also help nurses to become more comfortable with discussing and addressing the topic of death, allowing them to provide better support and guidance to patients and their families. Additionally, reflecting on the significance of death can also help nurses to recognize their own biases and beliefs, allowing them to provide culturally sensitive care that respects varying cultural beliefs and practices related to death.

Explanation

Reflecting on the significance of death can be the most helpful strategy for nurses in assisting terminally ill patients with accepting death. By reflecting on the significance of death, nurses can develop a deeper understanding and empathy towards the patient's emotions and fears. This self-reflection can also help nurses to become more comfortable with discussing and addressing the topic of death, allowing them to provide better support and guidance to patients and their families. Additionally, reflecting on the significance of death can also help nurses to recognize their own biases and beliefs, allowing them to provide culturally sensitive care that respects varying cultural beliefs and practices related to death.

24. The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient's first priority concerning self-injection in this situation is to:

Assess the injection site

Select the appropriate injection site

Check the syringe to verify that the nurse has removed the prescribed insulin dose

Clean the injection site in a circular manner with alcohol sponge

The patient's first priority concerning self-injection in this situation is to check the syringe to verify that the nurse has removed the prescribed insulin dose. This is important because the patient needs to ensure that the correct dose of insulin is in the syringe before injecting it. If the nurse has not removed the prescribed dose, the patient may inject the wrong amount of insulin, which can have negative effects on their blood sugar levels. Therefore, it is crucial for the patient to double-check the syringe to ensure the correct dose has been prepared.

Explanation

The patient's first priority concerning self-injection in this situation is to check the syringe to verify that the nurse has removed the prescribed insulin dose. This is important because the patient needs to ensure that the correct dose of insulin is in the syringe before injecting it. If the nurse has not removed the prescribed dose, the patient may inject the wrong amount of insulin, which can have negative effects on their blood sugar levels. Therefore, it is crucial for the patient to double-check the syringe to ensure the correct dose has been prepared.

25. Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:

Have the patient take a 30- to 60-minute nap in the afternoon

Turn on the television in the patient’s room

Provide quiet music and interesting reading material

Massage the patient’s back with long strokes

The correct answer is "Have the patient take a 30- to 60-minute nap in the afternoon." This option is the exception because taking a nap in the afternoon can interfere with the patient's ability to sleep restfully at night. The other options, such as providing quiet music and interesting reading material, and massaging the patient's back with long strokes, are nursing interventions that can help the patient relax and sleep restfully. Turning on the television in the patient's room is not recommended as it can be stimulating and disrupt sleep.

Explanation

The correct answer is "Have the patient take a 30- to 60-minute nap in the afternoon." This option is the exception because taking a nap in the afternoon can interfere with the patient's ability to sleep restfully at night. The other options, such as providing quiet music and interesting reading material, and massaging the patient's back with long strokes, are nursing interventions that can help the patient relax and sleep restfully. Turning on the television in the patient's room is not recommended as it can be stimulating and disrupt sleep.