FOUNDATION OF PROFESSIONAL NURSING Flashcards
- The nurse In-charge in labor and delivery unit
administered a dose of terbutaline to a client
without checking the client’s pulse. The standard
that would be used to determine if the nurse
was negligent is:
a. The physician’s orders.
b. The action of a clinical nurse specialist
who is recognized expert in the field.
c. The statement in the drug literature
about administration of terbutaline.
d. The actions of a reasonably prudent
nurse with similar education and
experience.
Answer: (D) The actions of a reasonably
prudent nurse with similar education and
experience.
Rationale: The standard of care is determined
by the average degree of skill, care, and
diligence by nurses in similar circumstances
- Nurse Trish is caring for a female client with a
history of GI bleeding, sickle cell disease, and a
platelet count of 22,000/μl. The female client is
dehydrated and receiving dextrose 5% in halfnormal
saline solution at 150 ml/hr. The client
complains of severe bone pain and is scheduled
to receive a dose of morphine sulfate. In
administering the medication, Nurse Trish
should avoid which route?
a. I.V
b. I.M
c. Oral
d. S.C
Answer: (B) I.M
Rationale: With a platelet count of 22,000/μl,
the clients tends to bleed easily. Therefore,
the nurse should avoid using the I.M. route
because the area is a highly vascular and can
bleed readily when penetrated by a needle.
The bleeding can be difficult to stop
- Dr. Garcia writes the following order for the
client who has been recently admitted “Digoxin
.125 mg P.O. once daily.” To prevent a dosage
error, how should the nurse document this order
onto the medication administration record?
a. “Digoxin .1250 mg P.O. once daily”
b. “Digoxin 0.1250 mg P.O. once daily”
c. “Digoxin 0.125 mg P.O. once daily”
d. “Digoxin .125 mg P.O. once daily”
- Dr. Garcia writes the following order for the
client who has been recently admitted “Digoxin
.125 mg P.O. once daily.” To prevent a dosage
error, how should the nurse document this order
onto the medication administration record?
a. “Digoxin .1250 mg P.O. once daily”
b. “Digoxin 0.1250 mg P.O. once daily”
c. “Digoxin 0.125 mg P.O. once daily”
d. “Digoxin .125 mg P.O. once daily”
- A newly admitted female client was diagnosed
with deep vein thrombosis. Which nursing
diagnosis should receive the highest priority?
a. Ineffective peripheral tissue perfusion
related to venous congestion.
b. Risk for injury related to edema.
c. Excess fluid volume related to peripheral
vascular disease.
d. Impaired gas exchange related to
increased blood flow
Answer: (A) Ineffective peripheral tissue
perfusion related to venous congestion.
Rationale: Ineffective peripheral tissue
perfusion related to venous congestion takes
the highest priority because venous
inflammation and clot formation impede blood
flow in a client with deep vein thrombosis
- Nurse Betty is assigned to the following clients.
The client that the nurse would see first after
endorsement?
a. A 34 year-old post-operative
appendectomy client of five hours who
is complaining of pain.
b. A 44 year-old myocardial infarction (MI)
client who is complaining of nausea.
c. A 26 year-old client admitted for
dehydration whose intravenous (IV) has
infiltrated.
d. A 63 year-old post operative’s
abdominal hysterectomy client of three
days whose incisional dressing is
saturated with serosanguinous fluid.
Answer: (B) A 44 year-old myocardial
infarction (MI) client who is complaining of
nausea.
Rationale: Nausea is a symptom of impending
myocardial infarction (MI) and should be
assessed immediately so that treatment can
be instituted and further damage to the heart
is avoided
- Nurse Gail places a client in a four-point restraint
following orders from the physician. The client
care plan should include:
a. Assess temperature frequently.
b. Provide diversional activities.
c. Check circulation every 15-30 minutes.
d. Socialize with other patients once a shift.
Answer: (C) Check circulation every 15-30
minutes.
Rationale: Restraints encircle the limbs, which
place the client at risk for circulation being
restricted to the distal areas of the
extremities. Checking the client’s circulation
every 15-30 minutes will allow the nurse to
adjust the restraints before injury from
decreased blood flow occurs.
- A male client who has severe burns is receiving
H2 receptor antagonist therapy. The nurse Incharge
knows the purpose of this therapy is to:
a. Prevent stress ulcer
b. Block prostaglandin synthesis
c. Facilitate protein synthesis.
d. Enhance gas exchange
Answer: (A) Prevent stress ulcer Rationale: Curling’s ulcer occurs as a
generalized stress response in burn patients.
This results in a decreased production of
mucus and increased secretion of gastric acid.
The best treatment for this prophylactic use of
antacids and H2 receptor blockers
- The doctor orders hourly urine output
measurement for a postoperative male client.
The nurse Trish records the following amounts of
output for 2 consecutive hours: 8 a.m.: 50 ml; 9
a.m.: 60 ml. Based on these amounts, which
action should the nurse take?
a. Increase the I.V. fluid infusion rate
b. Irrigate the indwelling urinary catheter
c. Notify the physician
d. Continue to monitor and record hourly
urine output
Answer: (D) Continue to monitor and record
hourly urine output
Rationale: Normal urine output for an adult is
approximately 1 ml/minute (60 ml/hour).
Therefore, this client’s output is normal.
Beyond continued evaluation, no nursing
action is warranted
- Tony, a basketball player twist his right ankle
while playing on the court and seeks care for
ankle pain and swelling. After the nurse applies
ice to the ankle for 30 minutes, which statement
by Tony suggests that ice application has been
effective?
a. “My ankle looks less swollen now”.
b. “My ankle feels warm”.
c. “My ankle appears redder now”
d. “I need something stronger for pain
relief”
Answer: (B) “My ankle feels warm”.
Rationale: Ice application decreases pain and
swelling. Continued or increased pain, redness,
and increased warmth are signs of
inflammation that shouldn’t occur after ice
application
- The physician prescribes a loop diuretic for a
client. When administering this drug, the nurse
anticipates that the client may develop which
electrolyte imbalance?
a. Hypernatremia
b. Hyperkalemia
c. Hypokalemia
d. Hypervolemia
Answer: (B) Hypokalemia
Rationale: A loop diuretic removes water and,
along with it, sodium and potassium. This may
result in hypokalemia, hypovolemia, and
hyponatremia
- She finds out that some managers have
benevolent-authoritative style of management.
Which of the following behaviors will she exhibit
most likely?
a. Have condescending trust and
confidence in their subordinates.
b. Gives economic and ego awards.
c. Communicates downward to staffs.
d. Allows decision making among
subordinates.
Answer:(A) Have condescending trust and
confidence in their subordinates
Rationale: Benevolent-authoritative managers
pretentiously show their trust and confidence
to their followers.
- Nurse Amy is aware that the following is true
about functional nursing
a. Provides continuous, coordinated and
comprehensive nursing services.
b. One-to-one nurse patient ratio.
c. Emphasize the use of group
collaboration.
d. Concentrates on tasks and activities
Answer: (A) Provides continuous, coordinated
and comprehensive nursing services.
Rationale: Functional nursing is focused on
tasks and activities and not on the care of the
patients.
- Which type of medication order might read
“Vitamin K 10 mg I.M. daily × 3 days?”
a. Single order
b. Standard written order
c. Standing order
d. Stat order
Answer: (B) Standard written order
Rationale: This is a standard written order.
Prescribers write a single order for
medications given only once. A stat order is
written for medications given immediately for
an urgent client problem. A standing order,
also known as a protocol, establishes
guidelines for treating a particular disease or
set of symptoms in special care areas such as
the coronary care unit. Facilities also may
institute medication protocols that specifically
designate drugs that a nurse may not give
- A female client with a fecal impaction frequently
exhibits which clinical manifestation?
a. Increased appetite
b. Loss of urge to defecate
c. Hard, brown, formed stools
d. Liquid or semi-liquid stools
- Answer: (D) Liquid or semi-liquid stools
Rationale: Passage of liquid or semi-liquid
stools results from seepage of unformed
bowel contents around the impacted stool in
the rectum. Clients with fecal impaction don’t
pass hard, brown, formed stools because the
feces can’t move past the impaction.
- Nurse Linda prepares to perform an otoscopic
examination on a female client. For proper
visualization, the nurse should position the
client’s ear by:
a. Pulling the lobule down and back
b. Pulling the helix up and forward
c. Pulling the helix up and back
d. Pulling the lobule down and forward
Answer: (C) Pulling the helix up and back
Rationale: To perform an otoscopic
examination on an adult, the nurse grasps the
helix of the ear and pulls it up and back to
straighten the ear canal. For a child, the nurse
grasps the helix and pulls it down to straighten
the ear canal. Pulling the lobule in any
direction wouldn’t straighten the ear canal for
visualization
- Which instruction should nurse Tom give to a
male client who is having external radiation
therapy:
a. Protect the irritated skin from sunlight.
b. Eat 3 to 4 hours before treatment.
c. Wash the skin over regularly.
d. Apply lotion or oil to the radiated area
when it is red or sore.
Answer: (A) Protect the irritated skin from
sunlight.
Rationale: Irradiated skin is very sensitive and
must be protected with clothing or sunblock.
The priority approach is the avoidance of
strong sunlight
- In assisting a female client for immediate
surgery, the nurse In-charge is aware that she
should:
a. Encourage the client to void following
preoperative medication.
b. Explore the client’s fears and anxieties
about the surgery.
c. Assist the client in removing dentures
and nail polish.
d. Encourage the client to drink water prior
to surgery.
Answer: (C) Assist the client in removing
dentures and nail polish.
Rationale: Dentures, hairpins, and combs must
be removed. Nail polish must be removed so
that cyanosis can be easily monitored by
observing the nail beds
- A male client is admitted and diagnosed with
acute pancreatitis after a holiday celebration of
excessive food and alcohol. Which assessment
finding reflects this diagnosis?
a. Blood pressure above normal range.
b. Presence of crackles in both lung fields.
c. Hyperactive bowel sounds
d. Sudden onset of continuous epigastric
and back pain.
Answer: (D) Sudden onset of continuous
epigastric and back pain.
Rationale: The autodigestion of tissue by the
pancreatic enzymes results in pain from
inflammation, edema, and possible
hemorrhage. Continuous, unrelieved epigastric
or back pain reflects the inflammatory process
in the pancreas
Which dietary guidelines are important for nurse
Oliver to implement in caring for the client with
burns?
a. Provide high-fiber, high-fat diet
b. Provide high-protein, high-carbohydrate
diet.
c. Monitor intake to prevent weight gain.
d. Provide ice chips or water intake.
Answer: (B) Provide high-protein, highcarbohydrate diet.
Rationale: A positive nitrogen balance is
important for meeting metabolic needs, tissue
repair, and resistance to infection. Caloric
goals may be as high as 5000 calories per day
- Nurse Hazel will administer a unit of whole
blood, which priority information should the
nurse have about the client?
a. Blood pressure and pulse rate.
b. Height and weight.
c. Calcium and potassium levels
d. Hgb and Hct levels
Answer: (A) Blood pressure and pulse rate.
Rationale: The baseline must be established to
recognize the signs of an anaphylactic or
hemolytic reaction to the transfusion
- Nurse Michelle witnesses a female client sustain
a fall and suspects that the leg may be broken.
The nurse takes which priority action?
a. Takes a set of vital signs.
b. Call the radiology department for X-ray.
c. Reassure the client that everything will
be alright.
d. Immobilize the leg before moving the
client.
Answer: (D) Immobilize the leg before moving
the client.
Rationale: If the nurse suspects a fracture,
splinting the area before moving the client is
imperative. The nurse should call for
emergency help if the client is not hospitalized
and call for a physician for the hospitalized
client
- A male client is being transferred to the nursing
unit for admission after receiving a radium
implant for bladder cancer. The nurse in-charge
would take which priority action in the care of
this client?
a. Place client on reverse isolation.
b. Admit the client into a private room.
c. Encourage the client to take frequent
rest periods.
d. Encourage family and friends to visit.
Answer: (B) Admit the client into a private
room.
Rationale: The client who has a radiation
implant is placed in a private room and has a
limited number of visitors. This reduces the
exposure of others to the radiation.
- A newly admitted female client was diagnosed
with agranulocytosis. The nurse formulates
which priority nursing diagnosis?
a. Constipation
b. Diarrhea
c. Risk for infection
d. Deficient knowledge
. Answer: (C) Risk for infection
Rationale: Agranulocytosis is characterized by
a reduced number of leukocytes (leucopenia)
and neutrophils (neutropenia) in the blood.
The client is at high risk for infection because
of the decreased body defenses against
microorganisms. Deficient knowledge related
to the nature of the disorder may be
appropriate diagnosis but is not the priority.
- A male client is receiving total parenteral
nutrition suddenly demonstrates signs and
symptoms of an air embolism. What is the
priority action by the nurse?
a. Notify the physician.
b. Place the client on the left side in the
Trendelenburg position.
c. Place the client in high-Fowlers position.
d. Stop the total parenteral nutrition.
Answer: (B) Place the client on the left side in
the Trendelenburg position.
Rationale: Lying on the left side may prevent
air from flowing into the pulmonary veins. The
Trendelenburg position increases intrathoracic
pressure, which decreases the amount of
blood pulled into the vena cava during
aspiration.
