Transcript MCQs on Fundamentals of Nursing students 3

MCQs On Fundamentals of
Nursing 3
1. The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a
patient with end-stage chronic obstructive pulmonary disease. How should the NAP
proceed?
A. Bathe the patient’s entire body using 8 to 10 washcloths.
B. Assist the patient to a chair and provide bathing supplies.
C. Saturate a towel and blanket in a plastic bag, and then bathe the patient.
D. Assist the patient to the bathtub and provide a bath chair.
The answer is : A.
Bathe the patient’s entire body using 8 to 10 washcloths.
A towel bath is a modification of the bed bath in which the NAP places a large towel
and a bath blanket into a plastic bag, saturates them with a commercially prepared
mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a
microwave, and then uses them to bathe the patient. A bag bath is a modification
of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or
blanket. Each part of the patient’s body is bathed with a fresh cloth. A bag bath is
not given in a chair or in the tub.
2. For a morbidly obese patient, which intervention should the nurse choose to counteract
the pressure created by the skin folds?
A. Cover the mattress with a sheepskin.
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
The answer is : B.
Keep the linens wrinkle free.
Separating the skin folds with towels relieves the pressure of skin rubbing on skin.
Sheepskins are not recommended for use at all. Petrolatum barrier creams are
used to minimize moisture caused by incontinence.
3. A patient exhibits all of the following during a physical assessment. Which of these is
considered a primary defense against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
The answer is : B.
Intact skin
Intact skin is considered a primary defense against infection. Fever, the
inflammatory response, and phagocytosis (a process of killing pathogens) are
considered secondary defenses against infection.
4. A patient with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus
(MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be
observed to follow contact precautions?
A. A clean gown and gloves must be worn when in contact with the patient.
B. Everyone who enters the room must wear a N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard
waste.
D. Place the patient in a room with a patient with an upper respiratory
infection.
The answer is :A. A clean gown and gloves must be worn when in contact with the
patient.
A clean gown and gloves must be worn when any contact is anticipated with the
patient or with contaminated items in the room. A respirator mask is required only
with airborne precautions, not contact precautions. All linen must be doublebagged and clearly marked as contaminated. The patient should be placed in a
private room or in a room with a patient with an active infection caused by the
same organism and no other infections.
5. A patient requires protective isolation. Which patient can be safely paired with this patient
in a patient-care assignment? One:
A. admitted with unstable diabetes mellitus.
B. who underwent surgical repair of a perforated bowel.
C. with a stage 3 sacral pressure ulcer.
D. admitted with a urinary tract infection.
The answer is : A.
admitted with unstable diabetes mellitus.
The patient with unstable diabetes mellitus can safely be paired in a patient-care
assignment because the patient is free from infection. Perforation of the bowel
exposes the patient to infection requiring antibiotic therapy during the postoperative
period. Therefore, this patient should not be paired with a patient in protective
isolation. A patient in protective isolation should not be paired with a patient who
has an open wound, such as a stage 3 pressure ulcer, or with a patient who has a
urinary tract infection.
6. A newly hired at Nurseslabs Medical Center is assigned in the OR Department. Which
action demonstrates a break in sterile technique?
A. Remaining 1 foot away from nonsterile areas
B. Placing sterile items on the sterile field
C. Avoiding the border of the sterile drape
D. Reaching 1 foot over the sterile field
The answer is : D.
Reaching 1 foot over the sterile field
Reaching over the sterile field while wearing sterile garb breaks sterile technique.
While observing sterile technique, healthcare workers should remain 1 foot away
from nonsterile areas while wearing sterile garb, place sterile items needed for
the procedure on the sterile drape, and avoid coming in contact with the 1-inch
border of the sterile drape.
7. Nurse Berta is facilitating a monthly mothers’ class at a small village. As a knowledgeable
nurse, she must know that a mother who breastfeeds her child passes on which antibody
through breast milk?
A. IgA
B. IgE
C. IgG
D. IgM
The answer is : C.
IgG
The antibody IgG is passed to the child through the mother’s breast
milk during breastfeeding. IgA, IgE, and IgM are produced by the child’s body
after exposure to an antigen.
8. The clinical instructor asks her students the rationale for hand washing. The students are correct if
they answered that hand washing is expected to remove:
A. transient flora from the skin.
B. resident flora from the skin.
C. all microorganisms from the skin.
D. media for bacterial growth.
The answer is : A.
transient flora from the skin.
There are two types of normal flora: transient and resident. Transient flora are normal
flora that a person picks up by coming in contact with objects or another person
(e.g., when you touch a soiled dressing). You can remove these with hand
washing. Resident flora live deep in skin layers where they live and multiply
harmlessly. They are permanent inhabitants of the skin and cannot usually be
removed with routine hand washing. Removing all microorganisms from the skin
(sterilization) is not possible without damaging the skin tissues. To live and thrive in
humans, microbes must be able to use the body’s precise balance of food,
moisture, nutrients, electrolytes, pH, temperature, and light. Food, water, and soil
that provide these conditions may serve as nonliving reservoirs. Hand washing does
little to make the skin uninhabitable for microorganisms, except perhaps briefly
when an antiseptic agent is used for cleansing.
9. Which of the following incidents requires the nurse to complete an occurrence report?
A. Medication given 30 minutes after scheduled dose time
B. Patient’s dentures lost after transfer
C. Worn electrical cord discovered on an IV infusion pump
D. Prescription without the route of administration
The answer is : B.
Patient’s dentures lost after transfer
You would need to complete an occurrence report if you suspect your patient’s
personal items to be lost or stolen. A medication can be administered within a halfhour of the administration time without an error in administration; therefore, an
occurrence report is not necessary. The worn electrical cord should be taken out of
use and reported to the biomedical department. The nurse should seek clarification
if the provider’s order is missing information; an occurrence report is not necessary.
10. The nurse is orienting a new nurse to the unit and reviews source-oriented charting.
Which statement by the nurse best describes source-oriented charting? Source-oriented
charting:
A. Separates the health record according to discipline
B. Organizes documentation around the patient’s problems
C. Highlights the patient’s concerns, problems, and strengths
D. Is designed to streamline documentation
The answer is : A.
Separates the health record according to discipline
In source-oriented charting, each discipline documents findings in a separately
labeled section of the chart. Problem-oriented charting organizes notes around
the patient’s problems. Focus charting highlights the patient’s concerns,
problems, and strengths. Charting by exception is a unique charting system
designed to streamline documentation.
11. When the nurse completes the patient’s admission nursing database, the patient reports
that he does not have any allergies. Which acceptable medical abbreviation can the nurse
use to document this finding?
A. NA
B. NDA
C. NKA
D. NPO
The answer is : C.
NKA
The nurse can use the medical abbreviation NKA, which means no known allergies,
to document this finding. NA is an abbreviation for not applicable. NDA is an
abbreviation for no known drug allergies. NPO is an abbreviation that means
nothing by mouth.
12. The nurse is working on a unit that uses nursing assessment flow sheets. Which statement
best describes this form of charting? Nursing assessment flow sheets:
A. Are comprehensive charting forms that integrate assessments and nursing
actions
B. Contain only graphic information, such as I&O, vital signs, and medication
administration
C. Are used to record routine aspects of care; they do not contain assessment
data
D. Contain vital data collected upon admission, which can be compared with
newly collected data
The answer is : A.
Are comprehensive charting forms that integrate assessments
and nursing actions
Nursing assessment flow sheets are organized by body systems. The nurse checks the
box corresponding to the current assessment findings. Nursing actions, such as
wound care, treatments, or IV fluid administration, are also included. Graphic
information, such as vital signs, I&O, and routine care, may be found on the graphic
record. The admission form contains baseline information.
13. At the end of the shift, the nurse realizes that she forgot to document a dressing change
that she performed for a patient. Which action should the nurse take?
A. Complete an occurrence report before leaving.
B. Do nothing; the next nurse will document it was done.
C. Write the note of the dressing change into an earlier note.
D. Make a late entry as an addition to the narrative notes.
The answer is : D.
Make a late entry as an addition to the narrative notes.
If the nurse fails to make an important entry while charting, she should make a late
entry as an addition to the narrative notes. An occurrence report is not necessary in
this case. If documentation is omitted, there is no legal verification that the
procedure was performed. It is illegal to add to a chart entry that was previously
documented. The nurse can only document care directly performed or observed.
Therefore, the nurse on the incoming shift would not record the wound change as
performed.
14. Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used.
Which response by the nurse indicates an understanding of the rationale for an EHR system?
A. It includes organizational reports of unusual occurrences that are not part of
the patient’s record.
B. This type of system consists of combined documentation and daily care
plans.
C. It improves interdisciplinary collaboration that improves efficiency in
procedures.
D. This type of system tracks medication administration and usage over 24
hours.
The answer is : C.
It improves interdisciplinary collaboration that improves efficiency
in procedures.
The EHR has several benefits for use, including improving interdisciplinary collaboration
and making procedures more accurate and efficient. An occurrence report is an
organizational record of an unusual occurrence or accident that is not a part of the
patient’s record. Integrated plans of care (IPOC) are a combined charting and care
plan format. A medication administration record (MAR) is used to document
medications administered and their usage.
15. In the United States, the first programs for training nurses were affiliated with:
A. The military
B. General hospitals
C. Civil service
D. Religious orders
The answer is :
D. Religious orders
When the Civil War broke out, the Army used nurses who had already been trained
in religious orders. Although the Army did provide some training, it occurred later
than in the religious orders. Although nurses were trained in hospitals, the training
and the hospitals were affiliated with religious orders. Civil service was not
mentioned in Chapter 1 and was not a factor in the early 1800s. Nursing started
with religious orders. The Hindu faith was the first to write about nursing. In the
United States, all training for nurses was affiliated with religious orders until after
the Civil War.
16. Which of the following is/are an example(s) of a health restoration activity? Select all
that apply.
A. Administering an antibiotic every day
B. Teaching the importance of hand washing
C. Assessing a patient’s surgical incision
D. Advising a woman to get an annual mammogram after age 50 years
The answer is : A, C
Health restoration activities help an ill patient return to health. This would include
taking an antibiotic every day and assessing a patient’s surgical incision. Hand
washing and mammograms both involve healthy people who are trying to
prevent illness.
17. Which of the following aspects of nursing is essential to defining it as both a profession
and a discipline?
A. Established standards of care
B. Professional organizations
C. Practice supported by scientific research
D. Activities determined by a scope of practice
The answer is : C.
Practice supported by scientific research
The American Nurses Association (ANA) has developed standards of care, but they
are unrelated to defining nursing as a profession or discipline. Having
professional organizations is not included in accepted characteristics of either a
profession or a discipline. A profession must have knowledge that is based on
technical and scientific knowledge. The theoretical knowledge of a discipline
must be based on research, so both are scientifically based. Having a scope of
practice is not included in accepted characteristics of either a profession or a
18. The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive
personnel (NAP) and medication administration to the licensed vocational nurse (LVN).
Which nursing model of care is this floor following?
A. Team nursing
B. Case method nursing
C. Functional nursing
D. Primary nursing
The answer is : C.
Functional nursing
With team nursing, an RN or LVN is paired with a NAP. The pair is then assigned to
render care for a group of patients. In case method nursing, one nurse cares for
one patient during her entire shift. Private duty nursing is an example of this care
model. This medical surgical floor is following the functional nursing model of
care, in which care is partitioned and assigned to a staff member with the
appropriate skills. For example, the NAP is assigned vital signs, and the LVN is
assigned medication administration. When the primary nursing model is utilized,
one nurse manages care for a group of patients 24 hours a day, even though
others provide care during part of the day.
19. Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team
member should be consulted to assess the patient’s risk for aspiration?
A. Respiratory therapist
B. Occupational therapist
C. Dentist
D. Speech therapist
The answer is : D.
Speech therapist
Respiratory therapists provide care for patients with respiratory disorders. Occupational
therapists help patients regain function and independence. Dentists diagnose and
treat dental disorders. Speech and language therapists provide assistance to
patients experiencing swallowing and speech disturbances. They assess the risk for
aspiration and recommend a treatment plan to reduce the risk.
20. Which of the following is/are an example(s) of theoretical knowledge? Select all that
apply.
A. Antibiotics are ineffective in treating viral infections.
B. When you take a patient’s blood pressure, the patient’s arm should be at
heart level.
C. In Maslow’s framework, physical needs are most basic.
D. When drawing medication out of a vial, inject air into the vial first.
The answer is : A, C
Theoretical knowledge consists of research findings, facts (e.g., “Antibiotics are
ineffective . . .” is a fact), principles, and theories (e.g., “In Maslow’s framework . .
.” is a statement from a theory). Instructions for taking a blood pressure and
withdrawing medications are examples of practical knowledge—what to do
and how to do it.
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MCQs On Fundamentals of
Nursing 2
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