Compre 2.0

• the patient self management

  1. Peplau
  2. Roy
  3. Neuman
  4. orem

  4. orem
• The nurse must transfer the adult client with R sided weakness from bed to a

  wheelchair. Where should the nurse position the wheelchair?

  at a 90 degree angle to the head of the bed on the client's affected side.

  at a 45 degree angle to the head of the bed on the client's unaffected side.

  parallel to the foot of the bed on the client's affected side.

  facing the head of the bed on the client's unaffected side.

  at a 45 degree angle to the head of the bed on the client's unaffected side.
• Which of the following personal protective equipment (PPE) should be removed first after performing a nursing procedure?

  Gloves Hair cover Gown Mask

  Gloves
• One example of a nursing model is the self-deficit theory. In this model, nursing care becomes necessary when client is unable to fulfill biological, psychological,d evelopmental or social needs. This model was popularized by:

  Virginia Henderson

  Dorothea Orem

  Faye Abdellah

  Hildegard peplau

  Dorothea Orem
• Which position should you use for unconscious patients to allow postural drainage and prevent the tongue obstructing the airway?

  Upright position

  Fowler position

  Recovery position

  Trendelenburg position

  Recovery position
• The nurse is assigned to care for a Jehovah's Witness client. The client had

  massive upper gastrointestinal bleeding due to peptic ulcer disease. Which of the following orders for the client should be verified by the nurse from the physician?

  NaCl 0.9%/IV D5 Lactated Ringers/IV Hetastarch/IV Cryoprecipitate transfusion

  Cryoprecipitate transfusion
• What is the primary purpose of using a drawsheet on a bed?

  Providing additional warmth to the patient. Enhancing the appearance of the bed. Preventing the formation of pressure ulcers Facilitating easier movement of the patient

  Facilitating easier movement of the patient
• When one eye is exposed to bright light, a ____________ occurs (constriction of that pupil) as well as a _____________(simultaneous constriction of the other pupil).

  Primary light reflex, secondary light reflex Consensual light reflex, primary light reflex Direct light reflex, consensual light reflex Consensual light reflex, direct light reflex

  Direct light reflex, consensual light reflex
• A patient with diabetes is controlling the disease with insulin and diet. The nursing health care provider is focusing efforts to teach the patient self-management. Which of the following nursing theories is useful in promoting self management?

  Peplau Orem Roy Neuman

  Orem
• Which is an example of objective data

  Patient's use of medications at home 2 X 5 cm scar present on the right lower forearm Last menstrual period 1 month ago Patient's history of allergies

  2 X 5 cm scar present on the right lower forearm
• Knowledge of the use of personal space is helpful for the health care provider.

  Personal distance is generally considered to be:

  4 to 12 ft 1.5 to 4 ft 0 to 1.5 ft 12+ ft

  1.5 to 4 ft
• Which position relaxes tension for the abdominal muscles?

  Fowler position Lower limbs raised position Recumbent position Trendelenburg position 


  Fowler position
• Which of the following is an appropriate nursing action when implementing

  standard precautions?

  Wear gown and gloves when caring for a client in droplet precaution. Wear gloves whenever in contact with clients. Consider all body substances potentially infectious. Place a body substance isolation sign on the client's door.

  Wear gloves whenever in contact with clients
• A skin lesion which is fluid-filled, less than 1 cm in size is called

  Vesicle Macule Bulla Papule

  Vesicle
• A 42-year-old woman who has problems during the near vision testing due to the decrease in the power of accommodation, suffers from which of the following conditions?

  Phoria Strabismus Tropia Presbyopia

  


  Presbyopia
• A patient asks the nurse, "May I ask you a question?" This is an example of:

  A double-barreled question An open- ended question A closed question A reflective question

  A closed question
• Which of the following is an example of appropriate use of personal protective equipment (PPE)?

  Reusing a disposable gown after disinfection Wearing goggles only when there is a risk of splashing Wearing a surgical mask in place of a respirator when caring for a patient with tuberculosis Wearing gloves when handling non-infectious materials

  Wearing a surgical mask in place of a respirator when caring for a patient with tuberculosis
• During the interview process and physical assessment of Ms. Wong, which of the following would alert the nurse of a possible fluid volume deficit?

  Lips and mucous membranes dry Skin warm Abdominal tenderness Nausea

  Lips and mucous membranes dry
• The health care provider orders progressive ambulation for the client with an injury to the lower back. The client has been on bed rest. Which should the nurse do when assisting the client in getting gout of bed for the first time?

  place socks on the client remove the elastic stockings that the client has been wearing. dangle the client at the side of the bed before client stands up allow the nursing assistive personnel to ambulate the client.

  dangle the client at the side of the bed before client stands up
• You are reviewing concepts related to steps in the nursing process for determining prioritization and developing patient outcomes. To what are these actions attributed?

  Assessment Implementation Diagnosis Planning

  Planning
• When interviewing a patient, it is best to be:

  Standing above the patient. 2 to 3 feet from the patient. Sitting below the patient. At eye-level with the patient.

  At eye-level with the patient
• Jake is complaining of shortness of breath. The nurse assesses his respiratory rate to be 30 breaths per minute and documents that Jake is tachypneic. The nurse understands that tachypnea means:

  Respiratory rate greater than 20 breaths per minute Blood pressure of 140/90 Frequent bowel sounds Pulse rate greater than 100 beats per minute

  Respiratory rate greater than 20 breaths per minute
• Which of the following is the most effective practice by health care workers and family when caring for a patient with low resistance to infection due to cancer?

  Wear mask in the patient's room at all times. Meticulous housekeeping of the patient's room. Wash hands frequently. Allow 2 visitors only at a time.

  Wash hands frequently
• Although a full mental status examination may not be required, you must be aware of the 4 main headings of the assessment while performing the interview and physical examination. These headings are:

  Memory, attention, thought content, and perceptions Language, orientation, attention, and abstract reasoning Appearance, behavior, cognition, and thought process Mood, affect, consciousness, and orientation

  


  Appearance, behavior, cognition, and thought process
• Legally, patient’s charts are:

  Owned by the hospital and should not be given to anyone who requests other than the doctor in charge Owned by the government since it is a legal document Owned by the doctor in charge and should be kept from the administrator for whatever reason Owned by the patient and should be given by the nurse to her client if requested

  Owned by the hospital and should not be given to anyone who requests other than the doctor in charge
• When a patient is confused,left alone with the side rails down, and the bed in a high position,the patient falls and breaks a hip. What law has been broken.

  Battery Civil tort Negligence Assault

  Negligence
• Newborn screening is done to every newborn in the Philippines. This is an example of:

  Rehabilitation Secondary prevention Tertiary prevention

  Primary prevention

  Primary prevention
• The nurse performs assessment in a client. She correctly assesses tactile fremitus by:

  Using the thumb and fingerson 1 Using the fingers Using the heel of the hands Using the palm of the hands

  Using the palm of the hands
• Which of the following is closely aligned with Leininger's theory?

  Caring for patients who cannot adapt to internal and external environmental demands Understanding the humanistic aspects of life Caring for patients from unique cultures Variables affecting a patient's response to a stressor

  Caring for patients who cannot adapt to internal and external environmental demands
• When assessing the eyes, OD ____________ refers

  Neither Left Both Right

  Right
• Nurse Cathy on the other hand, knows the case immediately even before a diagnosis is done. Based on Benner's theory she is a/an:

  Expert Competent Advanced beginner Novice

  Expert
• When was the “spirit of Nursing” thought to have started?

  Time when hospitals and school of nursing were established Florence Nightingale time During the establishments of universities, colleges and schools of nursing As early as civilization

  As early as civilization
• What is the purpose of mitering the corners when making a bed?

  To make it easier to change the sheets later To prevent wrinkles and creases in the sheets. To ensure the comfort of the patients To create a neat and decorative appearance

  To prevent wrinkles and creases in the sheets.
• Which of the following positions of the client and the hospital bed is most appropriate in doing a bed bath for the patient?

  Move the client away from you and adjust the bed in low position Move the client towards you and adjust the bed in low position Move the client towards you and adjust the bed in high position Move the client away from you and adjust the bed in high position

  Move the client towards you and adjust the bed in low position
• The nurse is obligated to follow a physician’s order unless:

  The order is a verbal order. The order is an error, violates hospital policy, or would be detrimental to the client. The order has not been transcribed. The physician's order is illegible

  The order is an error, violates hospital policy, or would be detrimental to the client.
• Which of the following observation is most important to determine before providing oral hygiene to the unconscious patient?

  Dryness or discoloration of the tongue Presence of a functioning gag reflex Color, texture, or bleeding of gums Presence of dental carries of halitosis

  


  Presence of a functioning gag reflex
• Which of the following is an essential step in preventing the transmission of infection during bed making?

  Shaking the linens vigorously before spreading them on the bed Using scented fabric softener Using the same linens for multiple patients Wearing gloves

  Wearing gloves
• In the physical examination of the patient with abdominal pain, the following sequence of techniques is recommended:

  Inspection, percussion, palpation, and auscultation Inspection, auscultation, percussion and palpation Inspection, percussion, auscultation, and palpation Inspection, palpation, percussion, and auscultation

  Inspection, auscultation, percussion and palpation
• A nursing measure to psychologically prepare the client for physical examination is:

  Explain the procedure and allow her to verbalize her discomforts and doubts Provide screen for privacy Avoid unnecessary noise, as it will interfere in the examination Tell the client what she can do to assist in the examination

  Explain the procedure and allow her to verbalize her discomforts and doubts
• The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the underlying tissue:

  turgor. consistency. density. texture.

  density