Nursing Board Review: Fundamentals of Nursing Practice Test Part 1

Health belief of an individual influences his/her preventive health behavior.

When teaching a patient about medications before discharge, the nurse is acting as an educator. A caregiver provides direct care to the patient. The nurse acts as s patient advocate when making the patient’s wishes known to the doctor.

The outcome, or the product of the planning phase of the nursing process is a Nursing care plan.

Physiologic needs (ex. Oxygen, fluids, nutrition) must be met before lower needs (such as safety and security, love and belongingness, self-esteem and self-actualization) can be met. Therefore, physiologic needs have the highest priority.

The sign and symptoms indicate extravasation so the IVF should be stopped immediately and put warm not cold towel on the affected site.

Expected outcomes are specific, measurable, realistic statements of goal attainment. The phrases “right amount”, “less nauseated” and “enough sleep” are vague and not measurable.

A nurse should record a nursing intervention (ex. Giving medications) after performing the nursing intervention (not before). Recording should also be done using a pen, be complete, and signed with the nurse’s full name and title.

Although diagnosing is basically the nurse’s responsibility, input from the patient is essential to formulate the correct nursing diagnosis.

Subjective data are those that can be described only by the person experiencing it. Therefore, only the patient can describe or verify whether he is experiencing pain or not.

Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output.

The patient should be positioned with the head of the bed completely flattened to perform an abdominal examination. If the head of the bed is elevated, the abdominal muscles and organs can be bunched up, altering the findings.

The nurse should aspirate the urine from the port using a sterile syringe to obtain a urine specimen. Opening a closed drainage system increase the risk of urinary tract infection.

Sister Roy’s theory is called the adaptation theory and she viewed each person as a unified biophysical system in constant interaction with a changing environment. Orem’s theory is called self-care deficit theory and is based on the belief that individual has a need for self-care actions. King’s theory is the Goal attainment theory and described nursing as a helping profession that assists individuals and groups in society to attain, maintain, and restore health. Henderson introduced the nature of nursing model and identified the 14 basic needs.

A respiratory rate of greater than 20 breaths per minute is tachypnea. A blood pressure of 140/90 is considered hypertension. Pulse greater than 100 beats per minute is tachycardia. Frequent bowel sounds refer to hyper-active bowel sounds.

The trial and error method of problem solving isn’t systematic (as in the scientific method of problem solving) routine, or based on inner prompting (as in the intuitive method of problem solving).

The change-of-shift report should indicate significant recent changes in the patient’s condition that the nurse assuming responsibility for care of the patient will need to monitor. The other options are not critical enough to include in the report.

To be effective, the nursing care plan developed in the planning phase of the nursing process must reflect the individualized needs of the patient.

Capillary refill greater than 3 seconds and buccal cyanosis indicate decreased oxygen to the tissues which requires immediate attention/intervention. Oriented to date, time and place, hemoglobin of 13 g/dl are normal data.

The height of the feeding is above 12 inches above the point of insertion, bot 20 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.

This is to verify or to make sure that the medication was taken by the patient as directed.

Wheezes are indicated by continuous, lengthy, musical; heard during inspiration or expiration. Rhonchi are usually coarse breath sounds. Gurgles are loud gurgling, bubbling sound. Vesicular breath sounds are low pitch, soft intensity on expiration.

A patient’s privacy may be violated if security measures aren’t used properly or if policies and procedures aren’t in place that determines what type of information can be retrieved, by whom, and for what purpose.

The correct order of the nursing process is assessing, diagnosing, planning, implementing, evaluating.

The goal is the opposite, healthy response of the problem statement of the nursing diagnosis. In this situation, the problem statement is diarrhea.

To convert °F to °C use this formula, ( °F – 32 ) (0.55). While when converting °C to °F use this formula, ( °C x 1.8) + 32. Note that 0.55 is 5/9 and 1.8 is 9/5.