Nursing Pre-board Exam

Controlled substance issues for a particular nursing unit are the responsibility of that unit’s nurse manager.

This is the primary indication for a pacemaker because there is an interfere with the electrical conduction system of the heart.

The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2), supporting the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.

Transformational leadership relies heavily on visioning as the core of leadership.

The principle of unity of command means that employees should receive orders coming from only one manager and not from two managers. This averts the possibility of sowing confusion among the members of the organization.

Rheumatoid arthritis can cause inflammation of the iris and ciliary body of the eyes which may lead to blindness.

Pulmonic stenosis increases resistance to blood flow, causing right ventricular hyperthropy; with right ventricular failure there is an increase in pressure on the right side of the heart.

Efficiency is determining whether the goals were attained at the least possible cost.

Monitoring a pedal pulse will assess circulation to the foot.

Path Goal theory according to House and associates rewards good performance so that others would do the same.

Vitamin K, a fat soluble vitamin, is not absorbed from the GI tract in the absence of bile; bile enters the duodenum via the common bile duct.

The catchment area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services.

Excess extracellular fluid moves into cells (water intoxication); intracellular fluid excess in sensitive brain cells causes altered mental status; other signs include anorexia nervosa, nausea, vomiting, twitching, sleepiness, and convulsions.

Bag technique is performed before and after handling a client in the home to prevent transmission of infection to and from the client.

The purpose of isolating a client with a communicable disease is to protect those who are not sick (specific disease prevention).

According to Winslow, all public health efforts are for people to realize their birthrights of health and longevity.

The client’s statement infers an emptiness with an associated loss.

Inspires others with a vision is characteristic of a transformational leader. He is focused more on the day-to-day operations of the department/unit.

Cenral cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by either decreased lung expansion or right to left shunting of blood.

Impulse conduction of skeletal muscle is impaired with decreased potassium levels, muscular weakness and cramps may occur with hypokalemia.

These abilities are age-appropriate for the 6 month old child.

Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the limb and the prosthesis.

Clients with anorexia nervosa have a disturbed self image and always see themselves as fat and needing further reducing.

This occurs with stenosis of the stoma; forcing insertion of the tube could cause injury.

A new dietary regimen, with a balance of foods from the food pyramid, must be established and continued for weight reduction to occur and be maintained.

All these interventions promote aeration of the re-expanding lung and maintenance of function in the arm and shoulder on the affected side.

Excessive blood loss predisposes the client to an increased risk of infection because of decreased maternal resistance; they expected blood loss is 350 to 500 ml.

The most vigorous sucking will occur during the first few minutes of breastfeeding when the infant would be on the unaffected breast; later suckling is less traumatic.

This indicates a fibrinogenemia; massive clotting in the area of the separation has resulted in a lowered circulating fibrinogen.

Taking with others in similar circumstances provides support and allows for sharing of experiences.

As long as the client has no nausea or vomiting, there are no dietary restriction.

“Where are you?” is the best question to elicit information about the client’s orientation to place because it encourages a response that can be assessed.

Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.

Ovulation occurs approximately 14 days before the next menses, about the 16th day in 30 day cycle; the 15th to 17th days would be the best time to avoid sexual intercourse.

This strategy shuns discussing the issue head-on and prefers to postpone it to a later time. In effect the problem remains unsolved and both parties are in a lose-lose situation.

Swelling can obstruct nasal breathing, interfering with the senses of taste and smell.

Fatigue is a major problem caused by an increase in waste products because of catabolic processes.

The client has signs of diabetes, which may result from steroid therapy, testing the blood glucose level is a method of screening for diabetes, thus gathering more data.

Discussion with parents who have children with similar problems helps to reduce some of their discomfort and guilt.

Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 liter of fluid weighs about 2.2 pounds.

The client is incapable of accepting responsibility for self-created problems and blames society for the behavior.

Caregivers must use surgical asepsis when performing wound care or any procedure in which a sterile body cavity is entered or skin integrity is broken. To achieve surgical asepsis, objects must be rendered or kept free of all pathogens. Inserting an I.V. cannula requires surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). The other options are used to ensure medical asepsis or clean technique to prevent the spread of infection. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

When the functional method is used, the psychological and sociological needs of the patients are neglected; the patients are regarded as ‘tasks to be done”.

Persons with high anxiety levels develop various behaviors to relieve their anxiety; by reducing anxiety, the need for these obsessive-compulsive action is reduced.

Cerebral compression affects pyramidal tracts, resulting in decorticate rigidity and cranial nerve injury, which cause pupil dilation.

Choice A is not correct since a home visit requires that the nurse spend so much time with the family. Choice C is an advantage of a group conference, while choice D is true of a clinic consultation.

With specific manipulation, an audible click may be heard of felt as he femoral head slips into the acetabulum.

A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken.

The volume of food in the stomach should be kept small to limit pressure on the cardiac sphincter.

This is characteristic finding in newborns with Down syndrome.

Clients should use a blowing pattern to overcome the premature urge to push.

Drainage flows by gravity.

Staffing is a management function involving putting the best people to accomplish tasks and activities to attain the goals of the organization.

The end of each entry should include the nurse's signature and title; the signature holds the nurse accountable for the recorded information. Erasing errors in documentation on a legal document such as a client's chart isn't permitted by law. Because a client's medical record is considered a legal document, the nurse should make all entries in ink. The nurse is accountable for the information recorded and therefore shouldn't leave any blank lines in which another health care worker could make additions.

Signs of an epidural hematoma in children usually do not appear for 24 hours or more hours; a follow-up visit usually is arranged for one to two days after the injury.

Corticosteroids act to decrease inflammation which decreases edema.

Mediastinal structures move toward the uninjured lung, reducing oxygenation and venous return.

Levels close to 2 mEq/L are dangerously close to the toxic level; immediate action must be taken.

The nurse must deal with these feelings and establish basic trust to promote a therapeutic milieu.

Stream seeding is done by putting tilapia fry in streams or other bodies of water identified as breeding places of the Anopheles mosquito.

Stimuli are provided via all the senses; since the infant’s behavioral development is enhanced through parent-infant interactions, these interactions should be encouraged.

Because the tumor is of renal origin, the rennin angiotensin mechanism can be involved, and blood pressure monitoring is important.

Decentralized structures allow the staff to make decisions on matters pertaining to their practice and communicate in downward, upward, lateral and diagonal flow.

This is soothing to the oral mucosa and helps prevent infection.

Goal is a desired result towards which efforts are directed. Options AB, C and D are all objectives which are aimed at specific end.

The client’s comfort, safety, and nutritional status are the priorities; the client may feel comfortable to eat if the food has been sealed before reaching the mental health facility.

The early compensation of shock is cardiovascular and is seen in changes in pulse, BP, and pulse pressure; blood is shunted to vital centers, particularly heart and brain.

Academic deficits, an inability to function within constraints required of certain settings, and negative peer attitudes often lead to low self-esteem.

Act 3573, the Law on Reporting of Communicable Diseases, enacted in 1929, mandated the reporting of diseases listed in the law to the nearest health station.

Promoting hydration maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and possible infection.

When a bilateral oophorectomy is performed, both ovaries are excised, eliminating ovarian hormones and initiating response.

Pelvic examination would reveal dilation and effacement.

Of the selections offered, this is the highest in calories and protein, which are needed for increased basal metabolic rate and for tissue repair.

Lactated Ringer’s solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not primary fluid replacement. Dextrose isn’t given to burn patients during the first 24 hours because it can cause pseudodiabetes. The patient is hyperkalemic from the potassium shift from the intracellular space to the plasma, so potassium would be detrimental.

Oxygen has cooling effect, and the baby should be kept warm so that metabolic activity and oxygen demands are not increased.

The client expects the nurse to focus on eating, but the emphasis should be placed on feelings rather than actions.

R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU.

This does not remove client’s only way of coping, and it permits future movement through the grieving process when the client is ready.

The expected effect should be more than a one point decrease in the pain level.

Respiratory complications can occur because of edema of the glottis or injury to the recurrent laryngeal nerve.

General background data consist of such components as allergies, medical history, habits, socioeconomic status, lifestyle, beliefs, and sensory deficits. Urine output, gastric reflex, and bowel habits are significant only if a disease affecting these functions is present.

Shortened attention span and fussy behavior may indicate a change in intracranial pressure and/or shunt malfunction.

This is all the nurse can do until trust is established; facing the client to attend will disrupt the group.

This would absorb the drainage without causing further trauma.

The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol/nasogastric tube, Oresol/orem. When the foregoing measures are not possible or effective, tehn urgent referral to the hospital is done.

Statistics indicate that the most frequent cause of falls by hospitalized clients is getting up or attempting to get up to the bathroom unassisted.

Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dl; deep tendon reflexes disappear when the serum level is 10 to 12 mg/dl; the drug is withheld in the absence of deep tendon reflexes; the therapeutic serum level is 5 to 8 mg/dl.

Ensuring the accessibility and quality of health care is the primary mission of DOH.

This portrays a nonjudgmental attitude that recognizes the client’s needs.

R.A. 8976 mandates fortification of rice, wheat flour, sugar and cooking oil with Vitamin A, iron and/or iodine.

Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

Swaroop’s index is the percentage of the deaths aged 50 years or older. Its inverse represents the percentage of untimely deaths (those who died younger than 50 years).

The best source of information about the priority needs of the patient is the patient himself. Hence using a nursing care plan based on his expressed priority needs would ensure meeting his needs effectively.

The nurse should offer support and use clear, simple terms to allay client’s anxiety.

This could indicate a recurrence of the pneumothorax as one side of the lung is inadequate to meet the oxygen demands of the body.

The anatomic characteristics of the palms allow a reliable and convenient basis for examination for pallor.

Tubercle bacilli are transmitted through air currents; therefore personal protective equipment such as an Ultra-Filter mask is necessary.

An invasive procedure such as amniocentesis requires informed consent.

Pancreases capsules must be taken with food and snacks because it acts on the nutrients and readies them for absorption.

Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that accompanies partial cord compression (umbilical vein) during contractions; changing the maternal position can alleviate the compression.