NCMA – 113 – FUNDAMENTALS IN NURSING (REVIEWER QUIZ)

Lubricate nares with oil to prevent dryness of the mucous membrane

Situation: You are the nurse assigned to take care of the client receiving oxygen therapy Nurse Grace is about to administer oxygen to Patient Tirso. Which of the following nursing intervention is NOT  to be included for a client receiving oxygen therapy?

 

Lubricate nares with oil to prevent dryness of the mucous membrane

 

Place the client in Semi-fowler’s Position

 

Place Sterile water into the oxygen humidifier

 

Place a “No Smoking” sign at the bedside

1,2,3

Situation: You are the nurse assigned to take care of the client receiving oxygen therapy Nurse Grace is about to administer oxygen to Patient Tirso. You are the nurse assigned to take care of the client receiving oxygen therapy. The following are the appropriate nursing diagnosis for clients with oxygenation problems: Please SELLECT ALL THAT APPLY

               

1. Ineffective airway clearance related to tracheobronchial secretions

2. Ineffective breathing pattern related to decreased energy and fatigue

3. Impaired gas exchange related to altered oxygen-carrying capacity of the blood

4. Risk for ineffective coping mechanism

 

Have the patient breathe through pursed lips

A client, is diagnosed with chronic obstructive pulmonary disease receiving oxygen at 1.5 LPM via nasal cannula, is complaining difficulty of breathing and shortness of breath. What action should the nurse take?

 

Lower the head of the client's bed to semi fowlers position

Have the patient breathe through pursed lips

 

Increase the oxygen to 3 liters per minute

 

Encourage the client to breath more rapidly

non re breather mask

A patient has carbon monoxide poisoning and is in need of 100% oxygen therapy, what type of mask will you prepare for this patient?

 

Simple mask

non re breather mask

 

Partial non rebreather mask

 

Face ten

1,2,3,4

The following are purposes of oropharyngeal, nasopharyngeal and nasotracheal suctioning. Please SELLECT ALL THAT APPLY

1. To remove secretions that obstruct the airway

2. To facilitate ventilation

3. To obtain secretions for diagnostic procedures

4. To prevent infection that may result from accumulated secretions

 

1,2,4

 

1,2

 

1,2,3,4

 

1,2,3

Lateral position facing you

You are going to suction the oropharyngeal airway of an unconscious client, how will you position the patient?

 

Semi fowler's position

Lateral position facing you

 

Supine position

 

High Fowler's Position

1,2,3,4

The following are clinical signs indicating the need for suctioning. Please SELLECT ALL THAT APPLY

 

1. Restlessness

2. Noisy respirations

3. Abnormal breath sounds upon auscultation

4. Decreased oxygen saturation

5. Bronchovesicular breath sound

 

1,2,3,4

 

1,2,3,4,5

 

2,3,4,5

 

1,2,3

Inhalation and exhalation are involuntary and therefore requires an effort

Which one among the statement about inhalation and exhalation is correct?

 

Inhalation and exhalation are involuntary and therefore requires no effort

 

Inhalation and exhalation are voluntary and therefore requires no effort

 

Inhalation and exhalation are voluntary and therefore requires an effort

 

Inhalation and exhalation are involuntary and therefore requires an effort

Minimize cigarette smoking.

The following are appropriate nursing interventions to promote normal respiratory function EXCEPT:

 

Adequate fluid intake.

Minimize cigarette smoking.

 

Frequent change of position for bedridden clients.

 

Deep breathing and coughing exercise.

Eupnea

It is an easy and noiseless breathing.

 

Eupnea

 

Apnea

 

Dyspnea

 

Orthopnea

apnea

t is the cessation of breathing.

 

Eupnea

 

Apnea

 

Orthopnea

 

Dyspnea

Pulmonary vein

The structure that is responsible for returning oxygenated blood to the heart is the:

 

Pulmonary vein

 

Pulmonary Artery

 

Inferior vena cava

 

Superior vena cava

Hyperventilation

Altered breathing pattern in volume wherein there is an over expansion of the lungs characterized by rapid and deep breaths;

 

Hyperventilation

 

Orthopnea

 

Hypoventilation

 

Dyspnea

A 3 year old in preschool

Which client is most at risk for developing an upper respiratory infection?

A 3 year old in preschool

 

A 13 year old with broken leg

 

A 20 year old healthy adult

 

A 50 year old non-smoker

hypoxemia

The physician notes that the patient may to suffer _______ if there is an insufficient oxygen in the blood.

 

hypooxygenemia

hypoxia

 

hypoxemia

 

hypovolemia

Fr. 8-10

The Nurse planning care to a 7 year old female patient who needs a foley catheter inserted. It is most important for the nurse to use which size of catheter?

 

Fr. 5-6

 

Fr. 12

 

4. Fr. 14-16

Fr. 8-10

Remove obvious encrustations form the external catheter surface by washing it gently with soap and water

 

Care of indwelling catheters should include which of the following interventions?

 

Insert the catheter using a clean technique

 

Lay the drainage bag on the floor for maximum drainage through gravity

Remove obvious encrustations form the external catheter surface by washing it gently with soap and water

 

Keep the drainage bag on the bed with the client

Spinal Cord Injury

Which of the following may require an insertion of Foley Catheter?

 

Bone fracture

 

Diarrhea

 

Heartburn

Spinal Cord Injury

All of the above

Appropriate insertion follows aseptic technique which includes the use of the following?

 

Sterile drape

 

Sterile skin antiseptic

 

Sterile gloves

 

All of the above

2, 3, 4

A nurse is preparing cleansing enema to a sult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? SELLECT ALL THAT APPLY

 

1. Warm the enema prior to administration

2. Position the client on the left side with the right flexed forward

3. Lubricate the rectal tube

4. Slowly insert the rectal about 2 inches

5. Hang the container 24 inches above the clients anus

 

1, 2, 4

 

2, 3, 4

 

1, 3, 4

 

1, 2, 3

Discontinue the fluid installation

While the nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is an appropriate intervention?

 

Have the client hold his breath briefly

Discontinue the fluid installation

 

Remind the client that cramping is common at that time

Lower the enema fluid container

Insert the tube 3- 4 inches ( 7.5- 10 cm) and angle toward the navel

The nurse is inserting an enema tube into the anus of the client to treat constipation. How should the nurse insert the tube?

lubricate the rectal tube or nozzle

 

Have a client hold his breath briefly

 

4. Position the client on the left side

3. Insert the tube 3- 4 inches ( 7.5- 10 cm) and angle toward the navel

oil retention enema

A nurse needs to insert an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer?

oil retention enema

 

retention enema

 

cleansing enema

 

carminative enema

14 French, 5-mL balloon, latex catheter

A 68-year-old female patient is admitted for knee-replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The physician has ordered an indwelling Foley catheter to be inserted preoperatively. Which catheter should you choose?

 

16 French plastic catheter

 

14 French, 5-mL balloon, latex catheter

 

18 French, 5-mL balloon, latex catheter

 

Coude catheter

It is important to anchor the catheter tubing in order to minimize the risk for urethral trauma, minimize bladder spasms from traction, and prevent accidental dislodgment.

 A nurse demonstrates how to insert an indwelling urinary catheter. Which of the following explanations for catheter anchoring is most accurate?

 

An indwelling catheter tube is secured to the male's inner thigh with a strip of nonallergenic tape or a commercial tube holder.

 

When securing the catheter tubing, slack in the catheter should be avoided to prevent movement and possible tissue injury

It is important to anchor the catheter tubing in order to minimize the risk for urethral trauma, minimize bladder spasms from traction, and prevent accidental dislodgment.

 

An indwelling catheter tube is secured to a female patient's abdomen to prevent accidental dislodgment.

Rectum, sigmoid, descending colon, transverse colon, and ascending colon

When performing a Barium Enema, what is the proper sequence for filling the large intestine with barium?

 

Sigmoid, rectum, descending colon, transverse colon, and ascending colon

 

Rectum, sigmoid, ascending colon, transverse colon, and descending colon

 

Rectum, sigmoid, descending colon, transverse colon, and ascending colon

 

Sigmoid, rectum, ascending colon, transverse colon, and descending colon

Place the patient in the dorsal recumbent position on a bedpan.

Nurse Cindy, is getting ready to give a cleansing enema to a Client who has history of fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is best suited to this patient?

 

Place the patient in the dorsal recumbent position on a bedpan.

 

Administer an antidiarrheal medication 3 hr prior to the enema.

 

Instill 200 mL of fluid at 15-min intervals times four.

 

Administer the enema while the patient sits on the toilet.

Warm the enema solution prior to instillation.

A medical health care provider ordered for two large-volume of  cleansing enemas for  a client in preparation for a diagnostic procedure. As Nurse, which of the following is an appropriate step in the procedure?

 

Hang the enema container 24 inches above the anus

 

Prepare 1,500 mL of enema fluid.

 

Use tap water as the enema fluid.

Warm the enema solution prior to instillation.

cathartic

An agent that causes bowel emptying that is generally result to be more potent than a laxative.

 

Cleansing

 

Soap sud

 

cathartic

 

Barium

" i will administer up to three enemas until there is no more pieces of stool in enema return"

 

Nurse Karen, is caring for a client whose health care provider has written a prescription for "enemas until clear". which explanation to the client about this procedure?

 

" i will administer an enema and just tell me if you want to get up, so that I can assist you in the toilet”.

 

" Let me know if you feel cramping and bloating during enema administration"

" i will administer up to three enemas until there is no more pieces of stool in enema return"

 

“ I will give you an enema just take short, panting breaths until the cramping subsides”.

Extravasation

Patient Rody suddenly complains of stinging pain at his left arm at the venipuncture site of his IV
cannula. The nurse assesses the IV access site and finds out there is swelling into the surrounding tissue
after administration of a vesicant drug for chemotherapy. This is a sign of:

 

Circulatory overload

 

Extravasation

 

Phlebitis

 

Infiltration

Regulate the IV fluid into its desired time of infusion as ordered by the doctor

Ensuring correct IV fluid regulation is essential in the administration of IV therapy and to avoid fluid
overload to our client. Which nursing action should be done to avoid this complication of having a
circulatory overload?

 

Regulate in medium flow using the desired gauge of IV cannula

 

Watch out for slow infusion as ordered by the physician

 

Fast-drip infusion for faster effect of the IV therapy on the client

Regulate the IV fluid into its desired time of infusion as ordered by the doctor

Immediately Stop the infusion and remove the IV cannula. Restart the IV infusion in another site

Nurse Renz is doing his rounds to one of his postoperative patients to check for the level of IV fluid
and notices an intermittent flow of fluid into the drip chamber. Upon assessment, he noticed swelling,
coolness, and pallor within the insertion site. The nurse initial action should be;

 

Change the IV line and cannula

Immediately Stop the infusion and remove the IV cannula. Restart the IV infusion in another site

 

IKeep the line open and flush with 10 cc of PNSS

 

. Immediately notify the doctor and stop the infusion. Apply cold compress for return of adequate blood flow.

Intravenous

 It is the route of drug administration that promotes most rapid absorption

 

Intramuscular

 

Intradermal

 

Subcutaneous

Intravenous

Albumin

35. Patient Jose was brought to the nearest hospital due to a vehicular accident. The client is in a
hypovolemic state because of severe blood loss. The nurse anticipates an order to transfuse blood
products. Which of the following colloid products is a plasma expander?

 

Cryoprecipitate

 

Packed RBC

 

Albumin

 

Platelets

0.9% NaCl

Which of the following crystalloid solutions is compatible for blood transfusion?

 

Fresh Frozen Plasma

 

D5LR

 

0.9% NaCl

 

0.45% NaCl

2-4 hours

Nurse Vic is preparing to transfuse 1 unit of Packed RBC to one of his patients with severe anemia.
The nurse understand that the blood product should be transfused within the duration of;

 

4-6 hours

 

4-6 hours

2-4 hours

 

20-30 minutes

Air embolism

What type of IV complication can be prevented when priming the IV tubing with IV solution?

Air embolism

 

Cardiac overload

 

Phlebitis

 

Thromboembolism

Preparing appropriate size of cannula and sterile microset line.

These are nursing actions being done prior to starting blood transfusion, except:

 

Verifying identity of the client and checking blood product information with another RN

 

Checking the vital signs for baseline

 

Preparing appropriate size of cannula and sterile microset line.

 

Verify doctor’s order for BT

Secure informed consent for BT

Stop the infusion

A patient is receiving a blood transfusion when suddenly complains of generalized itching, difficulty
of breathing and low back pain. The initial action of the nurse should be;

Stop the infusion

 

Check the vital sign

 

Inform the blood bank

 

Notify the physician immediately

167 mL/hr

Nurse Kian will infuse 1 Liter of D5LR in over 6 hours as ordered by the doctor using a macroset.
What flow rate in mL/hr should the nurse set on the IV infusion pump?

 

170 mL/hr

 

200 mL/ hr

 

160 mL/ hr

 

167 mL/hr

71 gtts/min

A 5-year-old boy was admitted in the Pediatric Unit due to moderate dehydration. The doctor
ordered to infuse PNSS half liter to run for 6 hours. How many drops per minute should be delivered
using microset?

71 gtts/min

 

18 gtts/min

 

24 gtts/min

83 gtts/min

Macroset

A student nurse asks his clinical instructor what the appropriate IV infusion set for an adult patient?,
the correct response should be;

 

Soluset

 

Whatever is available

 

Macroset

 

Microset

31 gtts/min

Doctor’s order says: Start IVF D5LR 1 L to run for 8 hours, using IV infusion set with a drip factor of 15
gtts/mL. How many drops per minute should be delivered?

 

42 gtts/min

 

125 gtts/min

 

83 gtts/min

 

31 gtts/min

100 mL/ hr

Doctor’s order says: IVF D5IMB 1 L to finish within 10 hours duration. How many mL/ hr should be
delivered?

 

33 mL/ hr

 

125 mL/ hr

 

100 mL/ hr

 

25 mL/ hr

Effective teamwork

What critical element is key for ensuring that responsibilities are shared, role interdependence is
promoted, and members' experiences are respected?

 

Effective teamwork

 

Effective collaboration

 

Effective communication

 

Effective leadership

Best possible patient outcomes

The primary goal of an interdisciplinary approach is?

 

Greatest continuity of care

 

Best possible patient outcomes

 

Lowest patient readmission rates

 

Highest degree of patient and staff satisfaction

Collaboration

The interdisciplinary team needed to meet to discuss a home patient's discharge. The nurse notified the family of the team meeting, the social worker emailed the vendor to get the specific details of the available equipment to be able to discuss it with the team and the health care provider brought the MOLST- Medical Orders for Life-Sustaining Treatment form to discuss it with the patient and family. These are all examples of what critical element of interprofessional teams?

 

Communication

 

Patient-centered practice

 

Leadership

Collaboration

Effective Communication

A principles with agreeable commitment by both parties and understanding each other professional roles is known as?

 

Measurable processes

Clear roles and expectations

Effective Communication

 

Shared goals

Collaborates plan of care

Refers patients to allied health team partner’s expertise is?

Collaborate multi- disciplinary

Collaborates plan of care

 

Collaborate effectively in multi-cultural teams

 

Collaboration and teamwork

Teamwork

What word describes joint action by 2 or more people, each contributing different skills,
expressing individual interests/opinions based on skillset, and working towards a common
goal?

 

Patient engagement

Collaboration

 

Communication

Teamwork

All except 2 and 6

What do these characteristics describe by Collaboration? SELECT ALL THAT APPLY

 

1. mutual respect
2. worldview differences,
3. clear communication
4. primary focus on client/patient/family
5. shared goals
6. professional autonomy
7. shared decision making

All except 2 and 6

 

All except 3 and 5

 

All except 1 and 4

 

All of the above

Fresh Whole Blood (FWB)

A blood products used to replaces blood volume during acute hemorrhage?

Fresh Whole Blood (FWB)

 

Autologous Red Blood Cells

 

Fresh Frozen Plasma (FFP)

 

Packed Red Blood Cells (PRBCs)

1, 4 and 5

What should be completed prior to administration of blood products? Select all that apply

 

1. Client should be asked their religious preference
2. Type and screen within last 4 days
3. #22 gauge IV inserted into the client
4. #18 gauge IV inserted into the client
5. Type and screen completed within last 3 days

 

1, 3 and 5

 

1, 2 and 4

 

All of the above

 

1, 4 and 5

15 minutes

Your patient needs 1 unit of packed red blood cells. You had completed all the preparations
and started the blood therapy. How long after the administration begins do transfusion
reactions usually occur? 

 

30 minutes

 

5 minutes

 

60 minute

 

15 minutes

3, 4, and 5

What signs and symptoms would a client display if they are experiencing a transfusion
reaction? SELLECT ALL THAT APPLY.

1. Low heart rate
2. High blood pressure
3. Low blood pressure
4. Shortness of breath
5. High heart rate

 

2, 3 and 4

3, 4, and 5

 

All of the above

 

1, 2 and 3

Circulatory Overload

Nurse Claire started the Blood Therapy; after 15 minutes, her patient stated that she could 
hardly breathe when lying down and upon auscultation, there were crackles (rales), 
distended neck veins, and tachycardia. These manifestations are blood transfusion reaction is
related to?

Circulatory Overload

Hemolytic Reaction.

 

Allergic Reaction (Severe)

 

Sepsis

Benadryl

What type of medication might be administered prior to blood product administration to prevent a transfusion reaction?

 

Morphine

 

Xanax

 

Toradol

 

Benadryl

Normal Saline

Tubing utilized for blood administration should be primed with what type of fluid?

 

0.5% Normal Saline

 

Dextrose

Normal Saline

 

Dextrose 0.45% Normal Saline

1, 3, 4 and 5

Mrs. DJ needs 2 units of packed red blood cells. The patient is cross matched and  typed with  B+ result.  As the nurse you know the patient can receive what type of blood? SELLECT ALL THAT APPLY

1.   B-

2.   A+

3.   O-

4.   B+

5.   O+

6.   A-

7.   AB+

8.   AB-

1, 3, 4 and 5

 

All of the above

 

3, 4, 5 and 7

 

All except 1 and 6

Terminate the blood transfusion immediately.

Mr. Cruz, is receiving his first unit of Fresh whole blood; after 15 minutes he experienced chills, fever, headache and dyspnea. The nurse first initial action is?

1. Wear clean gloves and obtain vital signs.

2. Continue the BT therapy, this is only a normal reactions

3. Adjust Blood therapy ordered rate.

4. Terminate the blood transfusion immediately.

Terminate the blood transfusion immediately.

 

Continue the BT therapy, this is only a normal reactions

 

Wear clean gloves and obtain vital signs.

 

Adjust Blood therapy ordered rate.

All except 5

When providing supportive care for the dying or grieving patient, which of the following assessments should be considered? SELLECT ALL THAT APPLY

 

1. Physical assessment

2. Emotional assessment

3. Intellectual assessment

4. Sociocultural assessment

5. Philosophical assessment

 

All except 3

 

All of the above

 

All except 5

 

All except 4

Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%.

 

A patient started receiving their first unit of blood at 10:00 AM. It is now 1010 AM and the patient is reporting itching, chills, and a headache. You immediately stop the transfusion. Next you will:

 

Collect urine sample.

 

Send the blood tubing and bag to the blood bank.

Disconnect the blood tubing from the IV site and replace it with a new IV tubing set-up and keep the vein open with normal saline 0.9%.

 

Notify the physician.

Increase self-esteem through cosmetic improvements

The following are the nursing care during the dying and grieving process, nursing interventions should target the following. EXCEPT

 

Pain-reduction techniques

 

Promotion of sleep and rest

 

Energy conservation

 

Comfort measures

Increase self-esteem through cosmetic improvements

Finding new ways to transition to a lifestyle of mourning

65. The following are the tasks that facilitate the passage from grief to closure. EXCEPT

 

Experiencing the pain of grief

 

Adjusting to an environment that no longer includes the lost person, object, or aspect of self

 

Accepting the reality of the loss

 

Finding new ways to transition to a lifestyle of mourning

 

Removing emotional energy into new relationships

ALL EXCEPT 1

Which of the following statements regarding organ donations are true? SELLECT ALL THAT APPPLY

 

1. A person's organs can be donated by a family member for a fee with or without the patient's 
consent
 2. The Uniform Anatomical Gifts Act stipulates that the physician who certifies death shall not be involved in removal or transplantation of organs.

3. Legally competent people are free to donate their bodies or organs for medical use
4. It is possible for adults to request organ donation by signing the back of their 
driver's license 

 

ALL EXCEPT 3

ALL EXCEPT 1

 

ALL EXCEPT 2

 

ALL OF THE ABOVE

It is vitally important to remember that there is always a way for you to "solve" the problem of dying

 

Which of the following is NOT APPROPRIATE when communicating with a dying patient?

It is vitally important to remember that there is always a way for you to "solve" the problem of dying

 

When appropriately used, touching is a highly effective means of communication

 

One of the most important task of the bedside nurse is to empower patients and families to participate in the final act of living

 

Therapeutic communication requires that the nurse pays careful attention to what the patient expresses verbally and nonverbally

Diminished libido

The following are clinical signs of death? EXCEPT

Diminished libido

 

Cheyne-stokes respiration

 

Skin is cool, clammy and with profuse diaphoresis

 

Slow, weak, and thready pulse; lowered blood pressure

 

Absence of apical pulse, no reflexes, detached look in the eye

1, 2, and 6

A nurse who cared for a dying patient and his family documents that the family is 
experiencing a period of mourning. Which behaviors would the nurse expect to see at this 
stage? SELECT ALL THAT APPLY

1. The family arranges for a funeral for their loved one.
2. The family arranges for a memorial scholarship for their loved one.
3. The coroner pronounces the patient's death.
4. The family arranges for hospice for their loved one.
5. The patient is diagnosed with terminal cancer.
6. The patient's daughter writes a poem expressing her sorrow

1, 2, and 6

 

1,3 and 5

 

4, 5 and 6

 

1, 2, and 3

Denial

When terminally-ill client assumes artificial cheerfulness and refuses to believe that loss is 
happening, what stage of grieving is he in?

 

Acceptance

 

Denial

 

Depression

 

Bargaining

 

 

The nurse places the patient in a sitting position while the family visits

Nurse Rea is providing postmortem care. Which nursing action violates the standards of 
caring for the body after a patient has been pronounced dead and is not scheduled for an 
autopsy?

 

The nurse places the patient in a sitting position while the family visits

 

The nurse makes sure a death certificate is issued and signed.

 

The nurse removes soiled dressings and tubes.

 

The nurse places identification tags on both the shroud and the ankle

Acceptance

A home health care nurse has been visiting a patient with AIDS who says, "I'm no longer 
afraid of dying. I think I've made my peace with everyone, and I'm actually ready to move 
on." This reflects the patient's progress to which stage of death and dying?

Acceptance

 

Bargaining

 

Anger

 

Denial

All except 3

A nurse is planning care for the dying patient, the following are interventions to promote 
the patient’s dignity; SELECT ALL THAT APPLY

1. providing respect
2. viewing pts as a whole
3. providing symptom management
4. showing interest
5. being present
6. using a preferred name 

 

All except 1

 

All except 2

 

All except 3

 

All of the above

All except 2 and 5

The physical changes that occur as death approaches are the following; EXCEPT

1. unresponsiveness
2. erythema
3. mottling
4. restlessness
5. increased urine output
6. weakness

 

None of the above

 

All except 3 and 4

 

All except 5 and 6

All except 2 and 5

Preparing the body to look as clean and natural as possible.

The nurse demonstrates an important principle of postmortem care by:

 

Removing all indwelling catheters and tubes

Preparing the body to look as clean and natural as possible.

 

Pulling the sheet over the client’s face until the family is comfortably seated in the room

 

Calling the mortician to declare death.