Fundamentals of Nursing Practice Quiz 6

Answer: C – Floor of the mouth

Explanation: The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream form the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the tablet is placed between the gum and the cheek.

Answer: A – Cleaning from the center outward in a circular motion

Explanation: The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask is not necessary.

Answer: C – 32 drop per minute

Explanation: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute: 125/60 min = X/1 minute 60X = 125X = 2.1 ml/minute To find the number of drops/minute: 2.1 ml/X gtts = 1 ml/15 gtts X = 32 gtts/minute, or 32 drops/minute

Answer: A – Restlessness

Explanation: Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

Answer: D – Carotid

Explanation: During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation.

Answer: B – Administering a measles, mumps, and rubella immunization to an infant

Explanation: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.

Answer: B – Inspection

Explanation: Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.

Answer: D – S1 is loudest at the apex, and S2 is loudest at the base

Explanation: The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.

Answer: B – Nursing diagnosis

Explanation: The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.

Answer: B – Bananas and oranges

Explanation: Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.