85 ITEMS - Nursing Practice (Basic Health Care Procedures) with Answers and Rationales
85 ITEMS - Nursing Practice (Basic Health Care Procedures) with Answers and Rationales
The following are review questions of our basic health care procedures particularly the following concepts:
a. Moving, Transferring and Positioning Clients
b. ROM Exercises
c. Assessing Vital Signs
d. Hygienic Care
These are the answers and rationales for this practice test.
Kindly post comments for any misleading answers.
Thank you.
Brewed
Situation 1: Moving a client in good body alignment and positioning body parts properly and systematically are essential aspects of nursing practice.
1. To elicit patient’s cooperation and promote sense of well-being, Nurse Kelly must do which of the following?
a. Proper handwashing
b. Explain the procedure
c. Greet the client and introduce oneself
d. Wear a smile
Answer: C. Greet the client and introduce oneself
Rationale: Proper handwashing maintains asepsis. Explaining procedure and wearing a smile can only elicit patient’s cooperation but greeting first the client and introducing oneself is the best way and at the same time promoting sense of well-being for your client.
2. Frequent change of position helps prevent which of the following?
a. muscle tone
b. stimulation of postural reflexes
c. good body alignment
d. formation of pressure ulcer
Answer: D. Formation of pressure ulcer.
Rationale: Options a, b and c are the main purposes of positioning you client.
3. Before moving or transferring a client, what assessment should Nurse Justin anticipates?
a. client’s ability to assist
b. good body mechanics
c. client’s comfort
d. client’s well being
Answer: A. Client’s ability to assist
Rationale: Performing good body mechanics prevents injury from the nurse and patient. Options c and d may be correct but assessing your client’s ability to assist will elicit his cooperation thus promotes comfort and well being before you move or transfer him.
4. In order to protect the client and the nurse from injury, Nurse Rihanna should observe which of the following?
a. manner of walking
b. maintaining good posture
c. maintaining good poise
d. good body mechanics
Answer: D. Good body mechanics
Rationale: Good body mechanics involves proper manner of walking, maintaining good posture and poise. (Look for the umbrella effect)
5. Body mechanics can be best described as:
a. correct positioning, moving and transferring of clients
b. efficient use of body weight, coordination and strength
c. efficient, coordinated and unsafe use of the body
d. maintaining good body alignment
Answer: B. Efficient use of body weight, coordination and strength
Rationale: Option a and d may be correct but the aspects are incomplete. Good body mechanics is best described ad the efficient used of body weight combined with coordination and body strength. Option c is a wrong statement.
Situation 2: A nurse can do a number of things to ensure proper alignment and promote client’s comfort and safety.
6. Nurse Beyonce ensures that the mattress is firm. A sagging mattress used over a prolonged period can contribute to the development of which of the following?
a. Neck flexion
b. Foot drop
c. Low back pain
d. Pressure ulcer
Answer: C. Low back pain
Rationale: Neck flexion may be due to too high/large pillows. Foot drop may result when no foot boards or boot splints available. Pressure ulcer results to wrinkled linens and incorrect positioning.
7. The use of supportive devices can prevent stress on client’s muscles and joints. What supportive device is recommended to be placed beneath a too soft mattress for client’s who have back problems?
a. Pillows
b. Chair beds
c. Mattress
d. Bed boards
Answer: D. bed boards
8. To avoid excessive pressure and predisposition of thrombus formation to the clients, Nurse Michelle must:
a. avoid placing one body part directly on top on another body part
b. make use of supportive devices
c. ensure that the bed is kept clean and dry
d. elicit information from the clients’ desired position
Answer: A. Avoid placing one body part directly on top on anther body part.
Rationale: This prevents pressure points to come in contact thus preventing excessive pressure and formation of thrombus especially post operatively.
9. In order to prevent pressure ulcers in immobilized clients; Nurse Erik must plan to do which of the following?
a. Plan a systematic 24-hour schedule for position changes
b. Reposition clients every 4 hours throughout the day
c. Use only supportive devices available
d. Assume clients’ responsibility
Answer: A. Plan a systematic 24-hour schedule for position changes
Rationale: Positioning of clients should be at least q 2 hours. Promoting independence rather dependency is one of our goals to client’s confined in the hospital. In option C, the word ONLY made the statement wrong.
10. Common alignment problems that can be corrected with supportive devices include all of the following EXCEPT:
a. Flexion of the neck
b. Extension of the wrist
c. Adduction of shoulder
d. External rotation of the hips
Answer: B. Extension of the wrist
Rationale: options A, c and d are some of the common alignment problems being corrected with the use of supportive device. Flexion of the wrist is a problem, not extension of the wrist because this is anormal anatomical position.
Situation 3: Ill people may have difficulty in moving even in bed. The amount of assistance the clients require depends on their own ability to move and their health status. In general, nurses should be sensitive to both the need of clients to function independently and their need for assistance to move.
11. Nurse Carrie is changing an occupied bed and is about to turn Mr. Foxx to the side. Which of the following is NOT an appropriate nursing action?
a. Move the client to one side of the bed before turning
b. Turn the client towards you with your hips, knees and ankles flexed, feet apart
c. Untuck the topsheet at the foot part of the bed to facilitate change of position
d. Turn the client away from you, with your back bent
Answer: d. Turn the client away from you, with your back bent
Rationale: Knees must be bent not the back for it might result to injury and undue strain.
12. In moving a client up in bed, Nurse Anika can elicit the client’s help in lessening workload by instructing him to initially do which of the following?
a. Ask client to flex the hips and knees and position the feet; be ready for pushing
b. Grasp the overhead trapeze with both hands and lift and pull during the move
c. Grasp the head of the bed with both hands and pull during the move
d. Lock the wheels on the bed and raise the side rails opposite to you
Answer: a. Ask client to flex the hips and knees and position the feet; be ready for pushing
Rationale: This is initial action before moving a client up in bed.
13. A client with spinal injury must in all times be kept in straight alignment when turning, so logrolling is the technique being used. The following are appropriate nursing actions EXCEPT:
a. Position yourselves and the client appropriately before the move
b. Move to the other side of the bed, and place supportive device
c. Ask client to place arms at the sides with the palms against the surface of bed
d. Roll and position the client in proper alignment in the count of three
Answer: c. Ask client to place arms at the sides with the palms against the surface of bed
Rationale: This is done when moving your client up in bed or assisting him to sit on bed.
14. Mr. Chiu is for X-ray at the Radiologic Department. To transfer him from the bed to the wheelchair, Nurse Paris should position the wheelchair:
a. parallel to the bed
b. right angle at the foot part
c. any desired position
d. at the foot part of the bed
Answer: A. Parallel to the bed
15. In pushing the stretcher, which of the following guidelines should be observed to protect the client’s head in the event of collision?
a. lock wheels of the bed
b. push from the end where head is positioned
c. fasten safety straps across the client
d. raise the side rails on both sides
Answer: B. push from the end where head is positioned
Situation 4: The nurse assists clients with appropriate exercise programs to maintain physical fitness and prepares them for ambulation.
16. Mr. Linux has undergone an abdominal surgery. To prevent thrombophlebitis, the following are appropriate nursing actions EXCEPT:
a. perform passive leg exercises
b. turn the client every one to two hours
c. massage the legs when painful
d. elevate legs to promote venous return
Answer: C. massage the legs when painful
Rationale: This is a contraindication in performing ROM exercises
17. The type of exercise that Nurse Julian can perform to Mr. Lim with joint contractures is:
a. active exercise
b. passive exercise
c. active – assistive exercise
d. active – resistive exercise
Answer: B. Passive exercise
18. To prevent plantar flexion in paralyzed patient which of the following protective devices may be used?
a. footboard only
b. footboard and trochanter roll
c. footboard and hand roll
d. footboard and boot splint
Answer: D. foot board and boot splint
19. Nurse Nico is aware that ROM exercise is contraindicated to patients who have/are:
a. joint swelling and inflammation
b. intermittent fever
c. cough and colds
d. post – operative
Answer: A. joint swelling and inflammation
20. In isometric exercises, Nurse Marie knows that this involves:
a. change in muscle tension and length
b. change in muscle tension
c. flexion and extension of a weak arm with sandbag tied on the forearm
d. use of weights and pulleys
Answer: B. change in muscle tension
Situation 5: Activities of daily living and protective positions are ways to promote activity and exercise. Correct positioning is essential to maintain an optimum level of functioning.
21. Nurse Sarah is caring to clients who have difficulty of breathing and some having heart problems. The position of choice for these clients is:
a. Supine position
b. Trendelenburg position
c. Fowler’s position
d. Orthopneic position
Answer: C. Fowler’s position
Rationale: this position promotes maximum lung expansion and ventilation in the alveoli
22. Mr. Cruize who had undergone spinal surgery should assume which position?
a. Horizontal recumbent position
b. Prone position
c. Reverse trendelenburg position
d. Dorsal recumbent position
Answer: B. Prone position
23. The only bed position that allows full extension of the hip and knee joint is:
a. Orthopneic position
b. Prone position
c. Sim’s position
d. Lateral position
Answer: B. Prone position
24. Mrs. Smith is for an examination of her genitalia. Nurse Cassie should assist her to assume which position?
a. Dorsal recumbent position
b. Sim’s position
c. Knee-chest position
d. Genupectoral position
Answer: A. Dorsal Recumbent position
25. The client assumes a posture halfway between the lateral and the prone position. Nurse Craig knows that this type of position is:
a. Lateral position
b. Prone position
d. Sim’s position
d. Supine position
Answer: D. Sim’s position
Situation 6: Nursing procedures are directed toward restoring optimal mobility and preventing some of the effects of immobility. When performing these procedures, a nurse must be efficient and competent in rendering nursing care.
26. In assisting client to an erect or standing position, Nurse Rufuz must observe all of the following EXCEPT:
a. Assist patient to stand
b. Place a chair near one side where he can rest hand for support
c. Drape with a double folded sheet around the body from the breast to legs
d. Elevate one foot on a foot stool if needed
Answer: C. Drape with a double folded sheet around the body from the breast to legs
Rationale: In male clients, draping should be from the hips to legs
27. Ms. Demeanor complains of difficulty of breathing while lying on bed. Nurse Missy can assist her in an orthopneic position by:
a. Elevating head of bed to 45 degrees
b. Assisting patient to sit up on bed with overbed table across the lap
c. Assisting patient to lie on his back
d. Raising knees and separate legs, with soles of feet resting on bed
Answer: B. Assisting patient to sit up on bed with overbed table across the lap
Rationale: Option A is semi fowler’s; C is supine and D is lithotomy.
28. Dr. Lopez ordered a cleansing enema for Mr. Rusty. Nurse David knows that his client assumes Sim’s position when:
a. the lower arm is positioned behind the client and upper arm is flexed
b. the client lies on his back, with the knees raised
c. one side of the body is flexing the top hip and knee and placing his leg in front
d. the client sits on bed with an overbed table across the lap
Answer: C. one side of the body is flexing the top hip and knee and placing his leg in front
29. How will you position Mr. Seoul to a Semi-Fowler’s position?
a. Elevate head of bed to an angle of 35 degrees
b. Place arms at the sides, pronated and elevate with pillow
c. Place patient in supine position
d. Elevate head of bed to an angle of 50 degrees
Answer: D. Elevate head of bed to an angle of 50 degrees
30. In genupectoral position, the client kneels on bed with hips in air and chest on table. In order to provide privacy, Nurse Jasmine must do which of the following?
a. Provide hand rolls if needed
b. Cover with top sheet and pick lower end of the sheet to expose the area
c. Drape with a double folded sheet around the body from the waist to legs
d. Cover with top sheet and fold back in area to be examined
Answer: B. Cover with top sheet and pick lower end of the sheet to expose the area
Situation 7: Vital signs are determined to monitor the functions of the body. Nurse Jasmine should measure VS more often if the client’s health status requires it.
31. Monitoring of client’s VS should not be a routine procedure. The following are times to assess VS except:
a. On admission to a health care agency
b. Before and after surgery or invasive procedure
c. According to a nursing or medical order
d. Only after administration of medications
Answer: D. Only after administration of medications
Rationale: There are certain medications where VS should be assessed before administering it.
32. Nurse Jasmine knows that the primary purpose of taking VS initially is:
a. To establish data base
b. To monitor for disease progression
c. To identify proper treatment
d. To prepare for surgery
Answer: A. To establish data base
33. Which of the following is not a cardinal sign?
a. Temperature
b. Blood pressure
c. Heart rate
d. Pain
Answer: D. Pain
Rationale: Although considered as a VS, pain is more subjective. Options A, B and C are objective vital signs.
34. In order to elicit the patient’s cooperation, Nurse Jasmine must do which of the following first?
a. Explain the procedure
b. Wash hands
c. Greet the client and introduce one self
d. Take a look and smile
Answer: C. Greet the client and introduce one self
35. Nurse Jasmine knows that the best way to prevent transfer of microorganisms is:
a. Use of hand sanitizer
b. Disinfection of used materials
c. Handwashing
d. Health assessment
Answer: C. Handwashing
Rationale: A MUST to health care workers to break the chain of infection.
Situation 8: Nurse Julian is the staff nurse assigned at the Medical Ward of Aquinas University Hospital. In order to render nursing care, he must be knowledgeable of the anatomy and physiology.
36. Mr. Yang is suffering from hyperthermia. Nurse Julian knows that the center for thermoregulation is:
a. Pituitary gland
b. Hypothalamus
c. Medulla oblongata
d. Pons
Answer: B. Hypothalamus
37. The primary center for respiration is:
a. Pituitary gland
b. Hypothalamus
c. Medulla oblongata
d. Pons
Answer: C. Medulla oblongata
38. Respiration is the act of breathing. The primary chemical stimulation for breathing is:
a. Low CO2 level in the blood
b. High O2 level in the blood
c. Stress
d. High CO2 level in the blood
Answer: D. High CO2 level in the blood
39. Ms. Cha asks Nurse Julian where she can find the apical pulse. Nurse Julian is correct when he says:
a. “On the right mid – clavicular line, in the 5th or 6th intercostal spaces”
b. “On the left mid – clavicular line, in the 2nd or 3rd intercostal spaces”
c. “On right mid – clavicular, in the apex of your heart”
d. “On the left mid – clavicular line, in the 5th or 6th intercostal spaces”
Answer: D. “On the left mid – clavicular line, in the 5th or 6th intercostal spaces”
40. Mr. Clean has myocardial infarction. Nurse Julian knows that rectal temperature taking is contraindicated. What cranial nerve will stimulate the sympathetic nervous system to cause bradycardia?
a. Vagus
b. Facial
c. Olfactory
d. Optic
Answer: A. Vagus
Situation 9: In assessing vital signs, there are many factors to be considered that affects the accuracy and reliability of data.
41. Sympathetic nervous system stimulation increases the production of epinephrine and norepinephrine thereby increasing metabolic rate and heat production. This factor affecting the temperature is:
a. Stress
b. Exercise
c. Diurnal variation
d. Hormones
Answer: A. Stress
42. Nurse Joe knows that if hemorrhage happens, the body’s compensatory mechanism is:
a. Increase heart rate
b. Decrease blood pressure
c. Increase pulse rate
d. All of the above
Answer: D. All of the above
43. All but one are factors affecting the respiratory rate:
a. Exercise
b. Stress
c. Diurnal variations
d. Environment
Answer: C. Diurnal Variations
44. Hypertension is one of the 10 leading cause of death among Filipinos. This factor can be classified into:
a. Age
b. Race
c. Genetics
d. Gender
Answer: B. Race
45. Which of the following is a non – modifiable factor affecting the blood pressure?
a. Stress
b. Race
c. Exercise
d. Diet
Answer: B. Race
Situation 10: Nurse Pido is going to take the VS of his patient. As a competent nurse, he must be knowledgeable of the variations in taking the body temperature, pulse, respiration and blood pressure.
46. The most accessible and convenient method of taking temperature is:
a. Oral
b. Axillary
c. Rectal
d. Tympanic
Answer: A. Oral
47. After taking the temperature per orem, Nurse Pido must clean the thermometer in what manner?
a. From bulb to stem in a back and forth motion
b. From stem to bulb in a rotating motion
c. From bulb to stem in a rotating motion
d. From center down and upward
Answer: B. From stem to bulb in a rotating motion
Rationale: Before taking the temperature, cleaning of thermometer is from bulb to stem in a rotating motion.
48. Nurse Pido is aware that his patient is febrile when the mercury reading in the thermometer is:
a. 36.5 degrees Celsius
b. 37.8 degrees Celsius
c. 97.6 degrees Fahrenheit
d. 99.6 degrees Fahrenheit
Answer: B. 37.8 degrees C
49. Mr. Dido is in traction, in order to assess good circulation in the foot, Nurse Pido must palpate for:
a. Apical pulse
b. Radial pulse
c. Posterior tibial
d. Femoral pulse
Answer: C. Posterior tibial
50. Nurse Pido observed the movement of Mr. Dido’s chest as upward and inward. This type of breathing is:
a. Costal breathing
b. Diaphragmatic breathing
c. Abdominal breathing
d. Kussmaul’s breathing
Answer: A. Costal breathing
Situation 11: The accuracy of VS taking is an important indicator of the client’s condition and is used extensively as a basis for nursing interventions.
51. The use of appropriate size of the BP cuff is an important factor to get an accurate reading. Nurse Lindsay knows that a cuff that is too narrow or tight can cause which findings?
a. Hypertension
b. False low reading .
c. False high reading
d. Ecchymosis
Answer: C. False high reading
52. Mrs. Lee is taking a beta blocker medication. Nurse Wolverine knows that this drug causes which of the following?
a. Decrease RR
b. Decrease PR
c. Decrease Temperature
d. Decrease BP
Answer: D. Decrease BP
53. Nurse Ray is going to take the RR of Mr. Black. Upon entrance in the room, he noticed that Mr. Black has deep and rapid respiration. Based from your assessment, what acid – base imbalance will occur?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
Answer: D. Respiratory alkalosis
54. Nico is the student nurse assigned at the neonatal intensive care unit. Dr. Lopez requested him to take the heart rate of Baby See. After doing so, Nico knows that the normal heart rate of a newborn is:
a. 80 – 180 beats/min
b. 75 – 120 beats/min
c. 80 – 140 breaths/min
d. 60 – 100 breaths/min
Answer: A. 80 – 180 beats per min
55. Rectal temperature taking is the most accurate method of measurement. To reduce friction and prevent trauma to the mucous membranes, Nurse Cindy must do which of the following?
a. Lubricate thermometer with soap
b. Insert thermometer 4 inches above the sphincter
c. Lubricate thermometer with water soluble jelly
d. Instruct the client to breathe out then insert thermometer
Answer: c. Lubricate thermometer with water soluble jelly
Questions 56 – 85 is all about promoting hygiene
56. The following are functions of the skin, EXCEPT:
a. First line of defense
b. Maintains body temperature
c. Is a secretory organ
d. produces and absorbs Vitamin E
Answer: D. produces and absorbs Vitamin E
Rationale: The skin produces and absorbs Vitamin D.
57. The gland that is primarily located in the axilla and anogenital areas is:
a. Apocrine gland
b. Eccrine gland
c. Sweat gland
d. Sebaceous gland
Answer: A. Apocrine gland
Rationale: Eccrine is located in the palms of the hands and soles of feet. Option C and D are under apocrine gland.
58. What is the science of health and its maintenance?
a. Nursing
b. Health Education
c. Hygiene
d. Personal Hygiene
Answer: C. Hygiene
59. If hygiene is promoted and maintained, the individual has a feeling of all of the following EXCEPT:
a. Comfort .
b. Shame and doubt
c. Well-being
d. Self-confidence
Answer: B. Shame and doubt
60. Which of the following is a personal hygiene?
a. Bathing
b. Hair care
c. Perineal care
d. Eye care
Answer: A. Bathing
61. When superficial layers of the skin are scraped or rubbed away, the term is:
a. Erythema
b. Abrasion
c. Acne
d. Vitiligo
Answer: Abrasion
Rationale: Redness of skin is erythema. Acne is in inflammatory condition of the skin while vitiligo are patches of hypopigmented skin present in elderly.
62. What is the most effective measure to relief dryness of the skin?
a. Increase fluid intake
b. Apply cream/lotion
c. Avoid use of alcohol
d. Bathe less frequently
Answer: A. Increase fluid intake
Rationale: All are interventions but increasing fluid intake is the best way and more economical.
63. A common skin problem that is characterized by papules, pustules and comedones is:
a. Wheal
b. Patch
c. Acne
d. Erythema
Answer: C. Acne
Rationale: A relatively reddened and elevated localized collection of edema fluids such as mosquito bites is a wheal. Patch is larger than macule such as birth mark.
64. It is a large fluid-filled sac:
a. Tumor
b. Papule
c. Cyst
d. Bulla
Answer: D. Bulla
Rationale: Tumor is a solid mass. Papule is a circumscribed elevation of the skin and a cyst is a semi solid matter.
65. Athlete’s foot is what type of secondary skin lesion?
a. Excoriation
b. Fissure
c. Erosion
d. Lichenification
Answer: B. Fissure
Rationale: Scratch is a form of excoriation. Erosion is loss of all part of the epidermis and lichenification is epidermal thickening.
66. The initial nursing action when providing bed bath is:
a. Close the door and windows of the patient’s room
b. Inform the client and explain the purpose of procedure
c. Remove the client’s gown under the top sheet
d. Place the bed in flat position
Answer: B. Inform the client and explain the purpose of procedure
67. Nurse Kenzo is giving bed bath to Mr. Hall who is on strict bed rest. To increase venous return, the nurse bathes the clients extremities by using:
a. Using firm strokes from distal to proximal
b. Firm circular strokes from proximal to distal
c. Short, patting strokes from distal to proximal
d. Smooth, light strokes back and forth
Answer: A. Using firm strokes from distal to proximal .
Rationale: This type of stroke promotes vasodilation and friction thus increasing venous return or blood circulation towards the heart.
68. Which of the following is inappropriate when performing genital care to male clients?
a. Wear gloves
b. Use circular motion from the penile shaft towards the glans
c. Retract prepuce if uncircumcised
d. Use moist washcloth with soap
Answer: B. Use circular motion from the penile shaft towards the glans
Rationale: It should be from the glans towards the penile shaft
69. Which of the following is the most important nursing consideration when performing perineal care to female clients?
a. Use up-downward stroke
b. Use posterior-anterior stroke
c. Wash from back to front
d. Use rubbing stroke
Answer: B. Use up-downward stroke
Rationale: Wash from the cleanest to dirtiest to prevent transfer of microorganisms
70. To ensure asepsis when bathing a client in bed, the nurse should do which of the following?
a. Wash from distal to proximal areas
b. Pat dry skin surface
c. Wash from clean areas to dirty areas
d. Assess bath water temperature
Answer: C. Wash from clean areas to dirty areas
71. When removing the client’s gown with IVF on his left arm, the nurse should:
a. Remove the side of the gown without the contraption first
b. Remove the side of the gown with contraption first
c. Remove either sides of the gown
d. Remove the IVF then just reinsert it
Answer: A. Remove the side of the gown without the contraption first
Rationale: In changing/removing the gown, start without the IV line first. In putting the gown back, start with the arm with IV line.
72. Moving the client to one side of the bed before bathing prevents which of the following?
a. Promotes relaxation and client’s comfort
b. Prevents injury to the nurse and client
c. Maintains asepsis
d. Prevents overreaching and undue muscle strain
Answer: D. Prevents overreaching and undue muscle strain
73. To retain heat and water better during bed bath, the nurse should:
a. Check water temperature frequently
b. Make bath mitt out of the wash cloth
c. Turn – off electric fans
d. Use warm water only
Answer: B. Make bath mitt out of the wash cloth
74. In peri care, in order to maintain client’s dignity, the nurse should:
a. Provide privacy
b. Explain the purpose of the procedure
c. Position and drape the client
d. Wear clean gloves
Answer: A. provide privacy
75. A type of massage that involves a smooth, long stroke and moving the hands up and down the back is:
a. Petrissage
b. Tapotement
c. Back Rub
d. Effleurage
Answer: D. Effleurage
Rationale: Petrissage is a large pinch of the skin. Tapotement is also called as tapping. Back rub is a back massage and under this are those types.
76. Which of the following can be an afternoon care to your client?
a. Bed bath
b. Back Massage
c. Perineal care
d. Stretching of bed linens
Answer: D. Stretching of bed linens
Rationale’ Options a, b and c are mostly done as morning care to the client.
77. In combing or brushing a long hair, the nurse should:
a. Start from the tip of the hair to remove tangles
b. Start from the mid part then down to the tip
c. Begin from the scalp then down to the tip
d. Distribute and part the hair into three sections
Answer: A. Start from the tip of the hair to remove tangles
Rationale: If the hair is short; begin from the scalp then down the tip
78. To stimulate the circulation of the blood in the scalp through massage, the nurse should perform which of the following?
a. Bed bath
b. Back rub
c. Hair shampoo
d. Hair care
Answer: C. Hair shampoo
79. In hair shampoo, to prevent from irritating the client’s eyes, the nurse should:
a. Wipe from inner to outer canthus
b. Cover the eyes with wash cloth
c. Plug ears with cotton balls
d. Advise clients to gently close the eyes
Answer: B. Cover the eyes with wash cloth
80. Infestation of the scalp with lice is:
a. Pediculosis humanis
b. Pediculosis pubis
c. Pediculosis capitis
d. Pediculosis corporis
Answer: C. Pediculosis capitis (head)
Rationale: Option A is wrong it should be humanus for body lice. Option B is crab or pubic lice and option D is for body louse.
81. Which of the following should not be included when providing patient’s teaching on hygienic measures?
a. Do not rub the eyes
b. Remove cerumen from the ear with cotton tipped applicator
c. Blow the nose with one nares closed
d. Use eye drops at regular basis
Answer: C. Blow the nose with one nares closed
Rationale: Both nares should be open when blowing nose
82. The best position for female client during perineal care is:
a. Supine
b. b. Dorsal recumbent
c. Lateral
d. Semi – fowlers
Answer: B. Dorsal Recumbent
83. The body’s first line of defense is which of the following?
a. Skin
b. b. An intact and healthy skin
c. Tissues
d. Hair
Answer: B. An intact and healthy skin
Rationale: Though skin can be correct but option B is more specific as a general guideline in skin care.
84. All of the following are primary purposes of bed bath EXCEPT:
a. Assessment
b. Nurse-patient interaction
c. Circulation
d. Documentation
Answer: D. Documentation
Rationale: This is the very least purpose in rendering bed bath
85. Mr. Liu is a diabetic client, he asked the nurse on how to cut his toenails particularly the corns, the nurse’s best response would be:
a. Cut nail straight across
b. Trim toenails from the edge
c. Consult a podiatrist
d. Soak foot to a basin with warm water
Answer: C. Consult a podiatrist
Rationale: In cases like this, the nurse’s role is collaborative through advising the client to consult a podiatrist (examines the foot or ankle) to avoid further complication.
End of Nursing Practice (Basic Health Care Procedures)
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BREWED
The following are review questions of our basic health care procedures particularly the following concepts:
a. Moving, Transferring and Positioning Clients
b. ROM Exercises
c. Assessing Vital Signs
d. Hygienic Care
These are the answers and rationales for this practice test.
Kindly post comments for any misleading answers.
Thank you.
Brewed
Situation 1: Moving a client in good body alignment and positioning body parts properly and systematically are essential aspects of nursing practice.
1. To elicit patient’s cooperation and promote sense of well-being, Nurse Kelly must do which of the following?
a. Proper handwashing
b. Explain the procedure
c. Greet the client and introduce oneself
d. Wear a smile
Answer: C. Greet the client and introduce oneself
Rationale: Proper handwashing maintains asepsis. Explaining procedure and wearing a smile can only elicit patient’s cooperation but greeting first the client and introducing oneself is the best way and at the same time promoting sense of well-being for your client.
2. Frequent change of position helps prevent which of the following?
a. muscle tone
b. stimulation of postural reflexes
c. good body alignment
d. formation of pressure ulcer
Answer: D. Formation of pressure ulcer.
Rationale: Options a, b and c are the main purposes of positioning you client.
3. Before moving or transferring a client, what assessment should Nurse Justin anticipates?
a. client’s ability to assist
b. good body mechanics
c. client’s comfort
d. client’s well being
Answer: A. Client’s ability to assist
Rationale: Performing good body mechanics prevents injury from the nurse and patient. Options c and d may be correct but assessing your client’s ability to assist will elicit his cooperation thus promotes comfort and well being before you move or transfer him.
4. In order to protect the client and the nurse from injury, Nurse Rihanna should observe which of the following?
a. manner of walking
b. maintaining good posture
c. maintaining good poise
d. good body mechanics
Answer: D. Good body mechanics
Rationale: Good body mechanics involves proper manner of walking, maintaining good posture and poise. (Look for the umbrella effect)
5. Body mechanics can be best described as:
a. correct positioning, moving and transferring of clients
b. efficient use of body weight, coordination and strength
c. efficient, coordinated and unsafe use of the body
d. maintaining good body alignment
Answer: B. Efficient use of body weight, coordination and strength
Rationale: Option a and d may be correct but the aspects are incomplete. Good body mechanics is best described ad the efficient used of body weight combined with coordination and body strength. Option c is a wrong statement.
Situation 2: A nurse can do a number of things to ensure proper alignment and promote client’s comfort and safety.
6. Nurse Beyonce ensures that the mattress is firm. A sagging mattress used over a prolonged period can contribute to the development of which of the following?
a. Neck flexion
b. Foot drop
c. Low back pain
d. Pressure ulcer
Answer: C. Low back pain
Rationale: Neck flexion may be due to too high/large pillows. Foot drop may result when no foot boards or boot splints available. Pressure ulcer results to wrinkled linens and incorrect positioning.
7. The use of supportive devices can prevent stress on client’s muscles and joints. What supportive device is recommended to be placed beneath a too soft mattress for client’s who have back problems?
a. Pillows
b. Chair beds
c. Mattress
d. Bed boards
Answer: D. bed boards
8. To avoid excessive pressure and predisposition of thrombus formation to the clients, Nurse Michelle must:
a. avoid placing one body part directly on top on another body part
b. make use of supportive devices
c. ensure that the bed is kept clean and dry
d. elicit information from the clients’ desired position
Answer: A. Avoid placing one body part directly on top on anther body part.
Rationale: This prevents pressure points to come in contact thus preventing excessive pressure and formation of thrombus especially post operatively.
9. In order to prevent pressure ulcers in immobilized clients; Nurse Erik must plan to do which of the following?
a. Plan a systematic 24-hour schedule for position changes
b. Reposition clients every 4 hours throughout the day
c. Use only supportive devices available
d. Assume clients’ responsibility
Answer: A. Plan a systematic 24-hour schedule for position changes
Rationale: Positioning of clients should be at least q 2 hours. Promoting independence rather dependency is one of our goals to client’s confined in the hospital. In option C, the word ONLY made the statement wrong.
10. Common alignment problems that can be corrected with supportive devices include all of the following EXCEPT:
a. Flexion of the neck
b. Extension of the wrist
c. Adduction of shoulder
d. External rotation of the hips
Answer: B. Extension of the wrist
Rationale: options A, c and d are some of the common alignment problems being corrected with the use of supportive device. Flexion of the wrist is a problem, not extension of the wrist because this is anormal anatomical position.
Situation 3: Ill people may have difficulty in moving even in bed. The amount of assistance the clients require depends on their own ability to move and their health status. In general, nurses should be sensitive to both the need of clients to function independently and their need for assistance to move.
11. Nurse Carrie is changing an occupied bed and is about to turn Mr. Foxx to the side. Which of the following is NOT an appropriate nursing action?
a. Move the client to one side of the bed before turning
b. Turn the client towards you with your hips, knees and ankles flexed, feet apart
c. Untuck the topsheet at the foot part of the bed to facilitate change of position
d. Turn the client away from you, with your back bent
Answer: d. Turn the client away from you, with your back bent
Rationale: Knees must be bent not the back for it might result to injury and undue strain.
12. In moving a client up in bed, Nurse Anika can elicit the client’s help in lessening workload by instructing him to initially do which of the following?
a. Ask client to flex the hips and knees and position the feet; be ready for pushing
b. Grasp the overhead trapeze with both hands and lift and pull during the move
c. Grasp the head of the bed with both hands and pull during the move
d. Lock the wheels on the bed and raise the side rails opposite to you
Answer: a. Ask client to flex the hips and knees and position the feet; be ready for pushing
Rationale: This is initial action before moving a client up in bed.
13. A client with spinal injury must in all times be kept in straight alignment when turning, so logrolling is the technique being used. The following are appropriate nursing actions EXCEPT:
a. Position yourselves and the client appropriately before the move
b. Move to the other side of the bed, and place supportive device
c. Ask client to place arms at the sides with the palms against the surface of bed
d. Roll and position the client in proper alignment in the count of three
Answer: c. Ask client to place arms at the sides with the palms against the surface of bed
Rationale: This is done when moving your client up in bed or assisting him to sit on bed.
14. Mr. Chiu is for X-ray at the Radiologic Department. To transfer him from the bed to the wheelchair, Nurse Paris should position the wheelchair:
a. parallel to the bed
b. right angle at the foot part
c. any desired position
d. at the foot part of the bed
Answer: A. Parallel to the bed
15. In pushing the stretcher, which of the following guidelines should be observed to protect the client’s head in the event of collision?
a. lock wheels of the bed
b. push from the end where head is positioned
c. fasten safety straps across the client
d. raise the side rails on both sides
Answer: B. push from the end where head is positioned
Situation 4: The nurse assists clients with appropriate exercise programs to maintain physical fitness and prepares them for ambulation.
16. Mr. Linux has undergone an abdominal surgery. To prevent thrombophlebitis, the following are appropriate nursing actions EXCEPT:
a. perform passive leg exercises
b. turn the client every one to two hours
c. massage the legs when painful
d. elevate legs to promote venous return
Answer: C. massage the legs when painful
Rationale: This is a contraindication in performing ROM exercises
17. The type of exercise that Nurse Julian can perform to Mr. Lim with joint contractures is:
a. active exercise
b. passive exercise
c. active – assistive exercise
d. active – resistive exercise
Answer: B. Passive exercise
18. To prevent plantar flexion in paralyzed patient which of the following protective devices may be used?
a. footboard only
b. footboard and trochanter roll
c. footboard and hand roll
d. footboard and boot splint
Answer: D. foot board and boot splint
19. Nurse Nico is aware that ROM exercise is contraindicated to patients who have/are:
a. joint swelling and inflammation
b. intermittent fever
c. cough and colds
d. post – operative
Answer: A. joint swelling and inflammation
20. In isometric exercises, Nurse Marie knows that this involves:
a. change in muscle tension and length
b. change in muscle tension
c. flexion and extension of a weak arm with sandbag tied on the forearm
d. use of weights and pulleys
Answer: B. change in muscle tension
Situation 5: Activities of daily living and protective positions are ways to promote activity and exercise. Correct positioning is essential to maintain an optimum level of functioning.
21. Nurse Sarah is caring to clients who have difficulty of breathing and some having heart problems. The position of choice for these clients is:
a. Supine position
b. Trendelenburg position
c. Fowler’s position
d. Orthopneic position
Answer: C. Fowler’s position
Rationale: this position promotes maximum lung expansion and ventilation in the alveoli
22. Mr. Cruize who had undergone spinal surgery should assume which position?
a. Horizontal recumbent position
b. Prone position
c. Reverse trendelenburg position
d. Dorsal recumbent position
Answer: B. Prone position
23. The only bed position that allows full extension of the hip and knee joint is:
a. Orthopneic position
b. Prone position
c. Sim’s position
d. Lateral position
Answer: B. Prone position
24. Mrs. Smith is for an examination of her genitalia. Nurse Cassie should assist her to assume which position?
a. Dorsal recumbent position
b. Sim’s position
c. Knee-chest position
d. Genupectoral position
Answer: A. Dorsal Recumbent position
25. The client assumes a posture halfway between the lateral and the prone position. Nurse Craig knows that this type of position is:
a. Lateral position
b. Prone position
d. Sim’s position
d. Supine position
Answer: D. Sim’s position
Situation 6: Nursing procedures are directed toward restoring optimal mobility and preventing some of the effects of immobility. When performing these procedures, a nurse must be efficient and competent in rendering nursing care.
26. In assisting client to an erect or standing position, Nurse Rufuz must observe all of the following EXCEPT:
a. Assist patient to stand
b. Place a chair near one side where he can rest hand for support
c. Drape with a double folded sheet around the body from the breast to legs
d. Elevate one foot on a foot stool if needed
Answer: C. Drape with a double folded sheet around the body from the breast to legs
Rationale: In male clients, draping should be from the hips to legs
27. Ms. Demeanor complains of difficulty of breathing while lying on bed. Nurse Missy can assist her in an orthopneic position by:
a. Elevating head of bed to 45 degrees
b. Assisting patient to sit up on bed with overbed table across the lap
c. Assisting patient to lie on his back
d. Raising knees and separate legs, with soles of feet resting on bed
Answer: B. Assisting patient to sit up on bed with overbed table across the lap
Rationale: Option A is semi fowler’s; C is supine and D is lithotomy.
28. Dr. Lopez ordered a cleansing enema for Mr. Rusty. Nurse David knows that his client assumes Sim’s position when:
a. the lower arm is positioned behind the client and upper arm is flexed
b. the client lies on his back, with the knees raised
c. one side of the body is flexing the top hip and knee and placing his leg in front
d. the client sits on bed with an overbed table across the lap
Answer: C. one side of the body is flexing the top hip and knee and placing his leg in front
29. How will you position Mr. Seoul to a Semi-Fowler’s position?
a. Elevate head of bed to an angle of 35 degrees
b. Place arms at the sides, pronated and elevate with pillow
c. Place patient in supine position
d. Elevate head of bed to an angle of 50 degrees
Answer: D. Elevate head of bed to an angle of 50 degrees
30. In genupectoral position, the client kneels on bed with hips in air and chest on table. In order to provide privacy, Nurse Jasmine must do which of the following?
a. Provide hand rolls if needed
b. Cover with top sheet and pick lower end of the sheet to expose the area
c. Drape with a double folded sheet around the body from the waist to legs
d. Cover with top sheet and fold back in area to be examined
Answer: B. Cover with top sheet and pick lower end of the sheet to expose the area
Situation 7: Vital signs are determined to monitor the functions of the body. Nurse Jasmine should measure VS more often if the client’s health status requires it.
31. Monitoring of client’s VS should not be a routine procedure. The following are times to assess VS except:
a. On admission to a health care agency
b. Before and after surgery or invasive procedure
c. According to a nursing or medical order
d. Only after administration of medications
Answer: D. Only after administration of medications
Rationale: There are certain medications where VS should be assessed before administering it.
32. Nurse Jasmine knows that the primary purpose of taking VS initially is:
a. To establish data base
b. To monitor for disease progression
c. To identify proper treatment
d. To prepare for surgery
Answer: A. To establish data base
33. Which of the following is not a cardinal sign?
a. Temperature
b. Blood pressure
c. Heart rate
d. Pain
Answer: D. Pain
Rationale: Although considered as a VS, pain is more subjective. Options A, B and C are objective vital signs.
34. In order to elicit the patient’s cooperation, Nurse Jasmine must do which of the following first?
a. Explain the procedure
b. Wash hands
c. Greet the client and introduce one self
d. Take a look and smile
Answer: C. Greet the client and introduce one self
35. Nurse Jasmine knows that the best way to prevent transfer of microorganisms is:
a. Use of hand sanitizer
b. Disinfection of used materials
c. Handwashing
d. Health assessment
Answer: C. Handwashing
Rationale: A MUST to health care workers to break the chain of infection.
Situation 8: Nurse Julian is the staff nurse assigned at the Medical Ward of Aquinas University Hospital. In order to render nursing care, he must be knowledgeable of the anatomy and physiology.
36. Mr. Yang is suffering from hyperthermia. Nurse Julian knows that the center for thermoregulation is:
a. Pituitary gland
b. Hypothalamus
c. Medulla oblongata
d. Pons
Answer: B. Hypothalamus
37. The primary center for respiration is:
a. Pituitary gland
b. Hypothalamus
c. Medulla oblongata
d. Pons
Answer: C. Medulla oblongata
38. Respiration is the act of breathing. The primary chemical stimulation for breathing is:
a. Low CO2 level in the blood
b. High O2 level in the blood
c. Stress
d. High CO2 level in the blood
Answer: D. High CO2 level in the blood
39. Ms. Cha asks Nurse Julian where she can find the apical pulse. Nurse Julian is correct when he says:
a. “On the right mid – clavicular line, in the 5th or 6th intercostal spaces”
b. “On the left mid – clavicular line, in the 2nd or 3rd intercostal spaces”
c. “On right mid – clavicular, in the apex of your heart”
d. “On the left mid – clavicular line, in the 5th or 6th intercostal spaces”
Answer: D. “On the left mid – clavicular line, in the 5th or 6th intercostal spaces”
40. Mr. Clean has myocardial infarction. Nurse Julian knows that rectal temperature taking is contraindicated. What cranial nerve will stimulate the sympathetic nervous system to cause bradycardia?
a. Vagus
b. Facial
c. Olfactory
d. Optic
Answer: A. Vagus
Situation 9: In assessing vital signs, there are many factors to be considered that affects the accuracy and reliability of data.
41. Sympathetic nervous system stimulation increases the production of epinephrine and norepinephrine thereby increasing metabolic rate and heat production. This factor affecting the temperature is:
a. Stress
b. Exercise
c. Diurnal variation
d. Hormones
Answer: A. Stress
42. Nurse Joe knows that if hemorrhage happens, the body’s compensatory mechanism is:
a. Increase heart rate
b. Decrease blood pressure
c. Increase pulse rate
d. All of the above
Answer: D. All of the above
43. All but one are factors affecting the respiratory rate:
a. Exercise
b. Stress
c. Diurnal variations
d. Environment
Answer: C. Diurnal Variations
44. Hypertension is one of the 10 leading cause of death among Filipinos. This factor can be classified into:
a. Age
b. Race
c. Genetics
d. Gender
Answer: B. Race
45. Which of the following is a non – modifiable factor affecting the blood pressure?
a. Stress
b. Race
c. Exercise
d. Diet
Answer: B. Race
Situation 10: Nurse Pido is going to take the VS of his patient. As a competent nurse, he must be knowledgeable of the variations in taking the body temperature, pulse, respiration and blood pressure.
46. The most accessible and convenient method of taking temperature is:
a. Oral
b. Axillary
c. Rectal
d. Tympanic
Answer: A. Oral
47. After taking the temperature per orem, Nurse Pido must clean the thermometer in what manner?
a. From bulb to stem in a back and forth motion
b. From stem to bulb in a rotating motion
c. From bulb to stem in a rotating motion
d. From center down and upward
Answer: B. From stem to bulb in a rotating motion
Rationale: Before taking the temperature, cleaning of thermometer is from bulb to stem in a rotating motion.
48. Nurse Pido is aware that his patient is febrile when the mercury reading in the thermometer is:
a. 36.5 degrees Celsius
b. 37.8 degrees Celsius
c. 97.6 degrees Fahrenheit
d. 99.6 degrees Fahrenheit
Answer: B. 37.8 degrees C
49. Mr. Dido is in traction, in order to assess good circulation in the foot, Nurse Pido must palpate for:
a. Apical pulse
b. Radial pulse
c. Posterior tibial
d. Femoral pulse
Answer: C. Posterior tibial
50. Nurse Pido observed the movement of Mr. Dido’s chest as upward and inward. This type of breathing is:
a. Costal breathing
b. Diaphragmatic breathing
c. Abdominal breathing
d. Kussmaul’s breathing
Answer: A. Costal breathing
Situation 11: The accuracy of VS taking is an important indicator of the client’s condition and is used extensively as a basis for nursing interventions.
51. The use of appropriate size of the BP cuff is an important factor to get an accurate reading. Nurse Lindsay knows that a cuff that is too narrow or tight can cause which findings?
a. Hypertension
b. False low reading .
c. False high reading
d. Ecchymosis
Answer: C. False high reading
52. Mrs. Lee is taking a beta blocker medication. Nurse Wolverine knows that this drug causes which of the following?
a. Decrease RR
b. Decrease PR
c. Decrease Temperature
d. Decrease BP
Answer: D. Decrease BP
53. Nurse Ray is going to take the RR of Mr. Black. Upon entrance in the room, he noticed that Mr. Black has deep and rapid respiration. Based from your assessment, what acid – base imbalance will occur?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
Answer: D. Respiratory alkalosis
54. Nico is the student nurse assigned at the neonatal intensive care unit. Dr. Lopez requested him to take the heart rate of Baby See. After doing so, Nico knows that the normal heart rate of a newborn is:
a. 80 – 180 beats/min
b. 75 – 120 beats/min
c. 80 – 140 breaths/min
d. 60 – 100 breaths/min
Answer: A. 80 – 180 beats per min
55. Rectal temperature taking is the most accurate method of measurement. To reduce friction and prevent trauma to the mucous membranes, Nurse Cindy must do which of the following?
a. Lubricate thermometer with soap
b. Insert thermometer 4 inches above the sphincter
c. Lubricate thermometer with water soluble jelly
d. Instruct the client to breathe out then insert thermometer
Answer: c. Lubricate thermometer with water soluble jelly
Questions 56 – 85 is all about promoting hygiene
56. The following are functions of the skin, EXCEPT:
a. First line of defense
b. Maintains body temperature
c. Is a secretory organ
d. produces and absorbs Vitamin E
Answer: D. produces and absorbs Vitamin E
Rationale: The skin produces and absorbs Vitamin D.
57. The gland that is primarily located in the axilla and anogenital areas is:
a. Apocrine gland
b. Eccrine gland
c. Sweat gland
d. Sebaceous gland
Answer: A. Apocrine gland
Rationale: Eccrine is located in the palms of the hands and soles of feet. Option C and D are under apocrine gland.
58. What is the science of health and its maintenance?
a. Nursing
b. Health Education
c. Hygiene
d. Personal Hygiene
Answer: C. Hygiene
59. If hygiene is promoted and maintained, the individual has a feeling of all of the following EXCEPT:
a. Comfort .
b. Shame and doubt
c. Well-being
d. Self-confidence
Answer: B. Shame and doubt
60. Which of the following is a personal hygiene?
a. Bathing
b. Hair care
c. Perineal care
d. Eye care
Answer: A. Bathing
61. When superficial layers of the skin are scraped or rubbed away, the term is:
a. Erythema
b. Abrasion
c. Acne
d. Vitiligo
Answer: Abrasion
Rationale: Redness of skin is erythema. Acne is in inflammatory condition of the skin while vitiligo are patches of hypopigmented skin present in elderly.
62. What is the most effective measure to relief dryness of the skin?
a. Increase fluid intake
b. Apply cream/lotion
c. Avoid use of alcohol
d. Bathe less frequently
Answer: A. Increase fluid intake
Rationale: All are interventions but increasing fluid intake is the best way and more economical.
63. A common skin problem that is characterized by papules, pustules and comedones is:
a. Wheal
b. Patch
c. Acne
d. Erythema
Answer: C. Acne
Rationale: A relatively reddened and elevated localized collection of edema fluids such as mosquito bites is a wheal. Patch is larger than macule such as birth mark.
64. It is a large fluid-filled sac:
a. Tumor
b. Papule
c. Cyst
d. Bulla
Answer: D. Bulla
Rationale: Tumor is a solid mass. Papule is a circumscribed elevation of the skin and a cyst is a semi solid matter.
65. Athlete’s foot is what type of secondary skin lesion?
a. Excoriation
b. Fissure
c. Erosion
d. Lichenification
Answer: B. Fissure
Rationale: Scratch is a form of excoriation. Erosion is loss of all part of the epidermis and lichenification is epidermal thickening.
66. The initial nursing action when providing bed bath is:
a. Close the door and windows of the patient’s room
b. Inform the client and explain the purpose of procedure
c. Remove the client’s gown under the top sheet
d. Place the bed in flat position
Answer: B. Inform the client and explain the purpose of procedure
67. Nurse Kenzo is giving bed bath to Mr. Hall who is on strict bed rest. To increase venous return, the nurse bathes the clients extremities by using:
a. Using firm strokes from distal to proximal
b. Firm circular strokes from proximal to distal
c. Short, patting strokes from distal to proximal
d. Smooth, light strokes back and forth
Answer: A. Using firm strokes from distal to proximal .
Rationale: This type of stroke promotes vasodilation and friction thus increasing venous return or blood circulation towards the heart.
68. Which of the following is inappropriate when performing genital care to male clients?
a. Wear gloves
b. Use circular motion from the penile shaft towards the glans
c. Retract prepuce if uncircumcised
d. Use moist washcloth with soap
Answer: B. Use circular motion from the penile shaft towards the glans
Rationale: It should be from the glans towards the penile shaft
69. Which of the following is the most important nursing consideration when performing perineal care to female clients?
a. Use up-downward stroke
b. Use posterior-anterior stroke
c. Wash from back to front
d. Use rubbing stroke
Answer: B. Use up-downward stroke
Rationale: Wash from the cleanest to dirtiest to prevent transfer of microorganisms
70. To ensure asepsis when bathing a client in bed, the nurse should do which of the following?
a. Wash from distal to proximal areas
b. Pat dry skin surface
c. Wash from clean areas to dirty areas
d. Assess bath water temperature
Answer: C. Wash from clean areas to dirty areas
71. When removing the client’s gown with IVF on his left arm, the nurse should:
a. Remove the side of the gown without the contraption first
b. Remove the side of the gown with contraption first
c. Remove either sides of the gown
d. Remove the IVF then just reinsert it
Answer: A. Remove the side of the gown without the contraption first
Rationale: In changing/removing the gown, start without the IV line first. In putting the gown back, start with the arm with IV line.
72. Moving the client to one side of the bed before bathing prevents which of the following?
a. Promotes relaxation and client’s comfort
b. Prevents injury to the nurse and client
c. Maintains asepsis
d. Prevents overreaching and undue muscle strain
Answer: D. Prevents overreaching and undue muscle strain
73. To retain heat and water better during bed bath, the nurse should:
a. Check water temperature frequently
b. Make bath mitt out of the wash cloth
c. Turn – off electric fans
d. Use warm water only
Answer: B. Make bath mitt out of the wash cloth
74. In peri care, in order to maintain client’s dignity, the nurse should:
a. Provide privacy
b. Explain the purpose of the procedure
c. Position and drape the client
d. Wear clean gloves
Answer: A. provide privacy
75. A type of massage that involves a smooth, long stroke and moving the hands up and down the back is:
a. Petrissage
b. Tapotement
c. Back Rub
d. Effleurage
Answer: D. Effleurage
Rationale: Petrissage is a large pinch of the skin. Tapotement is also called as tapping. Back rub is a back massage and under this are those types.
76. Which of the following can be an afternoon care to your client?
a. Bed bath
b. Back Massage
c. Perineal care
d. Stretching of bed linens
Answer: D. Stretching of bed linens
Rationale’ Options a, b and c are mostly done as morning care to the client.
77. In combing or brushing a long hair, the nurse should:
a. Start from the tip of the hair to remove tangles
b. Start from the mid part then down to the tip
c. Begin from the scalp then down to the tip
d. Distribute and part the hair into three sections
Answer: A. Start from the tip of the hair to remove tangles
Rationale: If the hair is short; begin from the scalp then down the tip
78. To stimulate the circulation of the blood in the scalp through massage, the nurse should perform which of the following?
a. Bed bath
b. Back rub
c. Hair shampoo
d. Hair care
Answer: C. Hair shampoo
79. In hair shampoo, to prevent from irritating the client’s eyes, the nurse should:
a. Wipe from inner to outer canthus
b. Cover the eyes with wash cloth
c. Plug ears with cotton balls
d. Advise clients to gently close the eyes
Answer: B. Cover the eyes with wash cloth
80. Infestation of the scalp with lice is:
a. Pediculosis humanis
b. Pediculosis pubis
c. Pediculosis capitis
d. Pediculosis corporis
Answer: C. Pediculosis capitis (head)
Rationale: Option A is wrong it should be humanus for body lice. Option B is crab or pubic lice and option D is for body louse.
81. Which of the following should not be included when providing patient’s teaching on hygienic measures?
a. Do not rub the eyes
b. Remove cerumen from the ear with cotton tipped applicator
c. Blow the nose with one nares closed
d. Use eye drops at regular basis
Answer: C. Blow the nose with one nares closed
Rationale: Both nares should be open when blowing nose
82. The best position for female client during perineal care is:
a. Supine
b. b. Dorsal recumbent
c. Lateral
d. Semi – fowlers
Answer: B. Dorsal Recumbent
83. The body’s first line of defense is which of the following?
a. Skin
b. b. An intact and healthy skin
c. Tissues
d. Hair
Answer: B. An intact and healthy skin
Rationale: Though skin can be correct but option B is more specific as a general guideline in skin care.
84. All of the following are primary purposes of bed bath EXCEPT:
a. Assessment
b. Nurse-patient interaction
c. Circulation
d. Documentation
Answer: D. Documentation
Rationale: This is the very least purpose in rendering bed bath
85. Mr. Liu is a diabetic client, he asked the nurse on how to cut his toenails particularly the corns, the nurse’s best response would be:
a. Cut nail straight across
b. Trim toenails from the edge
c. Consult a podiatrist
d. Soak foot to a basin with warm water
Answer: C. Consult a podiatrist
Rationale: In cases like this, the nurse’s role is collaborative through advising the client to consult a podiatrist (examines the foot or ankle) to avoid further complication.
End of Nursing Practice (Basic Health Care Procedures)
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Thank you.
BREWED
hi pa send naman sa email ko yung 85 items NURSING PRACTICE (basic health care procedures)w/answers and rationales.
thank you po.
chrisee81@yahoo.com
Posted by
Anonymous |
6:58 PM
hi gud day... please kindly send to my email ur latest questionares with answers and rationales.. it will be a big help 4 me... please please please...
thank u so much..
tsoko03@yahoo.com.ph
Posted by
frances |
8:02 AM