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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

CHN Drill 5

Situation 1: One health program of the DOH that is being implemented is environmental
sanitation.
1. If you were a farmer’s daughter, what specific program would you advocate so that your
production is high?
A. Rodents and insect control C. Water Supply
B. Institutional sanitation D. Occupational Health Work
2. As a nurse, how would you promote food sanitation?
A. Correct food to eat C. Wash fruits before eating
B. Utilize the media D. Handwashing before eating
3. Garbage disposal is a problem everywhere. What are examples of non-biodegradable
wastes?
A. Food refuse C. Cans
B. Newspaper D. Plastic wrappers and bottles
4. What would be your health teaching in the mothers’ class in relation to waste disposal?
A. Burn newspaper C. Separate biodegradable from nonbiodegradable
B. Throw away garbage in a pit D. Build compost pit
5. Which of the following is the most important instruction to families whose toilets are pit
latrines?
A. Use newspaper to wipe their anus
B. Proper handwashing
C. Cover latrines against flies
D. Burn the newspaper used in cleaning their anus
Situation 2: The grandmother of a 3-year old kid asks you to give immunization on another
day because they are going on a vacation.
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6. What would you do in the above-mentioned situation?
A. Explain that Wednesday is the immunization day.
B. Refuse to give immunization
C. Just give without question
D. Tell her to bring the card to the center where they are having a vacation
7. Men wearing police uniform requested you to keep a package of prohibited drug in your
cabinet. You know that it is metamphetamine hydrochloride or shabu. What would be
your answer to them?
A. ‘Sige na nga sir.’
B. ‘Sorry sir. But I cannot give in to what you want.’
C. ‘Sir, I’ll tell the mayor.’’
D. ‘Please do not involve me, sir.’
8. What would you do if you know of the existing group which keep drugs in your area of
duty?
A. Inform the proper authorities C. Keep quiet about it.
B. Call the narcotics command D. Tell you supervisor.
9. You are aware of a health provider using drugs too. What would you do?
A. Keep quiet. C. Tell him that you know about it.
B. Inform the authorities. D. Report him to your supervisor.
10. There was a quarrel outside your RHU. The men were drunk. What would you do?
A. Call the doctor C. Call the barangay officer
B. Let someone call for help D. Shout at them
Situation 3: Environmental protection is a global concern
11. To which program should a CHN participate actively to support global action for the
environment?
A. Toxic chemical waste management C. Zero hospital waste management
B. Anti-smoke belching D. Zero solid waste campaign
12. Under the environmental health services, which of the following should the nurse
participate in?
A. water-borne diseases C. environment-friendly initiatives
B. gastrointestinal diseases D. diarrhea and vector-borne
13. How could research data be utilized in the prevention of diseases?
A. in recording epidemics and in communicable disease control
B. in prescribing medications for communicable diseases
C. in monitoring effects of primary health care
D. in reporting case findings
14. Which step in the research process uses surveys and interviews to obtain data
A. statistical data C. review of related literature
B. statement of the problem D. data collection
15. As a PHN, what is your primary function or responsibility?
A. reporting of cases C. community diagnosis
B. assisting the doctor D. health teaching
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Situation 4: The Department of Health prepared the National Health Plan and its blue print
to define the country’s health problems, thrusts and strategies
16. Which DOH project aims to eradicate polio as expressed in one DOH slogan below?
A. Health in the hands of the people
B. Eradicate polio for 9 million kids
C. Ceasefire for children:Support Immunization Day
D. Shoot vaccines, not bullets
17. Sarah Jane is a victim of AIDS. Which program of the DOH was established to check the
prevalence rate of AIDS?
A. AIDS surveillance program C. National AIDS prevention and control
program
B. Philippine National AIDS control D. AIDS awareness activities
18. An advocacy and action strategy to fight cancer and cardiovascular disease affected by
smoking is reflected in one of the following campaigns:
A. Smoking is dangerous to your health C. This is a Smoke-free building
B. Tobacco and Smoke-Free Environment D. Smoke moderately
19. Hospitals as centers of wellness began in 1993 which institutionalized promotive and
preventive aspects of care. What is the best feature of the mother and baby-friendly
hospital?
A. Well-baby clinic C. Free immunization
B. Free maternal services D. breastfeeding is enforced
20. Health for More in ’94 included Oplan Alis Disease. As a nurse, which one below would
you promote as a non-pharmacological strategy to have a healthy heart?
A. Taking prescribed drugs C. Research on heart disease
B. Consulting a physician D. Client education on healthy
lifestyle
Situation 5: Based on the safe motherhood survey, maternal morbidity ratio is
209/100,000 livebirths and perinatal mortality rate is also high
21. Based on DOH findings, maternal tragedies occur due to delayed referrals. Which one
below contributes to delayed referrals?
A. transportation and communication C. late detection of complications
B. untrained manpower D. lack of blood supplies
22. Target population for total care during pregnancy, delivery and postpartum belongs to
this age group
A. 15-40 B. 15-44 C. 16-45 D.18-35
23. Maternal mortality is the number of maternal deaths per 1,000 livebirths in a specific
year. Which one below is the correct formula?
A. Livebirths + number of fetal deaths X 1,000
Number of deaths due to maternal causes
B. Livebirths - number of fetal deaths X 1,000
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Number of deaths due to maternal causes
C. Number of deaths due to maternal causes X 1,000
Livebirths + number of fetal deaths
D. Number of deaths due to maternal causes X 1,000
Livebirths in the same year
24. Neonatal mortality is the number of deaths of babies born alive before they reach 28
days for every 1,000 livebirths in a specific year. Which formula is correct?
A. Deaths under 28 days X 1,000
Livebirths in the same year
B. Deaths under 28 days X 100,000
Livebirths in the same year
C. Deaths under 28 days X 100
Livebirths in the same year
D. Livebirths in the same year X 1,000
Deaths under 28 days
25. Infant mortality is deaths under 1 year of age per 1,000 live births in a specific year.
Which formula is correct?
A. Deaths under 1 year of age X 1,000
Livebirths in the same year
B. Deaths below 1 year of age X 10,000
Livebirths in the same year
C. Deaths below 1 year of age X 100,000
Livebirths in the same year
D. Livebirths in the same year X 1,000
Deaths under 1 year of age
Situation 6: Maternal and child health service is one vital program in the DOH. Maternal
mortality rate is high due to hemorrhage, infection and hypertension complications.
26. Mrs. Santos came to the RHU to consult with MHO but she was attending a seminar.
What would you do first if she tells you that she is bleeding?
A. Check vital sign
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B. Give a transfusion at once
C. Tell her to go the city
D. Accompany her to the provincial hospital
27. Camille is 21 years old, 3 months pregnant and asks you about the prenatal services.
What would you tell her?
A. “Are you going to practice family planning?”
B. Do you have an Obstetrician?
C. Let me tell you the importance of prenatal check-up
D. “ Why did you come only today?
28. Home delivery for a normal pregnant woman is being encouraged by primary care
providers. If there is no licensed health professional in the RHU, who will attend to the
delivery of the woman?
A. Komadrona C. Trained hilot
B. New RN D. Licensed midwife
29. Postpartum complications must be avoided through appropriate prenatal counseling.
After home delivery, when will you do the first home visit to check for bleeding and
infection?
A. 24 hours C. 1 week
B. 2 weeks D. 40 hours
30. To promote appropriate health practice of pregnant women, you as a PHN must focus
on:
A. Public education program
B. Accurate record and report
C. Linkage with PNA and IMAP
D. Prompt referral system
31. Which of the following identifies increased risk for AIDS?
A. Sentinel site nationwide C. AIDS surveillance
B. AIDS prevention D. AIDS protection
32. Which program advocates the right to protection and human dignity?
A. AIDS national council C. Sentinel site
B. AIDS prevention D. HIV/AIDS patients
33. Which program broadens the context on women’s health and safe motherhood?
A. Family planning program of the Philippines
B. DOH family planning services
C. Family Planning Organization of the Philippines
D. None of these
34. Which innovative scheme provides health manpower in doctorless and nurseless
municipalities?
A. Human resources manpower of DOH C. Human resources for health
manpower
B. Health manpower resources program D. Health resources program
35. Which of these promote backyard propagation and herbal medication production?
A. Indigenous healing
B. Herbal and Philippine traditional medicines
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C. Anthropology and traditional medicines
D. Herbal collection of scientific benefits
Situation 7: The Expanded Program of Immunization (EPI) was started in July 1976 by the
virtue of PD 996, a compulsory immunization of children below 8 years old.
36. This EPI is based on 3 principles. Which one is pro-people?
A. Mass approach rather than individual C. A basic health services
B. Based on epidemiological situation D. Case finding and treatment on site
37. Which one is the primary component of EPI?
A. Surveillance and research C. Target setting
B. Information campaign D. Logistic management
38. The general objective of EPI is to reduce the morbidity and mortality rates among
children. BCG is given at birth followed by 1 dose. When is the 2nd dose given?
A. Every months for 2 months C. One and half months after
B. Two months after first dose D. Pre-school booster
39. Measles vaccine is given subcutaneous in a dose of 0.5ml. At what age is this done?
A. one year C. six months
B. one and half year D. nine months
40. Which collaborating agency in the world helps eradicate polio in children?
A. UNICEF C. WHO
B. Rotary International D. Canadian International Development Agency
Situation 8: Water quality and monitoring for surveillance is the responsibility for each
municipality through the RHU. Planning must be assisted by the environmental health
services.
41. The nurse should know that the examination of drinking water by the government and
non-government municipality is through the RHU. Planning must be assisted by:
A. City health C. Municipality
B. Department of health D. Sanitary engineer/inspector
42. Disinfections of water supply is required in a newly constructed well, repaired water
pipes, and contaminated container, EXCEPT:
A. River C. Open well
B. Surface water D. Unimproved spring
43. Approved types of toilet facilities may or may not need water depending on receiving
space. What type of toilet is without need for water?
A. Aqua privies C. Water sealed
B. Flush toilet D. Pit privies
44. Hospital waste management program is a requirement before construction of newly
facilities. The hospital personnel are required to train in waste management to prevent
which of the following?
A. Transmission infection C. Nosocomial infection
B. Cross infection D. Communicable disease
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45. Nursing responsibilities and activities toward environment and population is beyond
measure. The nurse is in the best position to conduct health education through which of
the following?
A. Role modeling approach
B. Development and distribution of IEC materials
C. Use of communication media
D. Development of designs or program
Situation 9: Care of the elderly as included in the WHO’s Health for all in the Philippines,
the elderly is properly cared for at home.
46. Which of the following needs, according to Maslow, apply to old people?
A. Belongingness C. Emotional
B. Economic D. Spiritual
47. Respiratory disease affects the elderly. Which nursing function would best assist your
grandparents?
A. Function specific to diseases C. Referral to specialist
B. Home management D. Guidance counseling
48. Humanitarian issue affect the care of the elderly. Filipino values is changing. Which one
would you maintain in the care of elderly?
A. Labor and management C. Educational and recreational
B. Income of elderly D. Security and protection
49. What would be the thrust of the program that you would make for the elderly?
A. Invoke elderly in a volunteer work C. Information on physical & social
process
B. Children to be responsible for parents D. Build homes for elderly
50. In our country senior citizens are given the privilege when they purchase their
medicines. How much is the discount?
A. 25% C. 15%
B. 10% D. 20%
Situation 10: Mrs. Florida Rasol, 35 years old and G4P4, expressed her desire to undergo
bilateral tubal ligation (BTL). Her youngest child is one year old.
51. In counseling Mrs. Rasol and her husband about BTL which of the following should be
the main focus of the nurse?
A. If the couple has any doubts, offer another contraceptive
B. Assist the couple to make a sound, well informed decision to undergo the
procedure
C. Motivate the couple to make a sound, well informed the decision to undergo the
procedure
D. Review the family and personal circumstances that could their affect their
decision
52. After sterilization, which of the following choices should be avoided by Mrs. Rasol?
A. Lift her youngest child
B. Resume sexual relationship with husband
C. Shower anytime, but keep the incision site dry for 7 days
D. Take medication as ordered
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53. Which of the following is NOT TRUE about the BTL?
A. very effective and safe C. Does not interfere with sexual
activities
B. Irreversible D. Allows immediate sterility
54. Mrs. Rasol asks, “Will it be possible for me to get pregnant after the procedure? The best
response of the nurse will be:
A. “What made you ask?”
B. “There are some report of the women getting pregnant, but this is comparatively
rare.”
C. “Absolutely not, this is a permanent sterility.”
D. “The doctor here are all specialists. I wouldn’t worry if I were you.”
55. Other methods of contraception are explored. Mrs. Rasol expressed her-non preference
for vasectomy. Which of the following are the main reasons why this method is not a
popular choice among men?
A. Diminishes macho image
B. Sterility is not immediate
C. Restoration of fertility does not always succeed
D. Very costly
Situation 11: Aling Dolor, a retired school teacher and a sari-sari store owner, came to the
health center complaining of easy fatigability. She is very much worried about her health
although according to her, work in the store is very light.
56. Based on the above situation, which of the following statements best exemplifies health
promotion priority goal for Aling Dolor?
A. Have regular physical examination
B. Encourage her to have a bed rest
C. Allay or reduce her stress
D. Plan a therapeutic diet for her
57. In doing risk appraisal for Aling Dolor, which of the following behaviors of the nurse is
most appropriate
A. show a helping attitude by supervising her ADL
B. show an attitude of concern considering her individuality as a person
C. develop client trust in you by explaining in technical terms her condition
D. perform physical assessment including technical gynecological history
58. The objective of a risk appraisal for Aling Dolor is to assess the:
A. Undesirable health practice C. Health habit and practice
B. Danger sign and disease D. Health threats in the community
Situation 12: As a community health nurse, your clients are usually diverse. It is important
that you should be aware of the needs of these clients according to their developmental
stages
59. Princess, 22 years old has just been accepted in an ambulatory health care clinic. She
approached you to report an outbreak of influenza in their neighborhood and has shared
with you how she anxiously awaits her first job. The major developmental focus of
Princess and her age group is:
A. rebelling against parental control in matter of dating and going out with friends
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B. deciding what worth can be shared by the next generation
C. finding oneself and developing initial commitments
D. resolving how one will confront death
60. In one of your clinics, you met Mrs. Baby a 42-year old woman, who began to feel
anxious about her life. Her husband has been very busy having been promoted as CEO
of their company. Her oldest child is already working and two younger ones are in
school. She daydreams about having another baby. You would consider her situation as:
A. Expected midlife disillusionment
B. Healthy life expectation
C. Serious developmental abnormality
D. Out of control midlife crisis
61. Mr. Melanio, 50 years old, is known to be obsessed with his graying and balding hair. He
makes frequent negative references to his body and energy level and at one time he told
to his wife to leave him for a younger man. His behavior probably indicates:
A. Mental and / or neurotic disorder C. Desire to separate from the wife
B. Loss of sexuality D. Awareness of aging and mortality
62. Aling Melody, 75 years old, is very active in church activities. She is in good physical
health but was brought to your clinic by her eldest daughter. Her daughter is disturbed
because Aling Melody always talks about “when she dies”. She has given away some of
her possessions to friends and other close relatives. She also told her family about
wanting to be cremated when the “time” comes. She say she is fine and just wants to be
realistic and ready. Your nursing interventions would most likely be:
A. Explain that her behavior is developmentally normal
B. Obtain a prescription for anti depressant
C. Refer her to the hospital for further observation
D. Just ignore the complaints of the eldest daughter
63. Mr. Valeros, 70 years old came to the clinic complaining about muscle weakness, fatigue
and shortness of breath with his regular walking exercise in the morning. Upon
examination, his BP is 136/86 and pulse rate is 70/min. He said that after the short rest,
he feels fine again. He is not taking any medication. Your analysis with his assessment
would most likely be that he:
A. Probably experiences signs of normal aging
B. Needs to take preventive “anti hypertensive” medication
C. Has cardiac pathology and needs to be seen by the doctors
D. None of the above
Situation 13: Flor, age 40 seeks consultation for difficulty of sleeping and poor appetite for
one month after their house was destroyed by lahar.
64. One of the basic goal for crisis intervention is:
A. Assist the person to attain higher level of functioning
B. Help the person return to the normal level of functioning
C. Assist the person explore available and appropriate resources in the community
D. Assist the person identify the nature and extent of her problem
65. After a thorough assessment, the nurse identifies this relevant nursing diagnosis:
A. Sensory perceptual disturbance C. Impaired adjustment
B. Impaired physical mobility D. Ineffective individual coping
10
66. The initial task in crisis intervention is to assess:
A. The client support system C. The individual and the problem
B. The type of crisis the client is experiencing D. The plan for coping with crisis
67. One important factor to consider in assessing Flor’s ability to handle a crisis is:
A. Person’s coping skills C. Her family background
B. Age and level of maturity D. Her intelligence
Situation 14: Currently, a lot of developments are happening in health care institutions.
Surfacing new health care agencies that are managed by nurses are slowly evolving amidst
the rising health care cost.
68. The following are major health problem in the current health care system that have
most affected the national health policy:
I. older adult population
ll. access to health care service
lll. Quality of health services
lV. Medical cost control
V. Nursing specialization
A. ll, lll, lV and V C. l, ll, lll, lV
B. l, lll, lV and V D. l, ll, lll, V
69. The unit in training hospitals which includes physicians’ offices, clinics, emergency care
centers as well as wellness center is called:
A. Community extension services
B. Emergency room department
C. Hospital care services
D. Out patient department
70. The following are major factors most significantly influencing the health care delivery
system over the last decade:
1 legal, ethical and bioethical issues
2 new knowledge and technology in the management of disease
3 political and economic condition
4 society and consumer movement
A. 1, 3, 4, 5
B. 2, 3, 4, 5
C. 1, 2, 3, 4
D. 1, 2, 3, 5
71. The Philippine Health Insurance Corporation is a:
A. Private insurance program to reduce client’s medical cost
B. Fixed payment to hospital based on cost incurred by each client
C. Fixed payment to hospital based on diagnostic categories
D. Government health insurance program to reduce client’s medical cost
72. Which of the following factors affecting health care cost is LEAST apparent in the
Philippines?
A. Increase poverty resulting in least preventive care
B. Increase in numbers of clients with AIDS and AIDS related illness
C. Growing specialization in medical practice
D. Emergent modern technology
11
Situation 15: Iodine deficiency affects more females than males in the reproductive years.
73. What would you include in your health teaching on iodine deficiency?
A. eat seafoods and vegetables
B. eat beans
C. eat meat and vegetables
D. eat sweet potatoes
74. The nurse recognizes that one of the major effects of iodine deficiency is mental
retardation. How would the nurse assess mental retardation?
A. ask questions
B. let child tell a story
C. ask mother if she has history of abortion
D. ask parents what they eat
75. Place where populations are affected by iodine deficiency are those where products are
goitrogenics. What are these foods?
A. pili nuts
B. saur kraut and mandarins
C. monggo sprouts
D. cassava and cauliflower
76. Which food prevents goiter?
A. broccoli
B. sea foods
C. green fruits and vegetables
D. cauliflower
77. Prevention of thyroidism should be included in health teaching. What should be your
topic?
A. foods to eat
B. operable goiters
C. cooking lessons
D. types of goiter
Situation 16: Reproductive Health is the exercise of reproductive rights with responsibility.
One of the goals of the program is to prevent illness/ injuries related to sexuality and
reproduction.
78. The following are goals of RH, EXCEPT:
A. every pregnancy should be intended
B. every birth should be healthy
C. all married couple should use artificial contraceptive
D. achieve a desired family size
79. In the international framework of RH, the focus is on:
A. past 40 years age group
B. women’s health
C. displaced people with RH problem
D. barren people
80. Which of the following is not an element of the RH?
A. prevention and management of abortion complications
12
B. violence against women
C. self- employment
D. men’s reproductivehealth
81. In the Philippines, the focus of RH in terms of its elements is/are on:
A. men and women
B. men only
C. women only
D. gender discrimination
82. What factor generally affects reproductive results in the international framework?
A. poverty
B. underemployment
C. environment
D. gender discrimination
Situation 17: For a developing country like the Philippines, sanitation is the most common
problem. Along with the programs to promote sanitation, the DOH also promotes a program
that helps control diarrheal disease.
83. Which of the following is the vital role of the nurse in the CDD program?
A. maternal and child health
B. sanitation and environment
C. health education
D. nutrition
84. What is the personal commitment of the nurse in the prevention of diarrheal disease
program?
A. setting good examples
B. encouraging barangay officials
C. motivating groups
D. health education
85. It is utilized in the extensive case management of diarrhea to reduce mortality rate
in children:
A. oral rehydration solution
B. oral rehydration therapy
C. proper waste disposal
D. improved weaning practices
86. What is the primary objective of the CDD advocated by the DOH?
A. to reduce mortality from diarrhea
B. environmental sanitation
C. maternal and child health
D. promote breastfeeding practices
87. What is the primary prevention for CDD advocated by DOH that is effective and
affordable?
A. fluid replacement
B. breastfeeding
C. oral rehydration therapy
D. measles immunization
13
Situation 18: Quality health services is the aim of the DOH. Numerous programs have
been devised to promote such.
88. It is the certification program that develops and promotes standard for health
facilities:
A. sentrong sigla movement
B. ‘sang milyong sepilyo
C. reproductive health
D. expanded program on immunization
89. Among the pillars of Sentrong Sigla Movement, except:
A. quality assurance
B. award
C. international recognition
D. health promotion
90. All are the priorities of Sentrong Sigla Movement, except:
A. EPI
B. Disease surveillance
C. Family planning
D. Voluntary blood donation
91. All of the following are the standard requirements of Sentrong Sigla Movement,
except:
A. infrastructure
B. equipment
C. pharmaceuticals
D. herbal medicines
92. An expected result of Sentrong Sigla Movement in every individual is to:
A. adapt healthy lifestyles
B. develop policies
C. develop a system of surveillance
D. advocacy law
Situation 19: One of the leading causes of morbidity and mortality is pulmonary infections.
Acute respiratory infection (ARI) could be managed at home, given the proper protocol.
93. Which of the following should a nurse include in the health teaching given top
mothers to prevent ARI?
A. wash hands after using toilet
B. avoid smoking in the home
C. avoid droplet infection
D. consult the doctor regularly
94. In adults with pneumonia or ARI in the home, which drug must be available at the
RHU based on
standard case management?
A. chloramphenicol
B. oxygen tanks
C. co- trimoxazole
D. injectable gentamycin
14
95. In far flung areas, who could dispose ARI standard orders in case of Pneumonia in
children?
A. sanitarian
B. midwife
C. nurse
D. barangay health worker
96. During home visit, the nurse assessed the child with ARI. Which of the following
signs indicate immediate medical intervention?
A. inability to drink
B. restlessness
C. temperature of 37.70C
D. poor appetite
97. Which of the following is not included in the prevention of acute respiratory
infection?
A. measles immunization
B. avoid smoking
C. breastfeeding
D. good ventilation
Situation 20: Being the public health nurse, you provide nursing care to the family.
98. The nurse performs the following to determine the family’s nursing problems/
needs:
A. family health care plan formulation
B. assessment
C. goal setting
D. evaluation
99. An appropriate source of information about the family is/ are:
A. interview results with the members of the family
B. family folder
C. actual observation of the family situation
D. all these are sources of information
100. The family presents several problems, which of the following criteria is considered
in determining
the priority health problem?
A. involvement of members of the family in the problem
B. cooperation and support of the family
C. modifiability of the problem
D. expected consequence of the problem
Answers
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