Fundamentals of Nursing Quiz | Practice MCQ #mcq.imBooz

• (A) The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system?
• (B) This type of system consists of combined documentation and daily care plans.
• (C) It improves interdisciplinary collaboration that improves efficiency in procedures.�
• (D) This type of system tracks medication administration and usage over 24 hours.

Check AnswerSolution[C]:- The EHR has several benefits for use, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage.

• (A) Complete an occurrence report before leaving.
• (B) Do nothing; the next nurse will document it was done.
• (C) Write the note of the dressing change into an earlier note.�
• (D) Make a late entry as an addition to the narrative notes.

Check AnswerSolution[D]:- If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed.

• (A) Are comprehensive charting forms that integrate assessments and nursing actions
• (B) Contain only graphic information, such as I&O, vital signs, and medication administration
• (C) Are used to record routine aspects of care; they do not contain assessment data
• (D) Contain vital data collected upon admission, which can be compared with newly collected data

Check AnswerSolution[A]:- Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information.

• (A) NA
• (B) NDA
• (C) NKA
• (D) NPO

Check AnswerSolution[C]:- The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth.

• (A) Separates the health record according to discipline
• (B) Organizes documentation around the patient’s problems
• (C) Highlights the patient’s concerns, problems, and strengths
• (D) Is designed to streamline documentation

Check AnswerSolution[A]:- In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient’s problems. Focus� charting highlights the patient’s concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation.

• (A) Medication given 30 minutes after scheduled dose time
• (B) Patient’s dentures lost after transfer
• (C) Worn electrical cord discovered on an IV infusion pump
• (D) Prescription without the route of administration

Check AnswerSolution[B]:- You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary.

• (A) transient flora from the skin.
• (B) resident flora from the skin
• (C) all microorganisms from the skin.
• (D) media for bacterial growth.

Check AnswerSolution[A]:- There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans, microbes must be able to use the body’s precise balance of food, moisture, nutrients, electrolytes, pH, temperature, and light. Food, water, and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms, except perhaps briefly when an antiseptic agent is used for cleansing.

• (A) IgA
• (B) IgE
• (C) IgG
• (D) IgM

Check AnswerSolution[C]:- The antibody IgG is passed to the child through the mother’s breast milk during breastfeeding. IgA, IgE, and IgM are produced by the child’s body after exposure to an antigen.

• (A) Remaining 1 foot away from nonsterile areas
• (B) Placing sterile items on the sterile field
• (C) Avoiding the border of the sterile drape
• (D) Reaching 1 foot over the sterile field

Check AnswerSolution[D]:- Reaching over the sterile field while wearing sterile garb breaks sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape.

• (A) admitted with unstable diabetes mellitus.
• (B) who underwent surgical repair of a perforated bowel.
• (C) with a stage 3 sacral pressure ulcer.
• (D) admitted with a urinary tract infection.

Check AnswerSolution[A]:- The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer, or with a client who has a urinary tract infection.

• (A) A clean gown and gloves must be worn when in contact with the client.
• (B) Everyone who enters the room must wear a N-95 respirator mask.
• (C) All linen and trash must be marked as contaminated and send to biohazard waste.
• (D) Place the client in a room with a client with an upper respiratory infection.

Check AnswerSolution[A]:- A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections.

• (A) Fever
• (B) Intact skin
• (C) Inflammation
• (D) Lethargy

Check AnswerSolution[B]:- Intact skin is considered a primary defense against infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection.

• (A) Cover the mattress with a sheepskin.
• (B) Keep the linens wrinkle free.
• (C) Separate the skin folds with towels.
• (D) Apply petrolatum barrier creams.

Check AnswerSolution[B]:- Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Sheepskins are not recommended for use at all. Petrolatum barrier creams are used to minimize moisture caused by incontinence.

• (A) Maceration
• (B) Abrasion
• (C) Excoriation
• (D) Pressure ulcer

Check AnswerSolution[D]:- The nurse should document a lesion caused by tissue compression and inadequate perfusion as a pressure ulcer. Abrasion, a rubbing away of the epidermal layer of skin, is commonly caused by shearing forces that occur when a patient moves or is moved in bed. Maceration is a softening of skin from prolonged moisture. Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces.

• (A) Orthostatic hypotension
• (B) Appendectomy
• (C) Dizziness
• (D) Dehydration

Check AnswerSolution[D]:- Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit, causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional status.

• (A) Male nursing assistant
• (B) Male licensed practical nurse
• (C) Female graduate nurse
• (D) Female graduate nurse and Female registered nurse

Check AnswerSolution[D]:- Orthodox Judaism prohibits personal care being provided by a member of the opposite sex. The patient who underwent a hysterectomy is female; therefore, out of respect for her religious beliefs, she should not be bathed by the male licensed practical nurse or nursing assistant.

• (A) Brushing teeth twice a day
• (B) Bathing every other day
• (C) Decreasing moisturizer use
• (D) Increasing soap use

Check AnswerSolution[B]:- As a person ages, sebaceous glands become less active, causing skin to dry. Older people may find it necessary to bathe every 2 days, increase the use of moisturizers, and decrease soap use to prevent further drying of skin. Older adults should brush their teeth after every meal and at bedtime to prevent tooth decay. It is recommended that people of all ages brush their teeth at least twice a day, so that option does not represent a change in an older adult’s hygiene practices.

• (A) Motor vehicle accidents
• (B) Poisoning
• (C) Choking
• (D) Falls

Check AnswerSolution[A]:- The leading causes of unintentional death for the total population, in this order, are automobile accidents, poisoning, falls, and drowning.

• (A) Attach the baby’s pacifier to a ribbon so that it does not fall on the floor.
• (B) Give a 2-year-old whole grapes instead of popcorn for a snack.�
• (C) Store firearms unloaded and out of sight in a location too high for the child to reach.
• (D) Install window guards; never leave a window wide open.

Check AnswerSolution[D]:- To prevent falls, install window guards and never leave a window wide open. A ribbon can become entangled around a small child’s neck, causing asphyxiation. Young children can easily choke on a grape. Firearms should be unloaded, but stored in a locked cabinet. Children are curious and like to explore and climb. It would not be too difficult for a child to find a firearm stored, for example, on a high closet shelf.

• (A) Call 9-1-1.
• (B) Encourage the person to cough vigorously.
• (C) Ask, “Are you choking?”
• (D) Give five back blows.

Check AnswerSolution[C]:- Clutching the throat is the universal sign of choking. The first action when you suspect airway obstruction is to ask, “Are you choking?” If the person indicates “yes,” or if the person cannot cough, speak, or breathe, that indicates choking. You must first be certain the person is choking because you can cause harm when you perform the choking maneuver. You would not call 9-1-1, encourage coughing, or give five back blows until you first establish that the person is choking. The client appears to be giving the universal sign for choking, but the nurse must validate the client’s meaning before acting.