Title EVAL EXAM - FUNDA 2 (KEY) ✅

TOP RANK REVIEW ACADEMY, INC. Page 2 | a. Florence Nightingale c. Imogene King b. Martha Rogers d. Betty Neuman Stress reduction is goal of systems model of nursing practice. These govern the levels of prevention: primary, secondary, or tertiary level. The goal of nursing is to assist individuals, families, and groups in attaining and maintaining maximal level of total wellness by purposeful interventions. 14. (33) Which of the following arterial blood gases (ABGs) should the nurse anticipate in the client with a nasogastric tube attached to continuous suction? a. pH 7.25 PCO2 55, HCO3 24 b. pH 7.49 PCO2 38, HCO3 30 c. pH 7.30 PCO2 38, HCO3 20 d. pH 7.48 PCO2 30, HCO3 23 15. (21) A nurse is providing discharge instructions to a client on the use of crutches. Which of the following statements from the client indicates that she needs further teaching from the nurse? a. “If my crutch gets broken, I should use my relative’s crutch as replacement.” b. “I can attach rubber tips to the crutches to increase surface friction with the ground.” c. “I should hold the crutches in a way that my axillae do not bear my body weight.” d. “My elbows should be a bit flexed if the crutch measurements are accurate.” 16. (39) A patient with crutches assuming a tripod position should place his crutches ____ to the side of each of his foot. a. 6 cm c. 3 inches b. 15 cm d. 10 inches 17. (6) Because of using ill-fitted crutches, a patient manifests Erb’s palsy or waiter’s tip. This is caused by the damage of which of the following? a. Sciatic nerve c. Obturator nerve b. Cervical plexus d. Brachial plexus 18. (47) What should be the distance between the axilla and the crutch pad? a. 1-2 fingerbreadths c. 3-4 fingerbreadths b. 5-8 fingerbreadths d. 6 inches 19. (40)To keep herself feeling cool, Nurse Anna stands in front of an electric fan. This process of promoting heat loss is an example of: a. Radiation c. Conduction b. Convection d. Evaporation 20. (8) Which among the following will not promote heat loss? a. Dipping in the pool b. Curling up in a fetal position c. Wearing clothes made of thin material d. Wiping the body with a wet towel 21. (31) A nurse was able to palpate a patient’s pulse at the area above and lateral to the right eye. She will noted this as the patient’s: a. Brachial pulse c. Carotid pulse b. Apical pulse d. Temporal pulse 22. (41) A full or strong pulse is usually graded as: a. +4 c. +2 b. +3 d. +1 23. (43) Which of these factors does a nurse not expect to cause an increase in a patient’s pulse rate? a. Intake of digitalis b. Jogging for 2 kilometers c. Fever with temperature of 38.5 o C d. Hemorrhage 24. (11) Nurse Rona is assigned in the emergency room to assess the vital signs of the patients. Which of the following actions of Rona in taking the blood pressure (BP) will cause a falsely high result? a. Using a BP cuff that is too wide b. Applying the stethoscope too firmly against the antecubital fossa c. Placing the arm below the heart level d. All of the above 25. (35) The medical ward nurse is using an electronic BP machine to assess for Patient G’s blood pressure. However, the machine is unable to measure the patient’s blood pressure. What should be the FIRST action of the nurse? a. Institute cardiopulmonary resuscitation. b. Tighten blood pressure cuff. c. Check machine connections. d. Notify the physician. 26. (7)A rectal temperature is a close measurement of the body temperature. How would Nurse Vivian be able to insert the rectal thermometer in an adult patient properly? a. Ask the patient to inhale and hold breath during insertion. b. Ask the patient to pant fast while inserting the thermometer. c. Forcefully insert the thermometer towards the direction of the symphysis pubis. d. Apply a liberal portion of lubricant to cover at least 1 to 1 ½ inches of the thermometer. 27. (18) A pulse oximeter and an electronic blood pressure are used in a patient who had stroke two hours prior to confinement. What would be the best nursing action of Nurse Jillian in measuring the patient’s pulse oximetry? a. Because nail polish does not affect determination of the S a O 2 , it is alright to leave the patient’s painted nails as they are. b. Place the pulse oximeter on the same extremity as the electronic blood pressure. c. If the SaO2 reveals 97%, the doctor should be notified immediately. d. Cover the pulse oximeter with a cloth to protect it from sunlight. 28. (10) After endorsements, you receive the following four patients. Which among them should you assess FIRST?