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Nursing Practice i edgeworth | Urinary Incontinence | Urination

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this all of my documents i use in my NLE and NCLEX just want to share to our coleagues and students.. i feel blessed so share my blessings to all of u guys..just leave a comment and i apprc8 all : ) thank u.. : D u can download it and save it in ur p.c.. : )
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  NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice Situation 1 – Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon whocame in with asthma. She has difficulty breathing and her respiratory rate is 40 per minute. Mr. Ibarra is asked to inject theclient epinephrine 0.3 mg subcutaneously.1. The indication for epinephrine injection for Mrs. Simon is to:A. Reduce anaphylaxisB. Relieve hypersensitivity to allergenC. Relieve respiratory distress due to bronchial spasmD. Restore client’s cardiac rhythm2. When preparing the epinephrine injection from an ampule, the nurse initially:A. Taps the ampule at the top to allow fluid to flow to the base of the ampuleB. Checks expiration date of the medication ampuleC. Removes needle cap of syringe and pulls plunger to expel air D. Breaks the neck of the ampule with a gauze wrapped around it3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to:A. Inject needle at a 15 degree angle over the stretched skin of the clientB. Pinch skin at the injection site and use airlock techniqueC. Pull skin of patient down to administer the drug in a Z trackD. Spread skin or pinch at the injection site and inject needle at a 45-90 degree angle4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be:A. Syringe 3-5 ml and needle gauge 21 to 23B. Tuberculin syringe 1 ml with needle gauge 26 or 27C. Syringe 2 ml and needle gauge 22D. Syringe 1-3 ml and needle gauge 25 to 275. The rationale for giving medications through the subcutaneous route is:A. There are many alternative sites for subcutaneous injectionB. Absorption time of the medicine is slower C. There are less pain receptors in this areaD. The medication can be injected while the client is in any positionSituation 2 – The use of massage and meditation to help decrease stress and pain have been strongly recommendedbased on documented testimonials.6. Martha wants to do a study on this topic: “Effects of massage and meditation on stress and pain”. The type of researchthat best suits this topic is:A. Applied researchB. Qualitative researchC. Basic researchD. Quantitative research7. The type of research design that does not manipulate independent variable is:A. Experimental designB. Quasi-experimental designC. Non-experimental designD. Quantitative design8. This research topic has the potential to contribute to nursing because it seeks toA. include new modalities of careB. resolve a clinical problemC. clarify an ambiguous modality of careD. enhance client care9. Martha does review of related literature for the purpose of A. determine statistical treatment of data researchB. gathering data about what is already known or unknown about the problemC. to identify if problem can be replicatedD. answering the research question10. Client’s rights should be protected when doing research using human subjects. Martha identifies these rights asfollows EXCEPT:A. right of self-determinationB. right to compensationC. right of privacyD. right not to be harmedSituation 3 – Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at riskfor infection because of retained secretions. Part of Nurse Mario’s nursing care plan is to loosen and remove excessivesecretions in the airway.  11. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriateposition to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:A. Client lying on his back then flat on his abdomen on Trendelenburg positionB. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on hisabdomenC. Client lying flat on his back and then flat on his abdomenD. Client lying on his right then left side on Trendelenburg position12. When documenting outcome of Richard’s treatment Mario should include the following in his recording EXCEPT:A. Color, amount and consistency of sputumB. Character of breath sounds and respiratory rate before and after procedureC. Amount of fluid intake of client before and after the procedureD. Significant changes in vital signs13. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on thefollowing EXCEPT:A. Amount of food and fluid taken during the last meal before treatmentB. Respiratory rate, breath sounds and location of congestionC. Teaching the client’s relatives to perform the procedureD. Doctor’s order regarding position restrictions and client’s tolerance for lying flat14. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration whendoing the procedure?A. Respiratory rate of 16 to 20 per minuteB. Client can tolerate sitting and lying positionsC. Client has no signs of infectionD. Time of last food and fluid intake of the client15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between theprocedures is:A. Percussion uses only one hand while vibration uses both handsB. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose onthe exhalation cycleC. In both percussion and vibration the hands are on top of each other and hand action is in tune with client’s breathrhythmD. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air Situation 4 – A 61 year old man, Mr. Regalado, is admitted to the private ward for observation after complaints of severechest pain. You are assigned to take care of the client.16. When doing an initial assessment, the best way for you to identify the client’s priority problem is to:A. Interview the client for chief complaints and other symptomsB. Talk to the relatives to gather data about history of illnessC. Do auscultation to check for chest congestionD. Do a physical examination while asking the client relevant questions17. Upon establishing Mr. Regalado’s nursing needs, the next nursing approach would be to:A. Introduce the client to the ward staff to put the client and family at easeB. Give client and relatives a brief tour of the physical set up the unitC. Take his vital signs for a baseline assessmentD. Establish priority needs and implement appropriate interventions18. Mr. Regalado says he has “trouble going to sleep”. In order to plan your nursing intervention you will:A. Observe his sleeping patterns in the next few daysB. Ask him what he means by this statementC. Check his physical environment to decrease noise levelD. Take his blood pressure before sleeping and upon waking up19. Mr. Regalado’s lower extremities are swollen and shiny. He has pitting pedal edema. When taking care of Mr.Regalado, which of the following interventions would be the most appropriate immediate nursing approach?A. Moisturize lower extremities to prevent skin irritationB. Measure fluid intake and output to decrease edemaC. Elevate lower extremities for postural drainageD. Provide the client a list of food low in sodium20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for dischargeinclude all EXCEPT:A. Making a final physical assessment before client leaves the hospitalB. Giving instructions about his medication regimenC. Walking the client to the hospital exit to ensure his safetyD. Proper recording of pertinent data  Situation 5 – Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told that she has breast cysts andthat she may need surgery. This causes her anxiety as shown by increase in her pulse and respiratory rate, sweating andfeelings of tension.21. Considering her level of anxiety, the nurse can best assist Nancy by:A. Giving her activities to divert her attentionB. Giving detailed explanations about the treatments she will undergoC. Preparing her and her family in case surgery is not successfulD. Giving her clear but brief information at the level of her understanding22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left alone, refusing to eat or talkto her family. A religious person before, she now refuses to pray or go to church stating that God has abandoned her. Thenurse understands that Nancy is grieving for her self and is in the stage of:A. bargainingB. denialC. anger D. acceptance23. The nurse visits Nancy and prods her to eat her food. Nancy replies “what’s the use? My time is running out.” Thenurse’s best response would be:A. “The doctor ordered full diet for you so that you will be strong for surgery”B. “I understand how you feel but you have to try for your children’s sake”C. “Have you told your doctor how you feel? Are you changing your mind about your surgery?”D. “You sound like you are giving up.”24. The nurse feels sad about Nancy’s illness and tells her head nurse during the end of shift endorsement that “it’s unfair for Nancy to have cancer when she is still so young and with two kids”. The best response of the head nurse would be:A. Advise the nurse to “be strong and learn to control her feelings”B. Assign the nurse to another client to avoid sympathy for the clientC. Reassure the nurse that the client has hope if she goes through all treatments prescribed for her D. Ask the other nurses what they feel about the patient to find out if they share the same feelings25. Realizing that she feels angry about Nancy’s condition, the nurse learns that being self-aware is a conscious processthat she should do in any situation like this because:A. This is a necessary part of the nurse – client relationship processB. The nurse is a role model for the client and should be strongC. How the nurse thinks and feels affect her actions towards her client and her workD. The nurse has to be therapeutic at all times and should not be affectedSituation 6 – Mrs. Seva, 52 years old, asks you about possible problems regarding her elimination now that she is in themenopausal stage.26. Instruction on health promotion regarding urinary elimination is important. Which would you include?A. Hold urine as long as she can before emptying the bladder to strengthen her sphincter musclesB. If burning sensation is experienced while voiding, drink pineapple juiceC. After urination, wipe from anal area up towards the pubisD. Tell client to empty the bladder at each voiding27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what physical changes predisposeher to constipation?A. inhibition of the parasympathetic reflexB. weakness of sphincter muscles of anusC. loss of tone of the smooth muscles of the colonD. decreased ability to absorb fluids in the lower intestines28. The nurse understands that one of these factors contributes to constipation:A. excessive exerciseB. high fiber dietC. no regular time for defecation dailyD. prolonged use of laxatives29. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezingand when she has a full bladder. Your most appropriate instruction would be to:A. tell client to drink less fluids to avoid accidentsB. instruct client to start wearing thin adult diapersC. ask the client to bring change of underwear “just in case”D. teach client pelvic exercise to strengthen perineal muscles30. Mrs. Seva asked for instructions for skin care for her mother who has urinary incontinence and is almost always inbed. Your instruction would focus on prevention of skin irritation and breakdown by:A. Using thick diapers to absorb urine wellB. Drying the skin with baby powder to prevent or mask the smell of ammoniaC. Thorough washing, rising and drying of skin area that get wet with urineD. Making sure that linen are smooth and dry at all times  Situation 7 – Using Maslow’s need theory, Airway, Breathing and Circulation are the physiological needs vital to life. Thenurse’s knowledge and ability to identify and immediately intervene to meet these needs is important to save lives.31. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues:A. Carol with tumor in the brainB. Theresa with anemiaC. Sonnyboy with a fracture in the femur D. Brigitte with diarrhea32. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in the blood. This condition iscalled:A. CyanosisB. HypoxiaC. HypoxemiaD. Anemia33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adultwould be:A. tip of the nose to the base of the neckB. the distance from the tip of the nose to the middle of the neckC. the distance from the tip of the nose to the tip of the ear lobeD. eight to ten inches34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:A. Apply suction for at least 20-30 seconds each time to ensure that all secretions are removedB. Using gloves to prevent introduction of pathogens to the respiratory systemC. Applying no suction while inserting the catheter D. Rotating catheter as it is inserter with gentle suction35. Myrna has difficulty breathing when on her back and must sit upright in bed to breath effectively and comfortably. Thenurse documents this condition as:A. ApneaB. OrthopneaC. DyspneaD. TachypneaSituation 8 – You are assigned to screen for hypertension. Your task is to take blood pressure readings and you areinformed about avoiding the common mistakes in BP taking that lead to false or inaccurate blood pressure readings.36. When taking blood pressure reading the cuff should be:A. deflated fully then immediately start second reading for same clientB. deflated quickly after inflating up to 180 mmHgC. large enough to wrap around upper arm of the adult client 1 cm above brachial arteryD. inflated to 30 mmHg above the estimated systolic BP based on palpation of radial or bronchial artery37. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death world wide and is apreventable disease. The primary cause of COPD isA. tobacco hackB. bronchitisC. asthmaD. cigarette smoking38. In your health education class for clients with diabetes you teach them the areas for control of Diabetes which includeall EXCEPTA. regular physical activityB. thorough knowledge of foot careC. prevention nutritionD. proper nutrition39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes. Which of the following istrue?A. both types diabetes mellitus clients are all prone to developing ketosisB. Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic inetiologyC. Type I (IIDM) is characterized by fasting hyperglycemiaD. Type II (NIDDM) is characterized by abnormal immune response40. Lifestyle-related diseases in general share areas common risk factors. These are the following except:A. physical activityB. smokingC. geneticsD. nutrition
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