Recalls 8: Nursing Practice 2 PDF

RECALLS 8: NURSING PRACTICE 2 Situation 1 Nurse Trining has been assigned to the pediatric ward for two years. She wants to join the team of nurses who Additional notes: will be conducting a study on sleep. The team leader wants to Types of breech presentation: be assured that...

RECALLS 8: NURSING PRACTICE 2 Situation 1 Nurse Trining has been assigned to the pediatric ward for two years. She wants to join the team of nurses who Additional notes: will be conducting a study on sleep. The team leader wants to Types of breech presentation: be assured that the nurse Trining is equipped with the basic Complete knowledge of nursing research. Frank Footling 1. The team leader decided to ask Nurse Trining the meaning of informed consent. After being able to define what the term means, she was further asked the reasons for its use. Nurse 6. Patient Presley asks the nurse why such a diagnostic Trining’s answer should be, which of the following? procedure is required. What is the MOST APPROPRIATE 1. To fully understand what the research is all about and answer can the nurse give? what will happen should the participants opt to involve A. Urinary tract infections are strongly associated with the themselves in the research study. occurrence of preterm labor. 2. To get assurance that participants have the right to B. Reduced sensation to urinate usually occurs during preterm withdraw from participating in the research at any given labor. time. C. Preterm labor treatment usually causes women bladder 3. To get complete and full information as to the objective infection because of restricted fluid intake. - does not of the study, procedures to be implemented, data restricts fluids unless the pregnant will undergo CS; NPO is collection, benefits and harm and options in the method possible as long as the patient is hooked to IVF of treatment. D. Catheterized urine is usually ordered for any woman 4. To get assurance how anonymity and confidentiality admitted to the labor and delivery unit. will be maintained. A. 1, 2 & 3 7. Betamethasone (Celestone) is prescribed to be administered B. 2 only and the patient asks nurse Hope about the purpose of this C. 1, 2, 3 & 4 medication? D. 3 only A. Promote fetal lung maturity. B. Prevent the premature closure of the ductus arteriosus. C. Delay delivery for at least 48 hours, Rationale: the nurse will sign as a witness; the nurse can D. Stop the premature uterine contractions. obtain a consent especially if they will be the one performing the procedure 8. Patient Presley, who is ordered for diagnostic pelvic ultrasounds, asks what preparation she’ll take. Appropriate 2. As to the observance of respecting privacy, Nurse Trining preparations for this procedure include___. explained about____. A. explanation of the procedure - done in all procedures A. breach of contract B. NPO 6 hours before - is not necessary B. anonymity C. Informed consent - this is not invasive C. ethical dilemma D. voiding D. confidentiality Rationale: According to Pilliteri, full bladder is needed for Rationale: Privacy: stability of the uterus in diagnostic pelvic ultrasound → Personal Identity (name) especially for 2nd trimester → Procedures → 1st trimester - best UTZ is tranvaginal (probe inserted to → Parts of the body (putting drape, closing of doors and vagina); uterus still inside the pelvis curtains) → 2nd trimester - full bladder → 3rd trimester - empty bladder to avoid puncture of 3. In nursing, Nurse Trining explained that the main GOAL of bladder/bladder may become a hindrance conducting research is to____. A. justify the role of nurses as health care provider 9. Pelvic ultrasound can detect, which of the following? B. establish a credible body of evidence to support and A. Congenital defects in the structure, fetal gender, H- improve the delivery of care. mole - snowflake pattern w/o fetal growth C. identify research priorities that will justify the oversupply of B. Fetal sex, number, and lung maturity - fetal gender will be nurses. - there will be lack of nurses by 2030, Kozier identified at 16th week D. develop a body of knowledge to address non-nursing C. Fetal DM, multiple pregnancies, fetal age of gestation problems D. Fetal congenital defects, placenta previa, fetal lung maturity - it cannot detect fetal lung maturity; should be LS ratio 4. In conducting a study on sleep, Nurse Trining was asked acquired by amniocentesis which of the types of research will be used should it involve collecting numerical data which is the most often under Additional note: Fetal maturity: considerable control. Her answer should be_____ Measure biparietal diameter: >8.5cm A. Ethnographic - ethinic groups Head Circumference: >34.5 cm - indicates 40 B. Phenomenological - lived experiences weeker/mature fetus C. Qualitative D. Quantitative 10. The labor progressed and the physician performed an 5. Should a 24-hour period of clinical observation and activities amniotomy. Nurse Hope should FIRST assess for: be considered in conducting the research on sleep, the type of A. bladder distention study that training will be conducting is___. B. maternal blood pressure A. Quantitative C. cervical dilatation B. Descriptive - describe variables D. fetal heart rate (FHR) pattern - to assess for fetal distress C. Ethnological D. Exploratory Rationale: artificial rupture of bag with use of amnihook for the labor to progress so that the baby will descend and Situation 2: Presley enters the labor and delivery unit in increase uterine contraction probable preterm labor at 36 weeks’ gestation. The patient WOF: was informed that the fetus is in breech presentation. She has → Cord prolapse - unang bumaba yung cord after rupture a catheterized urine specimen ordered. of BOW → Cord compression - fetal descend → naipit cord → seen through FHR pattern RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 → Early decelerations - head compression (normal) data → Variable decelerations - cord compression → Late decelerations - utero placental insufficiency 17. The objective of taking the history of present illness is to elicit the chronologic description of the chief complaint. Which of the following questions would try to answer what Nurse Nanie Situation 3: Sienna, a patient with severe preeclampsia is wishes to elicit? admitted to the hospital. She is a student from one of the local 1. History of immunizations - included in past medical universities and insists on continuing studies while in the history hospital, despite being instructed to rest. The patient studies 2. Aggravating and alleviating factors approximately 10 hours a day and has numerous visits from 3. Duration of disease onset fellow students, family and friends. 4. Any treatment and response to treatment A. 1, 2, & 3 11. Which intervention should the nurse use to promote rest? B. 2, 3 & 4 A. Develop a routine with the patient to balance her studies C. 1, 2, 3, & 4 and her rest needs. D. 1, 2, & 3 B. Include a significant other in helping the patients understand the need for rest. Rationale: use of COLDSPA (Characteristics, Onset, C. Instruct the patients that the baby’s health is more important Location, Duration, Severity, Predisposing/Precipitating than her studies at this time. Factors, Associated Symptoms) or PQRST during history D. Ask her why she is not complying with the prescription of taking bed rest. 12. Patient Sienna who seemed to be irritated with the nurse said 18. Past medical history section of Krini contains the following, “I don’t want to talk with you because you’re only a nurse. I will but NOT____. wait for my doctor.” Which of the following should the nurse say A. Prenatal history in response to the patient? B. Childhood illness A. Your doctor prescribed this for us to do nursing care. C. Current history B. I understand. I should call your doctor. D. Birth history C. I’m angry with the way you dismiss me. D. So then you would prefer to speak with your doctor? 19. Which of the following statements is TRUE? A. History taking must be long regardless if the child appears to be well. Rationale: If the patient is anxious → allow verbalization → to B. No proper history can be obtained without observation of be able to assess the coping mechanism of the patient and the child and the mother. alleviate anxiety C. Nurse Nanie should refrain from asking about the illness of other members of the family. - family history is being asked 13. Nurse Mauve is now in an ethical dilemma. This occurs D. An example of what can be elicited from a social history when____. is how the disease started. A. a decision had to be made quickly under stressful situation B. choices are unclear Rationale: to know precipitating/predisposing factors (if the C. there is a conflict between the nurse’s decision and that of child went to daycare center, playroom, who came near his/her superior children who are ill, lifestyle, diet, and nutrition); to have a clue D. there is a conflict of two or more ethical principles on how the disease started 14. Despite the reaction of the patient. Which of the ethical principles is that the nurse is responsible for providing all 20. In order not to frighten small children, it is best to examine patients with caring attention and information? things that are uncomfortable or frightening to them last so as A. Beneficence not to lose their cooperation. This means the LAST thing to do B. Nonmaleficence - promoting safety in a child is, which of the following, EXCEPT___. C. Veracity A. Inspections of the throat with a throat stick D. Advocacy B. Inspection of the ears with an otoscope C. Auscultation of the heart 15. Nurse Mauve should plan to initiate which action to provide D. Undressing the child a safe environment? A. Take the patient’s vital signs every 4 hours. Rationale: B. Encourage visits from family and friends for psychosocial → Assessment of a child: from distal to proximal; head to toe support - the patient should rest → Fear: body mutilation C. Maintain fluid and sodium restrictions. They get scared of seeing new things especially D. Take off the room lights and draw the window shades. when you place it near them or use it to assess them → Options AB are done last Rationale: should not be lights off because VS will be assessed every hour; light trigger seizure Situation 5: Ximena a Christian 29-year-old pregnant woman, was admitted to the hospital with a complaint of moderate Situation 4: Nurse Nanie is admitting five-year-old Krini due hypogastric pain. She intends to visit the clinic for her first to cough, respiratory distress, anxiety and signs of prenatal check-up and informs nurse Parker that she did not dehydration. The working diagnosis is pneumonia. realize she’s pregnant until a week ago. As a result, she has been on a diet, weightlifting at the health gym. 16. Nurse Nanie is aware that history taking and physical exams are critical to the diagnostic process and often provide 21. Patient Ximena was seen by the physician and was ordered more information than can be gained by broad testing strategies. for a medication that is larger than the standard dose. What History taking includes the following, EXCEPT___. should the nurse do with medication that is larger than the A. History of present illness standard dose? B. Religious affiliation A. Give a drug as prescribed - not concerned to the patient C. Social & Family history B. Inform the supervisor D. Past medical history C. Give the average dose of the medication D. Discuss the prescription with the physician Rationale: religious affiliation is included in the biographic RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 22. The patient refuses to take the medication because it causes 28. The newly hired nurse asks for advice from the supervisor. diarrhea. Nurse Parker explains the action of the drug but the The supervisors notices that the newly hired nurse felt uneasy patient vehemently refuses the medication. What should be the upon learning that the fetus is on breech presentation. Which of INITIAL action of the nurse? the following is the BEST RESPONSE by the supervisors? A. Discuss with a family member the need for the patient to A. “ I understand how you feel. Tell me more.” take the medication. B. “ Is this your first time to witness a breech presentation” B. Document the patient’s refusal to take the medication C. “Are you afraid to assist the case” C. Notify the physician of the patient’s refusal to take the D. “Don’t worry. There’s always a first time”. medication D. Explain again to the patient the consequences of Rationale: with verbalization refusing to take the medication 29. After the successful vaginal delivery, medication was Rationale: When patient refuses: ordered to be given immediately. The supervisors reassured the 1. Explain what is the S/E of the drug newly hired nurse that everything will be fine because the 2. Explain consequences (Kozier) medication will___. 3. Tell the MD A. Promote vasoconstriction of uterine muscles To explain again or continue the drug or discontinue B. hasten uterine contractility and control and control 4. Document bleeding C. facilitate the return of pregnancy vital signs 23. As a strong believer of her faith and the need for spiritual guidance, patient Ximena requests that she wants that allergy to Rationale: oxytocin is given for uterus to contract (prevent visit her. How did nurse Parker function when she initiated the atony) and prevent bleeding visit? → Hypotension - IV bolus A. Dependently - needs doctor’s order → Hypertension - IV infusion B. collegially - co-nurses C. Interdependently - different disciplines D. Independently - can be done w/o doctor’s order 30. The newly – hired nurse oriented the caregiver hired by the couple. Which of the following should a nurse encourage the 24. Patient Ximena sought referral to an abortion clinic from the parents to do? nurse. Reasons out that her pregnancy is a burden to her work A. Relate to each twin individually to enhance the and daily routines. What should be the BEST RESPONSE of the attachment process. nurse? B. Avoid assistance from other family members and support A. It will cause discrimination from friends and relatives. groups B. Inform her that abortion is morally and legally wrong by C. Bottle-feed the twins to prevent maternal exhaustion - X milk virtue of the law code C. It will cause infection A. XD. plan for each parent to spend equal amounts of time D. It is against any religion with each twin Rationale: unacceptable in the PH and is morally and legally Situation 7: Lillian 2-week postpartum mother is seen in the wrong by virtue of the law health center. Redness on the left breast, and the mother is diagnosed with mastitis. 25. The incoming nurse on duty reported, the nurse is administering medication. The patient says, “This pill looks 31. Which additional finding confirms the diagnosis that the different from the one I had taken before.“ What is the patient has mastitis? APPROPRIATE action of the nurse? A. Enlarged glands in the axilla - possible of cancer A. Explain the purpose of the medication B. Normal temperature - should be with fever →infection B. Encourage the patients to take the medication C. Engorged both breasts - d/t milk filling at 2nd day C. Check the original medication prescription postpartum; normal D. Ask what the other pill looked like D. Hard mass and reddened area Situation 6: A newly hired nurse is assigned in the OB ward. Rationale: Cause of mastitis: Nipple crack → entry of She was supervised by a senior nurse. microorganisms → Breastfeeding should be started within 7 days → Staphylococcus aureus, normal flora 26. She was asked by the nurse supervisor about her concern → E. Coli: due to improper hand washing when changing and what are the considered ideal fetal positions for a healthy perineal pads delivery? → DOC: Doxycycline and cephalosporin A. Right occipitoposterior with no flexion → Unilateral B. Right occipitoposterior with full flexion - vertex C. Left transverse anterior in moderate flexion - shoulder presentation; for CS delivery 32. Lillian asks the nurse the cause of these ailments. Which of D. Left sacroanterior with full flexion - breech the following would the nurse explain as predisposing factors of mastitis? (Select all that apply) I. Milk stasis - causes engorgement Additional Note: partial flexion - sinciput II. Nipple trauma III. Using alcohol in cleaning nipples - causes drying; more 27. The physician ordered sonography. The nurse informs the prone to nipple cracks; use of soap ultrasounds unit in charge and prepares the patients for the IV. Baby’s sitting position - if latching is not proper procedure. The patient asks the importance of the procedure, A. II and IV the nurse’s CORRECT response is____. B. I and IV A. to determine diameters of the fetal skull C. I and II B. increase sensitivity for common bile duct of the fetus - this D. II and III will be hard to visualize in the UTZ C. useful to a visualized cystic duct of the foetus Rationale: Prevention: D. to assess fetal’ well-being → Air drying → Well fitted bra and breast pads → Vitamin E → hand hygiene RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 33. Lillian complains of an unbearable plain. Which of the D. Begins after 48 hours of life following characteristics are EMPHASIZED in a culturally sensitive nursing care? (Select all that apply) Rationale: I. The expression of pain is affected by learned behavior → First 24 hours of life - pathologic II. physiologically, all individuals experience pain in a → 2-3 days - physiologic jaundice similar manner. → Once the baby starts to breastfeed and lasts for 7 days III. Some Asian people have a high response to pain → Immature liver → glucuronyl transferase → unconjugated medications. → conjugated → bilirubin IV. Patients should be assessed for plain regardless of Have laxative effect conjugated bilirubin goes with overt symptomatology. the feces and eventually it will stimulate to develop A. III and IV glucuronyl transferase B. I and II C. I and III D. II and III 39. Neonatal jaundice FIRST becomes visible in which of the following parts? (Select all that apply) 34. Nurse Addison provides instructions about measures to 1. Face prevent postpartum mastitis from breastfeeding her newborn. 2. Forehead Which of the following would indicate that the mother needs 3. Trunk further instruction? “ I should__. 4. Extremities A. wash my hands well before breastfeeding A. 3 & 4 B. breastfeed every 2- 3 hours - continuous breastfeeding; we B. 1 & 2 do not stop breastfeeding unless there is abscess formation C. 1 & 4 C. change the breast pads frequently - open area will happen D. 2 & 3 if this will not be changed frequently D. wash my nipples with soap and water prior to feeding 40. When caring for patients with hyperbilirubinemia, the nursing care plan should focus on the following, EXCEPT_____. 35. Considering her level of knowledge and the anxiety of her A. informing appropriately the significant others condition, patient Lillian raised questions on possible ways of B. preventing injury - cover eyes and genitalia; WOF: relieving her breast discomfort. Which of the statements NEEDS temperature further instructions? C. maintaining physiological homeostasis with bilirubin levels A. “ I have to stop breastfeeding until this condition increasing resolves.” D. preventing complications B. “ I can take antibiotics, and should begin to feel better in 24 to 48 hours.” Rationale: concerned by the MD C. “I can use analgesics to assist in alleviating some of these discomforts.” D. “ I have to wear a supportive bra to relieve the discomfort.” Situation 9: Lily, 23-year-old pregnant woman, 37th week’s gestation, is admitted in the intensive care unit due Situation 8: Nurse Lyca is assigned to the Nursery. She is paroxysmal ventricular tachycardia. The patient is performing newborn assessment on a baby Boy Pratts born conscious; cervix is open so they decided to induce labor. at 40 weeks gestation. 41. When the patient was informed about induction, she asked 36. Using APCAR Score, Nurse Lyca should bear in mind that Nurse Aurora what it was all about. Which of the following this method of evaluating a newborn’s condition is used at how statements by the nurse is correct? Inductions is a____ many minutes after birth? A. local anesthesia used for blocking pain during episiotomy A. 1 to 10 stimulate labor B. 1 to 3 B. deliberate initiation of uterine contractions that C. 1 to 7 stimulates labor D. 1 to 5 C. medication injected into the subarachnoid space and has a rapid onset of action D. procedure performed by artificial rupture of the membranes Rationale: APGAR is done during: - can be used in induction of labor, but it is called surgical → 1st minute of life - t is normal if the score is low because induction this is just a reaction to the labor and delivery → 1st 5 minutes of life - determines adjustment to the extra-uterine life Rationale: induce labor is permitted when there’s good result: 8-10 cardiovascular disease, diabetes mellitus 7-4 - further 0-3 - resuscitation 42. Which of the following statements is NOT an indication for any uterine stimulants (Oxytocin)? 37. Nurse Lyca is aware that testing of vision in infants and A. Preinduction of cervical ripening children has been treated separately from the testing adult. B. Controlling postpartum bleeding Which of the statements is not true? C. Inducing or augmenting labor a. Infants and children often cannot be tested with the same D. Manages an incomplete abortion - if >14 weeks medication materials and techniques as adults. will suffice b. Special techniques often must be used, especially to standards that apply to tests for adults. Rationale: The cervix will not respond in the labor if it’s not c. Some infants who appear visually impaired early in life ripe will not show normal visual responses several weeks or months later. Additional Note: d. Courses of visual and cognitive development must be taken → Induction - to start labor into account in evaluating infants’ and children’s visual → Augmenting - to help/assist labor (kulang contraction) abilities. → Abortion 8 - ripened cervix 4. Sim → Lidocaine is diluted with D5 water A. 1, 2 and 3 B. 2 only 43. Oxytocin drip was started to induce labor. Which assessment C. 1 & 2 findings should cause the nurse to IMMEDIATELY discontinue D. 1 only the oxytocin infusion? (SELECT ALL THAT APPLY) I. Fatigue and drowsiness 48. Usually the common indication (s) for the tracheostomy in II. Early decelerations of the fetal heart rate - head patients Irma’s condition is which of the following? (SELECT ALL compression THAT APPLY) III. Uterine hyperstimulation - duration of the contraction is 1. Prolonged intubation - first indication of tracheostomy 120 secs; baby does not oxygenate anymore; 2. Sepsis - antibiotic possibility of rupture of uterus; frequency 5 or more in 3. Hypoventilation associated with neurologic disorders - 10 minutes; interval is below 60 seconds between 2 CPAP contractions 4. Severe sleep Obstructive Apnea Syndrome (SOAS) - IV. Late decelerations of the fetal heart rate - after CPAP contractions; super abnormal; the blood coming to the A. 2 only baby is insufficient B. 1 & 2 A. III and IV C. 1, 2, 3 & 4 B. II and III D. 1 only C. I and III D. I and II Additional Note: 2nd indication of tracheostomy - for airway (emergency cases) Rationale: headache and vomiting rather than fatigue and drowsiness → resulting from water intoxication 49. The PRIORITY nursing objective when caring a patient with a tracheostomy is____ 44. Simultaneous with the oxytocin drip (left arm) is the A. To increase tissue oxygenation prescribed intravenous (IV) lidocaine (Xylocaine). Nurse Aurora B. To provide patient airway should dilute the concentrated solution of lidocaine (right arm) C. To decrease tissue oxygenation with which solution? D. To improve ventilation A. 5 percent Dextrose in water B. Normal saline 0.99 percent Rationale: patent airway → increased oxygenation C. Normal saline 0.45 percent D. Lactated Ringer’s 50. The Top nursing expected outcome performing suctioning is___ Rationale: A. Lessened amount of secretions leading to decreased frequency of suctioning 45. Take home medications given to patient Lily includes B. Secretions removed without complication digitalis therapy which was given to patients since she was C. Tube-fed patient does not aspirate feeding - not related pregnant. Which of the following would the nurse anticipate with D. Prevention of occurrence of hypoxemia and bradycardia. - the patient's drug therapy? complications due to vasovagal response A. Switching to a more potent drug B. Continuation of the same dosage Situation 11: Sonny, 11-year-old, is admitted due to C. Need for change in medication bronchitis. Upon production of mucus (sputum), yellowish in D. Addition of diuretic to the regimen color, fatigue, shortness of breath, slight fever and chills and chest discomfort. The physician orders 41/min oxygenation. Rationale: → Fluid volume will increase (starts at 2nd trimester)→ least 51. The first standard step in oxygen therapy that the nurse effective ang digitalis therapy → need for an additional should do is___. diuretic A. assess client’s condition → Options AC are the same B. gather all the equipment and supplies C. prepare the client for the oxygen treatment D. check the chart for ordered flow rate and oxygen Situation 10: The indication of tracheostomy in children has delivery method changed care of patient Irma, an eight-year-old female child, who was admitted to the pediatric ward due to pneumonia. 52. In planning for Sonny’s oxygen therapy the nurse should The child is taking care of this patient being her first day of consider which of the following EXCEPT___ duty in the pediatric Ward. A. Need for a humidifier B. length of tubing - it has a standard length 46. When preparing the patient for suctioning, what is the FIRST C. determine the age of Excel step? D. manner of administering oxygen, continuous or intermittent A. Perform hand hygiene B. Gather equipment 53. Which of the following is the PRIORITY action for the nurse C. Assess lung sounds, heart rate and care plan for Sonny who is on oxygen therapy? D. Check physician’s order and patient care plan A. Check the flow B. Connect the flow mater to the pipe oxygen outlet Rationale: check for considerations first C. turn on the oxygen D. attach the humidifier and connecting tubing to the oxygen delivery Rationale: Make sure you are delivering oxygen to the patient RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 54. What PRIORITY precautionary measure should be done by 57. Nurse Reese is preparing the patient assignment for the day the nurse during the oxygen therapy? and needs to assign a patient to the midwife and nursing A. Humidifier’s water should be checked regularly assistant. Which patient should the nurse assign to the midwife B. No smoking sign because of patient needs that cannot be met by the nursing C. Oxygen tank should had belt assistant? A patient requiring____. D. Limit visitors a. dressing change of post cesarean surgery - only done by the midwife b. collecting of urine specimen for urinalysis testing Rationale: c. performing range-of-motion exercise twice a day d. taking of vital signs measurement every 4 hours Rationale: Options BCD can be done by both midwife and nursing assistant 58. Because of the scarcity of nurses in the hospital settings, different service delivery models were proposed. Which situation represents the primary nursing care delivery model? A. The nursing aide is assigned to make beds and other errands. - functional nursing B. The nurse develops a plan of care for patients and collaborates with other team members. C. The nurse performs all tasks needed by the individual patient to optimize health. - total care/case method D. The nurse provides care to 4 patients while the nursing aide is to care for 2 patients. - team nursing Rationale: 24/7, from admission to discharge, may relay to other healthcare members 59. One of the post-cesarean patients has a private duty nurse and is responsible for providing holistic care to her patient during the shift. What modality of nursing care is implemented? A. Primary 55. One evening, Sonny complained of dyspnea despite B. Team continuous oxygen therapy. What should be the first action of C. Total care the nurse? D. Functional A. Reassess the client B. Give PRN medication 60. At which stage of Lewin’s planned change indicates the C. Assess the patency of the tubing nurse identifying, planning and implementing appropriate D. Refer client to the physician strategies ensuring that driving forces exceed restraining forces? Situation 12: The senior nurse Reese, is planning to revisit A. refreezing and implement a change in the management system for the B. unfreezing obstetric Unit. This would be a pilot unit as planned by the C. movement administration. Many problems have occurred, one of which D. in activism is the present documentation system, and the charge nurse determines that a change is required. Rationale: Kurt Lewin’s Change Model: → Unfreezing occurs when the change agent convinces 56. What should be the INITIAL STEP in the process of change members of the group to change or when guilt or for the senior nurse. concern can be elicited. This, people become A. Set goals and priorities regarding the change process discontented and aware of a need to change. For B. Plan strategies and implement the change. effective change to occur, the change agent needs to C. Identify potential solutions and strategies for the change. have made a thorough and accurate assessment of the D. Identify the inefficiency that needs improvement or extent of and interest in change, the nature and depth of correction. motivation, and the environment in which the change will occur → The second phase of planned change is movement. In Rationale: senior nurses might be resistant to changes movement, the change agent identifies, plans, and Planned Change: no problem yet, but there will be changes implements appropriate strategies, ensuring that driving → Stage 1 - Unfreezing forces exceed restraining forces. Because change is → Stage 2 - Movement such a complex process, it requires a great deal of 1. Develop a plan planning and intricate timing. Recognizing, addressing 2. Set goals and objectives and overcoming resistance may be a lengthy process 3. Identify areas of support and resistance and whenever possible, change should be implemented 4. Include everyone who will be affected by the change gradually. Any change of human behavior or the in its planning perceptions, attitudes, and values underlying that 5. Set target dates behavior takes time 6. Develop appropriate strategies → The last phase is refreezing. During the refreezing 7. Implement the change phase, the change assists in stabilizing the system 8. Be available to support others and offer change so that it becomes integrated into the status quo. encouragement through the change If refreezing is incomplete, the change will be ineffective 9. Use strategies for overcoming resistance to change and the pre change behaviors will be resumed. For 10. Evaluate the change refreezing to occur, the change must be supportive and 11. Modify the change, if necessary reinforce the individual adaptation efforts of those → Stage 3 - Refreezing (takes 3-6 months for them to adapt affected by the change. Because exchange needs at the change) least 3 to 6 months before it will be accepted as part of Source: Page 166 Leadership and Management Functions in the system, the change agent must be sure that he or she Nursing will remain involved until the change is completed. RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 65. Emotional lability is common to pregnant women. Identify Situation 13: Olivia, a 25-year-old, high school student Visited which of the following reactions is accepted as part of a normal the health center for prenatal checkup. Per nurse’s initial pregnancy? assessment, the patient has been drinking alcohol and A. Feelings are easily hurt by remarks smokes cigarettes about 5 sticks a day for 2 years now. Her B. Mood swing last menstrual period (LMP) was October 10, 2020 C. Amusing or even charming situation D. Narcissism - self-centered (pabebe) 61. Based on the nurse’s computation utilizing Naegele’s rule, the patient’s expected date of birth (EDB) Will be on____. Situation 14: Nurse Lingling is in the process of evaluating A. September 17, 2021 the effectiveness of her teaching which is the critical part of B. June 17, 2021 the process. C. July 17, 2021 D. August 17, 2021 66. Which of the following would BEST help Nurse Lingling in conducting her evaluation? Rationale: 01-03 months (+9 +7); 04-12 months (-3 +7 +1) A. Written examination B. Change in behavior 62. Which of the following is the MOST common emotional C. Return demonstration - if skills are taught response among women during the first trimester of pregnancy? D. Obtain feedback from the client A. Ambivalence B. Depression Rationale: application of what the patient had learned C. Acceptance D. Jealousy 67. Which of the following aspects nurses continually teach patients to do? (Select all that apply) Rationale: 1. Disease or disorder → First trimester task: Accepting the Pregnancy 2. Diet medication The woman and her partner both spend time 3. Treatments recovering from the surprise of learning they are 4. Self-care pregnant and concentrate on what it feels like to be A. 1 only pregnant. A common reaction is ambivalence, or B. 1, 2, 3 feeling both pleased and not pleased about the C. 1, 2, 3, & 4 pregnancy. D. 2 & 3 → Second trimester task: Accepting the fetus The woman and her partner move through emotions 68. The first step in teaching is assessing which of the following? such as narcissism and introversion as they (Select all that apply). concentrate on what it will feel like to be a parent. 1. Learning needs Role-playing and increased dreaming are common. 2. knowledge deficit Acceptance of the baby happens when the mother 3. Education background felt the movement of the baby (quickening) 4. Social status → Third trimester task: Preparing for the baby and end of A. 1, 2, 3 pregnancy B. 3 & 4 The woman and her partner prepare clothing and C. 1 only sleeping arrangements for the baby but also grow D. 1, 2, 3, 4 impatient as they ready themselves for birth. Nest building and preparation of 69. Which of the following environmental factors affect learning? parenthood/delivery/coming of the baby (Select all that apply) 1. Client comfort Impatient - excitement to see the baby 2. Lighting 3. Noise level 63. Olivia mentioned that she can experience uttering 4. Room temperature squeezing. Which of the following signs of normal pregnancy A. 2 & 4 should the nurse consider? B. 3 & 4 A. Braxton-Hicks contractions C. 1 only B. Hegar’s sign D. 1 ,2, 3, & 4 C. Ballottement D. Goodell’s sign 70. Which of the following environmental factors affect learning? (Select all that apply). Rationale: normal occurrence in pregnancy 1. Nursing specialist → Painless on 1st trimester 2. Videotapes 3. Demonstration equipment → 2nd and 3rd trimester - painful especially in 3rd trimester 4. Books → D/t Increased perfusion of uterus and placenta A. 2 & 4 → It is a rehearsal contraction to be ready on the contraction B. 2 & 3 of uterus nearing delivery C. 1, 2, 3, & 4 D. 1, 2 & 3 64. Nurse Emma advised the patient to quit smoking because nicotine will contribute to___. Situation 15: Ramon, 6-year-old, has been recently A. low birth weight infant diagnosed to have acute Lymphocytic Leukemia. The child B. ectopic tubal pregnancy has undergone chemotherapy. However, the father is C. congenital anomalies witnessing before his very eyes his first child dying. The father D. large for gestational age infants is very much depressed. Rationale: nicotine causes vasoconstriction → less blood will 71. In what way will the nurse handle the situation? go the baby → low nutrition A. Tell her to trust on god’s love and mercy B. Tell her that death is a reality C. Encourage her to keep calm because the health care team is doing their best to help Ramon recover. D. Encourage the mother to express more about her thought and feelings - allowing verbalization RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 72. The APPROPRIATE nursing diagnosis to protect the patient C. 1 only from further injury is, which of the following? D. 1, 2, 3, & 4 A. Altered mucous membrane related to chemotherapy. B. Interrupted family processes related to life threatening 77. The BEST rationale for the conduct of the program is which illness of a family member. of the following? C. Fatigue related to disease process. A. Ensure safe practice in the hospital D. Risk for injury related to thrombocytopenia. - protect = B. Provide knowledge and skills to all nursing staff in IV therapy prevention - limited only to IV therapy; does not address safety C. Improve nursing practice in general 73. Mouth sores have developed in the child’s mouth. The father D. Deliver safe and quality nursing to all care patients on asked the nurse the reasons for this. The MOST APPROPRIATE intravenous therapy response of the nurse is____ a. “The child’s oral hygiene needs to be improved.” - mouth 78. One of the lecturers discussed the complications that sores is not caused by poor hygiene patients may have while on IV therapy. Which of the following is b. “There is no need to have them” the most common complication that IV patients may contract c. “He is allergic to the drug so I will report this to the doctor while on IV therapy? and suggest a change of duration.” - not an allergic A. Embolism reaction. B. Cardiac overload d. ” Mouth sores result because the cells of the mouth are C. Phlebitis sensitive to chemotherapy D. Aneurysm Rationale: Nursing Diagnosis for patients with ALL Rationale: Signs and Symptoms of Common Local → Risk for infection, bleeding, or both Complications of Infusion Therapy → Impaired oral mucous membranes due to changes in epithelial lining of the GI tract from chemotherapy or INFILTRATION prolonged use of antimicrobial medications → Coolness of skin around site → Imbalanced nutrition: less than body requirements → Skin blanching, tautness (i.e., client states it feels "tight") related to hypermetabolic state, anorexia, mucositis, → Edema at, above, or below the insertion site pain, and nausea → Leakage at insertion site → Acute pain and discomfort related to mucositis, → Absence of or "pinkish" blood return leukocytes infiltration of systemic tissues, fever, and → Difference in size of opposite hand or arm infection → Fatigue and activity intolerance related to anemia, EXTRAVASATION infection, inadequate nutrition, and deconditioning → Same as infiltration and can also include: → Risk for imbalanced fluid volume related to renal → Burning, stinging pain dysfunction, diarrhea, bleeding, infection, increased → Redness followed by blistering, tissue necrosis, and metabolic rate, hypoproteinemia, and need for multiple ulceration intravenous medications and blood products → Self-care deficits (bathing, dressing, toileting) due to PHLEBITIS fatigue and malaise → Redness at the site → Anxiety and grieving due to uncertainty about future, → Skin warm anticipatory loss, and altered role functioning → Swelling → Risk for spiritual distress → Palpable cord along the vein → Deficient knowledge about disease process, treatment, → Increase in temperature complication management, and self-care measures 79. The participants may avail of continuing professional 74. Ramon died at 10:00 PM. His father cried a lot and refused Development (CPD) units if Nurse Mendoza had filed the to move Ramon’s body. What is the APPROPRIATE approach program to be CPD accredited to which of the following? of the nurse? A. Professional Regulatory Board of Nursing A. Talk about the reality of death B. Professional Regulation Commission B. Leave the mother and the child for the last time C. Continuing Professional Development Council for Nursing C. Silence to allow the mother to grieve. - allow them to D. Commission on Higher Education grieve D. Cry with the mother as you remember your own experience 80. The participants should know the way by which they may of death in the family. obtain CPD units aside from attending inservice training programs, which are EXCEPT____ 75. The nurse’s MAIN responsibility in preparing Ramon’s A. professional seminars and conference discharge is, which of the following? B. graduate studies - formal education A. Assist the mother to pay the hospital bill. C. short course training for specialization B. Prepare Ramon’s cadaver. - postmortem care D. joining nursing service committees - groups of nurses in C. Prepare the death certificate. the hospital D. Extend condolences to the bereaved family Situation 17: The concept of reproductive health is Rationale: physiologic over emotional needs of the relatives introduced as early as primary and secondary levels with different degrees of concentration. Students, interested to continue health courses were asking questions on human Situation 16: Asst Chief for education & Training, Nurse sexuality. Mendoza, is planning to conduct an in-service training program on intravenous therapy for the staff nurses. 81. Nurse Hailey discusses the 2020 National Health Goals. Which of the following statements is an EXCEPTION in planning 76. To be able to justify the conduct of any in-service training sexual health programs. program in a hospital, which of the following should be the A. Make sexual education program voluntary basis for the implementation of the program? B. Increase the proportion of adolescents who have never 1. Needs assessment engaged in sexual intercourse. 2. Needs analysis C. Reduce deaths from cancer resulting from uterine cervix. 3. Per recommendation by the chief Nurse D. Reduce deaths from cancer of the uterine cervix 4. Incident Reports - included in QI A. 1, 2, & 4 B. 1, 2, & 4 RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 Rationale: Situation 18: Ruby, a pregnant patient 37-week gestation is admitted due to who has a diagnosis of sickle cell anemia. 86. Nurse Sophia administers oxygen to patient Ruby and implements additional measures to prevent a sickling crisis from occurring? A. Maintain strict asepsis. B. Maintains adequate hydration. C. Monitors the temperature. D. Reassures the patient. Rationale: Sickle Cell Disease -SCD can cause a severe hemolytic anemia that results from inheritance of the sickle hemoglobin (HbS) gene, which causes the hemoglobin molecule to be defective. HbS acquires a crystal-like formation when exposed to low oxygen tension. The oxygen level in venous blood can be low enough to cause this change; consequently, the erythrocyte containing HbS loses its round, pliable, biconcave disc shape and becomes dehydrated, rigid, and sickle shaped → Painful d/t clumping of RBC → trapped to blood vessels → may result to sickle cell crisis 87. Nurse Sophie hooks a 1000 mL intravenous (IV) solution of 82. Maternal and child Nursing is a concept under the national D5 Water as ordered by the physician at 9 am to infuse 80 mL/hr. Goals. Which objective should nurse Hailey emphasize to via macro drop infusion at what would be the level of the support the program? remaining amount in the IV bag at 2 pm? A. Avoid having misdirected children and become street A. 500 children. B. 200 B. Promote the well-being of the mother’s family life and family C. 400 planning. D. 300 C. Consider that every child has love, security, and a better future. D. Avoid complications of pregnancy and promote vaginal Rationale: 600 ml should be the remaining deliveries. → 1000 ml → 80 ml/hr 83. Which of the following topics should the patient feel MORE → 5 hours time of infusion comfortable when reproductive anatomy and physiology is 5 hrs x 80 ml/hr = 400 ml/hr discussed with the nurse? 1000 - 400 = 600 ml A. Sexual health education B. Gender reassignment 88. The patient began receiving an intravenous (IV) infusion of C. Varied sexual positions packed red blood cells 30 minutes ago. The patients complain D. Gender identify of difficulty breathing, itching and a tight sensation in the chest. Which is the IMMEDIATE action of the nurse? 84. When can the patient tell all information to the nurse? A. Recheck the unit of blood for compatibility. A. All diagnostic laboratory test performed had been B. Call the physician. completed C. Check the patient’s temperature. B. Once the feeling of security is established in the nurse- D. Stop the infusion. patient relationship C. A change in physical appearance occurs D. The nurse knows the genogram of the patient Rationale: 85. Which nursing diagnosis is NOT RELEVANT to sexual health? A. Anxiety-related inability to conceive after six months. - for psychiatric; should be >12 months of subfertility B. Health-seeking behaviors related to reproductive functioning. C. Sexual dysfunction related to high-risk sexual behaviors. D. Risk for infection related to high-risk sexual behaviors. Additional Note: inability to conceive after six months - for women >35 years old RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 notes on human growth and development, specifically Erikson’s psychosocial theory. 91. The BEST reason why the nurse Nilda opted to review Erikson’s psychosocial theory is, which of the following statements? A. Completion of tasks results in a sense of competence and a healthy personality. B. Failure to master these tasks leads to feelings of inadequacy. C. Helps children grow into successful, contributing members of society. D. We are motivated by the need to achieve competence in certain areas of our lives. Rationale: INSERT PIC 92. Nurse Nilda immediately responds to any cry from her pediatric patients because it is, which of the following reasons? A. To attend to her patient who cannot communicate verbally B. To check if the child is hungry or wet C. To lessen the noise overload in the unit D. A powerful influence over that individual’s interactions with others for the remainder of his/her life Rationale: Option D shows trust vs. mistrust 93. Nurse Linda is attending to a two-year-old Neneng who was admitted due to chronic bronchitis. Neneng sports a long hair that extends after to her shoulder. As part of the morning care, Nurse Linda decided to style neneng’s hair into a ponytail. However, Neneng vehemently resisted her hair being tied by a rubber band. The BEST thing that Nurse Linda should do is, which of the following? A. Assert her authority B. Denny Neneng’s preference C. Explain that a ponytail would make Neneng’s more beautiful. D. Allow Neneng’s preference 89. Nurse Sophie checks the gauge of the patient’s intravenous 94. Joji, 17 years old, is admitted to a private room due to catheter. Which is the smallest gauge catheter that the nurse influenza. In one of Nurse Linda’s conversations with Joji, the can use to administer blood? patient expressed his unhappiness with the program he is taking A. 22-gauge up in the college. This is not his choice but rather the choice of B. 18-gauge his parents. In which of erikson’s stages of development does C. 20-gauge this case fall? D. 12-gauge A. Autonomy versus shame/doubt B. Integrity versus despair C. Identify versus role confusion Additional Note: Standard: gauge 14-18 (the larger the D. Trust versus distrust better) 95. When a 3-year-old patient of nurse Nilda asserts to choose Traditionally, blood has usually been administered through an the pants and shirt to wear to include food preference. Based on #18- to #20-gauge IV needle or catheter with the belief being Erikson’s development task, the child’s such behavior is that using smaller needles may slow the infusion and damage attributed to their which of the following? blood cells (hemolysis). However, studies have shown that 1. struggling to acquire a sense of autonomy blood infusions through smaller gauge catheters can be 2. discovering they have a will of their own completed within 4 hours with- out hemolysis. Current 3. awareness that they cannot control others practice guidelines established by the INS recommend that a 4. learning which behavior gains approval #20- to #24-gauge short peripheral catheter is acceptable for A. 1, 2, & 3 transfusion of cellular blood components in adults (INS, B. 2, 3, & 4 2016b, p. 225). When rapid transfusion is required a #14 to C. 1, 2, 3, & 4 #18-gauge is recommended (INS, 2016a, p. S135). D. 1, 2, & 4 90. The nurse reviews the patient’s plan of care. Which of the Rationale: toddlers: autonomy vs shame and doubt following nursing diagnoses will be the PRIORITY? → They discover they have will on their own A. Fluid volume, deficit - circulation → They want to see that they are the one who’s deciding B. Risk for pain, acute C. Coping, ineffective D. Body image, disturbed Situation 20: Gwen a unit manager is assigned to evaluate applicants for the position in the OB Unit. During the interview, the applicant was asked 5 questions. Rationale: priority = nakakamatay 96. when a patient is admitted to the OB ward with complaints of Situation 19: Nurse Nilda is a beginning nurse assigned in dizziness and body weakness, this is an example of___. the pediatrics Unit in a government hospital. The unit has A. secondary source B. primary source pediatric patients of different ages. Since she will be dealing C. objective data - observed by the nurse with patients of varied ages, she thought it best to review her D. subjective data RECALLS 8: NURSING PRACTICE 2  RECALLS 8: NURSING PRACTICE 2 97. What are the possible cases that need informed consent? → Routine A. Administering skin testing → ADLs B. Subjective the patients to an invasive procedure C. Hair shampooing the patients D. Performing a laboratory procedure Rationale: informed consent is needed for invasive procedures, needs to inject dye 98. The applicant was further asked about an incident report. Which of the following is a PRIORITY case for an incident report to be accomplished? A. Patient fell from the bed. B. A visitor encourages a patient on bed rest to ambulate. C. Refusal to go to the physical therapy session. D. Nurse left before his duty ends Rationale: Incident Report An incident report (also called an unusual occurrence report) is an agency record of an accident or unusual occurrence. Incident reports are used to make all facts available to agency personnel, to contribute to statistical data about accidents or incidents, and to help health personnel prevent future incidents or accidents. All accidents are usually reported on incident forms. → Identify the client by name, initials, and hospital or identification number. → Give the date, time, and place of the incident. Describe the facts of the incident. Avoid any conclusions or blame. Describe the incident as you saw it even if your impressions differ from those of others. → Incorporate the client's account of the incident. State the client's comments by using direct quotes. → Identify all witnesses to the incident. → Identify any equipment by number and any medication by name and dosage. 99. On which occasion would a nurse be charged with negligence? A. Giving the patient the wrong medication B. Giving competent care. C. Following standards of care. D. Communicating with another health team. Rationale: Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent individual. Such conduct places another individual at risk for harm. Both nonmedical and professional individuals can be liable for negligent acts. Gross negligence involves extreme lack of knowledge, skill, or decision making that the individual clearly should have known would put others at risk for harm. Malpractice is "professional negligence," that is, negligence that occurred while the individual was performing as a professional. Malpractice applies to primary care providers, dentists, and lawyers, and generally includes nurses. In some states nurses cannot be sued for malpractice, only professional negligence. The terms malpractice and professional negligence are often used interchangeably. → Applicable to lawyer, nurses and doctors 100. What can be delegated to his nursing assistant during his tour of duty? A. Changing wound dressings. B. Administering analgesic drugs. C. performing a physical drug. D. Taking vital signs. Rationale: Cannot delegate ADPE: → Teaching → Assessment → First time → Drugs Interventions that can be delegated: → Stable RECALLS 8: NURSING PRACTICE 2