Nursing Elites

1. The use of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what it is?

• A. These are statements that describe the maximum or highest level of acceptable performance in nursing practice
• B. It refers to the scope of nursing practice as defined in Republic Act 9173
• C. It is a license issued by the Professional Regulation Commission to protect the public from substandard nursing
• D. The Standards of Care includes the various steps of the nursing process and the standards of professional

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. Churns chyme and has an environment of pH2; holds 4-6 cups of food:

• A. stomach
• B. pancreas
• C. large intestine
• D. small intestine

Correct answer: A

Rationale: The stomach churns food into chyme and has a highly acidic environment (pH 2) to aid in the digestion of proteins and other nutrients.

3. In which of the following conditions does a person need to sit, stand, or use multiple pillows when lying down?

• A. Orthopnea
• B. Dyspnea
• C. Eupnea
• D. Apnea

Correct answer: A

Rationale: The correct answer is Orthopnea. Orthopnea is a medical condition in which a person has difficulty breathing while lying down. To alleviate this difficulty, the person may need to sit, stand, or use multiple pillows. On the other hand, Dyspnea refers to general shortness of breath which is not specifically related to the position of the body. Eupnea is the term for normal, unlabored breathing, and Apnea is a condition characterized by the cessation of breathing. Thus, none of these other choices directly relate to the need to adjust body position or use aids like multiple pillows to breathe comfortably when lying down.

4. You are caring for Conrad who has a brain tumor and increased Intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?

• A. Administer bowel softener
• B. Position Conrad with his head turned toward the side of the tumor
• C. Provide sensory stimulation
• D. Encourage coughing and deep breathing

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

5. All of the following are instructions for proper foot care to be given to a client with peripheral vascular disease caused by diabetes. Which one is not?

• A. Trim nails using a nail clipper
• B. Apply cornstarch to the foot
• C. Always check the temperature of the water before bathing
• D. Use canvas shoes

Correct answer: A

Rationale: The correct answer is 'A', which says trim nails using a nail clipper. This is incorrect because patients with peripheral vascular disease, particularly those caused by diabetes, should not trim their nails themselves due to the risk of injury, infection, and poor wound healing. The other options, 'B', 'C', and 'D', are correct advice for diabetic foot care. Applying cornstarch can help keep the feet dry and prevent fungal infections. Checking the water temperature before bathing can prevent burns, as patients with peripheral vascular disease often have decreased sensation in their feet. Wearing canvas shoes can improve foot ventilation and reduce the risk of foot ulcers and infections.

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