NPP1101 Exam Revision

33. What's the normal capillary refill time?

1-2 seconds

8. What is the correct sequence for PUTTING ON personal protective equipment (PPE)?

1. Hand hygiene 2. Gown 3. Mask 4. Eyewear 5. Gloves Pneumonic: (H)GMEG Her Gown Made Excellent Gloves

28. Almost ? of body water exists in extracellular fluid?

1/3

What is the minimal acceptable time when performing a normal (social) hand wash?

15 seconds

What is the prevalence of healthcare associated infections in the critical care setting?

20%

What is the normal oral temperature?

36.0 - 38.0

25. Describe the evaluation phase of the nursing process?

A continual process focused on the progress patients make towards established outcomes.

Susceptible Host

A person who cannot resist a microorganism invading the body, multiplying and resulting in infection

Susceptibility

A persons likelihood of acquiring an infection. Depends on individual resistance to pathogen

Reservoir

A place where a pathogen can survive and may, or may not, multiply

57. When you place your hands behind your head, with your elbows back this examines:

Abduction, external rotation of shoulder and elbow flexion.

Source

An individual person or animal that TRANSMITS the infection on an individual basis

50. When estimating the Jugular Venous Pressure (JVP) of a patient, you are measuring in centimetres the distance from the:

Angle of Louis, to the top of the distended neck vein.

Example of a reservoir:

Animals, insects, food, water and inanimate objects

34. The temporomandibular joint is located by palpating with both index and middle fingers on both sides of the face...

Anterior to tragus of the ear.

47. When performing anterior thoracic auscultation on a female patient, you would:

Ask the patient to displace breast tissue when necessary and/ or use the dorsum of the hand.

Nursing Process:

Assess, Plan, Implement & Evaluate

Infectious agents can be:

Bacteria, Viruses, Fungi, Protozoa

49. When auscultating the carotid artery you should use:

Bell of stethoscope.

15. What might you expect a healthy, young and sporty person's heart beat to be?

Bradycardia. Athletes commonly have resting heart rates below 60 beats per minute due to increased strength and efficiency of heart muscle

51. When palpating peripheral pulse you can palpate the pulses on both sides at the same time. The exception is:

Carotid pulse.

Modes of transmission

Contact, droplet, airborne, vehicles (water, medications, blood, food) or vector (external/internal mechanical)

17. In nursing documentation, what will you do when you make an error?

Cross out the error with a single line, date, time and sign the correction

27. The single best indicator of fluid status is the nurse's assessment of the patients...

Daily body weight.

54. When auscultating for bowel sounds, how should you place your stethoscope on the patient's abdomen?

Diaphragm

36. When palpating the thyroid gland using the anterior approach, you need first:

Displace the thyroid cartilage with your thumb.

What do you do when an AM shift staff member calls and says she has forgotten to document the tablets she's given to a patient?

Document that the colleague has phoned. Include time, colleagues name, patient's name and any other relative information in patient's notes.

32. The Glascow Coma Scale (GCS) is used to assess neurological responses to...

Eye opening Verbal response Motor response

56. The joint angle decreases in:

Flexion

What is the single most important technique to prevent transmission of infections?

Hand hygiene

14. Which gland controls oral temperature?

Hypothalamus

Susceptibility can depend on:

Immune status, health status, age, virulence of agent, factors that increase risk of transmission

describe the elements of the chain of infection?

Infectious agent Reservoir Portal of exit - from reservoir Mode of transmission Portal of entry - into susceptible host

Pathogen

Infectious agent or microorganism that is capable of causing disease

52. The spleen is located in:

Left Upper Quadrant

45. When examining the thorax, you are comparing the right anterior thorax at the apex of the lung with the:

Left anterior thorax at the apex of the lung

35. When palpating the thyroid gland using the posterior approach, what will you instruct the patient to do?

Lower chin slightly to relax neck muscles.

What percentage of healthcare acquired infections are preventable?

More than 30%

11. What will impact on a patient who has a large mouth ulcer?

Nutrition

24. Physical examination findings are...

Objective

A nurse documents 'elevated BP'. Is this subjective or objective?

Objective

38. When performing the Weber test, you strike the tuning fork and then place the stem firmly:

On middle, top of head.

37. When palpating the lymph nodes, you face the patient and palpate using the:

Pads and tips of middle 3 fingers.

30. Which part of your hand is used when assessing vibrations?

Palmar surface of fingers or ulnar of hand.

26. When using a fall assessment tool, what do you think the greatest indicator of risk is?

Past history of falls

44. Lung cancer, tuberculosis and pneumonia. Which respiratory condition is not considered a familial disease?

Pneumonia

31. The proper use of stethoscope includes...

Pointing the stethoscope ear piece towards the nose

12. When a nurse takes BP in the patient's leg, what pulse does the nurse need to palpate before the measurement?

Popliteal (behind the knee)

"I have lost my job and my wife has newly diagnosed cancer". Family/ Psychosocial/ environmental history?

Psychosocial

43. Which structure controls the amount of light entering the eye?

Pupil

46. Which tone should you expect when percussing the chest of a healthy adult?

Resonance

42. The opaque material covering the structures inside the eye is called the:

Sclera

29. Inspection includes vision and...?

Smell

3 elements of infection

Source, Mode & Susceptible host

18. "I feel cold". Is this subjective or objective?

Subjective

13. What is it called when a patients respirations are 40 breaths per minute?

Tachyopnea

48. Bronchovesicular sounds are normally auscultated at:

The 1st and 2nd Intercostal space, next to sternum.

Infection

The entry and multiplication of an infectious agent within the tissue of a host, resulting in an immune response with or without symptomatic disease

A patient had a fall while taking a shower. Who should write an incident report?

The nurse who witnessed the fall

39. When performing the Rinne test on a normal hearing person, you would expect:

The patient can still hear the sound after you move the fork from the bone, because air conduction is greater than (twice as long) than bone conduction.

55. The predominant sound heard when percussing the abdomen is?

Tympany

40. To palpate a patient's frontal sinuses, you need to gently apply pressure:

Under the bony ridge of the upper orbits with your thumbs.

41. Which direction should the pinna be pulled when you examine an adult's tympanic membrane?

Upwards and backwards.

What are the most common health care acquired infections?

Urinary Tract Infections (UTI's)

Categories of HAI

Urinary tract, Surgical/traumatic wounds, respiratory tract, blood stream, other

53. When performing an abdominal assessment, you should:

Visualise the underlying abdominal structures first.

16. Will a patient display a higher pulse rate when in a febrile (temperature) condition?

Yes

49) Which of the following terms best describes the straightening movement that increases the angle between body parts? a) Extension b) Flexion c) Pronation d) adduction

a) Extension

56) On expiration the lung is approximately at the level of: a) T10; b) T3; c) the fifth rib at the midaxillary line; d) the oblique.

a) T10;

65) Why is it important to determine the level of risk of developing a pressure injury in patients with limited mobility? a) To implement preventative strategies to reduce the risk; b) To establish the overall need for nursing care; c) To encourage self-care and independence; d) To ensure the patient does range of motion exercises daily.

a) To implement preventative strategies to reduce the risk;

52) I should NEVER palpate a pulsating abdominal mass. a) True b) False

a) True

53) Adventitious sounds are heard by the nurse during auscultation of the lungs. The most appropriate action the nurse would perform is: a) ask the patient to cough and listen again; b) document and handover findings; c) auscultate for egophony; d) perform a bronchoscopy

a) ask the patient to cough and listen again;

67) To prevent a false reading of the blood pressure, the nurse ensures: a) the cuff is wrapped evenly and snugly around the arm; b) the cuff is inflated as quick as possible during auscultation; c) the blood pressure is measured early in the morning; d) the stethoscope is placed firmly over the radial artery.

a) the cuff is wrapped evenly and snugly around the arm;

46) The following health care record entry shows the greatest need for further instruction to document only objective data: a) 'Patient states she was angry because breakfast was not to her liking'; b) 'Patient is depressed; was observed crying while alone in room'; c) 'Patient expressed pain as 9 out of 10, was diaphoretic, guarding her abdomen and clenching her fists'; d) 'Patient was verbally abusive to staff when approached concerning continued attempts to smoke in the bathroom.

b) 'Patient is depressed; was observed crying while alone in room';

66) A construction worker is asking the nurse if the mole on his arm looks like skin cancer. Which of the following would the nurse identify as suspicious: a) solid, dark brown even colour; b) asymmetric, irregular borders with multiple colour tones; c) diameter of less than 3mm; d) flat with silvery scales.

b) asymmetric, irregular borders with multiple colour tones;

58) During auscultation of the heart the nurse identifies that the patient's heart rhythm is irregular. The next assessment the nurse would perform is: a) inspect for a lift; b) auscultate for the pulse rate deficit; c) palpate for a thrill; d) listen for a ventricular gallop.

b) auscultate for the pulse rate deficit;

59) During auscultation of the carotid artery of a healthy adult, the nurse most likely listens for the following sound: a) resonance; b) bruit; c) S1 and S2; d) extra heart sounds.

b) bruit;

55) During percussion of the posterior chest, the tone heard over the scapula is: a) dullness; b) flatness; c) resonance; d) tympany.

b) flatness;

69) The physical assessment technique(s) performed during the examination of the eye is/are: a) inspection only; b) inspection and palpation; c) inspection, palpation and percussion; d) inspection, palpation, percussion and auscultation

b) inspection and palpation;

50) Dorsi flexion and plantar flexion are movements of the following body part: a) Spine b) Elbows c) Ankles d) Wrists

c) Ankles

47) An elderly patient is complaining of recent forgetfulness. The most appropriate nursing assessment tool the nurse would complete is the: a) Falls Risk Assessment; b) Pressure Injury Risk Assessment; c) Mini Mental State Examination; d) Glasgow Coma Scale.

c) Mini Mental State Examination;

71) The normal pacemaker of the heart is the: a) S-A node at 120bpm; b) Bundle of HIS at 60bpm; c) S-A node at 70bpm; d) A-V node at 40bpm.

c) S-A node at 70bpm;

43) The professional nurse realises there is both a legal and an ethical obligation to keep patient information obtained through examination, observation, conversation or treatment. a) secured; b) accessible; c) confidential; d) documented.

c) confidential;

61) A patient with Methicillin Resistant Staphylococcus Aureus (MRSA) is admitted to the health care facility. The nurse knows that admission of this patient to the unit will require the implementation of: a) airbourne precautions; b) droplet precautions; c) contact precautions; d) protective isolation.

c) contact precautions;

64) The nurse is collecting and measuring the patient's urine. The nurse notes all of the following characteristics except: a) colour; b) clarity; c) contour; d) odour.

c) contour;

51) The correct sequence for the physical examination of the abdomen is: a) inspection, palpation, percussion, auscultation b) inspection, percussion, palpation, auscultation c) inspection, auscultation, percussion, palpation d) inspection, percussion, auscultation, palpation

c) inspection, auscultation, percussion, palpation *aususcultate first as percussion & palpation may alter abdominal sounds

54) During auscultation of the lungs, it is most important for the nurse to remember to: a) auscultate the base of the lungs first; b) randomly select auscultation sites scattered across the lung fields; c) listen at each site for at least one full respiratory cycle; d) ensure to perform the examination in one single stream without any breaks.

c) listen at each site for at least one full respiratory cycle;

45) During the health interview, the nurse notices that the patient has a slumped posture, wears loose and untidy track pants and has a dull-looking facial expression. The nurse uses the following strategy to gather objective data: a) verbal communication; b) therapeutic relationship; c) non-verbal communication; d) intrapersonal communication.

c) non-verbal communication;

60) General guidelines for palpating peripheral pulses include: a) positioning the patient in a supine position with the head of the bed elevated 90 degrees; b) counting the pulse for 30 seconds and multiplying by 2; c) palpating the pulses on both sides of the patient's body simultaneously, with the exception of the carotid pulse; d) palpating with the fingers pads of all five fingers.

c) palpating the pulses on both sides of the patient's body simultaneously, with the exception of the carotid pulse;

70) During the percussion of the chest of a healthy patient, the nurse expects to hear: a) hyperresonance; b) dullness; c) resonance; d) tympany.

c) resonance;

62) The nurse is aware that it is important to break the chain of infection. An example of a nursing intervention that is implemented to reduce a reservoir of infection for a patient is: a) covering the mouth and nose when sneezing; b) wearing disposable gloves; c) reducing the virulence of a pathogen; d) Reducing opportunities for pathogens to survive and multiply.

d) Reducing opportunities for pathogens to survive and multiply.

68) The nurse documents normal findings of the physical assessment of the ear as: a) cover test positive; b) uvula rises symmetrically; c) mucous membranes intact; d) auricle, tragus and mastoid non-tender

d) auricle, tragus and mastoid non-tender

42) The registered nurse (RN) is evaluating the documentation of the nursing student. The RN notes that appropriate documentation is evident when the nursing student: a) makes entries into the health care record with a pencil; b) corrects errors with correction fluid; c) identifies an error made by the consultant physician; d) dates and signs all of the entries made in the record.

d) dates and signs all of the entries made in the record.

48) The Nurse prepares to obtain information about the patient's mental and psychosocial status. The nurse would perform the following action first. a) question the patient about usual lifestyle behaviours; b) perform a full neurological examination to determine deficits; c) check the patient's level of consciousness for changes; d) ensure privacy and explain the purpose of the examination.

d) ensure privacy and explain the purpose of the examination.

57) The nurse is assessing the patient's apical pulse. The nurse would be most successful by palpating the following location: a) second intercostal space, left sternal border; b) third intercostal space, left sternal border; c) fourth intercostal space, left sternal border; d) fifth intercostal space, left midclavicular line.

d) fifth intercostal space, left midclavicular line.

72) The nurse palpates the abdomen and feels a prominent, non-tender, pulsating 6cm mass above the umbilicus. The nurse would: a) refer the patient to an Oncologist; b) arrange a dietician consult for the patient to ensure adequate nutrition; c) continue with the physical assessment of the abdomen; d) stop palpating and seek medical assistance.

d) stop palpating and seek medical assistance

44) What is the purpose of the change-of-shift iSoBAR handover? a) to tell interesting stories about patient's interactions with staff; b) to review the routine care provided for the day; c) to give the routine care provided for the day; d) to report relevant information about the patient to the nurses of the next shift.

d) to report relevant information about the patient to the nurses of the next shift.

Heathcare Associated Infections (HAI)

infections acquired in health-care settings are the most frequent adverse event in health-care delivery worldwide

Carriers

people with no symptoms of illness but with evidence of pathogens on or in their bodies that can be transferred to others

Communicable disease

the infectious disease can be transmitted from one person to another