SAMPLE TEST QUESTIONS ANCC – PMHNP/QUESTIONS /VERIFIED ANSWERS/24/25, Exams of Nursing

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SAMPLE TEST QUESTIONS ANCC –

PMHNP/QUESTIONS /VERIFIED

ANSWERS/24/

1. What is the most effective method to prevent the transfer of clostridium dif- ficile (C. Difficile) ?: HAND HYGIENE with soap and water is effective to physically remove C. difficile spores from the hands. (Potter 1092)
2. What is the term for the [abnormal] method used to assist in stool passage by exerting pressure to expel fecal matter through voluntary contraction of the abdominal muscles while maintaining a forced expiration against a closed airway?: Valsalva Manuever Normal passage of bowels should be painless, passing soft formed stool 3. Which patients are at greatest risk for cardiac dysrhythmia and high blood pressure with the Valsalva manuever and MUST avoid straining to pass stool?- : Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound (Potter 1089)
3. What is the term for a collection of hardened feces in the rectum that cannot be expelled due to unrelieved constipation?: Fecal Impaction
4. Where does fecal impaction occur in the colon?: Rectum
5. Least formed stool is present in which portion of the digestive tract?: As- cending Colon
6. Most formed stool is present in which portion of the digestive tract?: De- scending Colon
7. Which position should the patient be in while administering an enema?: Left Side-Lying or Sim's Position
8. Which factors would contribute to stopping enema administration?: If bleed- ing occurs, abdomen becomes rigid and distended, pain occurs, or resistance is felt
9. Which enema solution is the safest for administration because it does NOT create a danger for excess fluid absorption?: Normal Saline [Isotonic Solution]
10. Which enema solution is contraindicated in patients who are dehydrated or young infants because of risk for fluid imbalance?: Hypertonic Solution
11. Which enema solution is considered to be hypotonic and should NOT be repeated because of the risk of water toxicity or circulatory overload if and because the body absorbs

excessive amounts of water?: Tap Water [Hypotonic Solution]

13. Which enema solution lubricates the rectum and allows the feces to absorb the oil making them soft and easier to pass?: Oil Retention
14. Which enema solution creates intestinal irritation to stimulate peristalsis by using castile soap?: Soapsuds
15. Which enema solution should used in caution in pregnant women and elderly because it may cause an electrolyte imbalance or damage to intestinal mucosa?: Soapsuds
16. Which laboratory test is used to measure microscopic amounts of blood in the feces (blood that cannot be seen): Guaiac Fecal Occult Blood Test Repeat the test at least three times while the patient refrains from ingesting foods (e.g., some raw vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin, non steroidal anti- inflammatory drugs) that cause false-positive results (Potter 1100)
17. When analyzing a fecal specimens for ova and parasites, what is required of the stool?: The stool MUST be warm. If the stool specimen remains at room temperature, bacteriological changes can alter the test results 18. Which cathartic form is most effective because of its stimulant effect on the rectal mucosa (Example: Dulcolax)?: Cathartic Suppositories
18. Which foods induce a constipating effect?: cheese, lean meats, eggs, and pasta
19. Which food induce a laxative effect?: fruits, vegetables, bran, chocolate, alcohol, and coffee
20. What are the assessment findings of a normal stoma?: bright pink or brick red Notify HCP of stoma is blue, purple, brown, or black which indicates circulation problem to the stoma
21. How does the nurse measure the length of the NG tube for insertion?: Tip of the nose --> earlobe --> xiphoid process
22. What is the most reliable method of verification for placement of the NG tube?: X-ray Other methods include: pH test (aspirate and inspect color)
23. What are the ranges for body mass index?: Normal = 19-24 Overweight = 25- Obese = 30-39 Extremely Obese = > 40

Breast milk benefits: fewer food allergies and intolerances; fewer infant infections; easier digestion; convenience, availability, and freshness; temperature always cor- rect; economical because it is less expensive than formula; and increased time for mother and infant interaction. (Potter 1002) Infants should not have regular cow's milk during the first year of life. It is too concentrated for an infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin and should not be used in an infant's diet. This toxin is potentially fatal in children under 1 year of age (Potter 1002)

42. What are the therapeutic diets?: Clear Liquid Clear fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, popsicles Full Liquid smooth-textured dairy products (e.g., ice cream), strained or blended cream soups, custards, refined cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings, frozen yogurt Pureed clear and full liquid, with addition of scrambled eggs; pureed meats, vegetables, and fruits; mashed potatoes and gravy Mechanical Soft As for clear and full liquid and pureed, with addition of all cream soups, ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried) Soft/Low Residue Addition of low-fiber, easily digested foods such as pastas, casseroles, moist tender meats, and canned cooked fruits and vegetables; desserts, cakes, and cookies without nuts or coconut High Fiber Addition of fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits

Low Sodium 4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no added salt to severe sodium restriction (500-mg sodium diet) Low Cholesterol 300 mg/day cholesterol Diabetic balanced intake of carbohydrates, fats, and proteins; varied caloric recommenda- tions to accommodate patient's metabolic demands Regular No restrictions, unless specified (Potter 1017)

43. Why is water critical?: Cell function depends on fluid environment Infants have greatest percentage of total body water; older adults have the least Water makes up 60-70% of total body weight
44. Saturated fats are found mostly in sources: Animal Sources
45. nitrogen balance occurs when the body loses more nitrogen than it gains from infection, trauma, burns, fever, starvation, etc.: Negative Nitrogen Balance MUST provide patient with protein and proper nutrients to put patient into positive nitrogen balance
46. Which vitamins are considered water-soluble vitamins and need to be provided in daily food intake because they are not stored in the body?: Vitamin C and B
47. Which vitamins are considered fat-soluble vitamins that are stored in fatty compartments of the body?: Vitamin A, D, E, and K
48. Which minerals require a daily intake of 100 mg or more?: Macrominerals These balance the pH of the body and certain amounts are necessary for acid-base balance
49. Which minerals require a daily intake of 100 mg or less: Microminerals
50. What are the six rights of medication administration?: 1. Right Patient 2.Right Medication

61. Which order is prescribed when patient needs medication QUICKLY but NOT right away? The nurse has 90 minutes to administer meds: Now Order

62. When the prescriber writes a Rx for medications taken outside hospital this is considered to be a : Prescription Order
63. If the patient is in severe pain and is requesting pain medication but it is before the PRN medication is supposed to be administer, what should the nurse do?: Call the prescriber and request a STAT order
64. If the physicians order is written incorrectly, is unable to be read, or is incomplete what should the nurse do?: Call the prescriber and verify/justify the order
65. If the patient refuses medications, what should the nurse do?: Explore reasons why patient does not want medication. Educate if misunderstandings of medication therapy are apparent. Educate the patient on the importance of the medication Do NOT force patient to take medication; patients have the right to refuse treatment. If patient continues to refuse medication despite educational attempts, document and explain reason for not administering the medication and notify the prescriber
66. What are methods to prevent medication errors from occurring?: Prepare medications for one person at a time. Follow the six rights of medication administration. Be sure to read labels at least three times (comparing medication administration record [MAR] with label) before administering the medication. Use at least two patient identifiers and review the patient's allergies whenever administering a medication. Do not allow any other activity to interrupt administration of medication to a patient (e.g., phone call, pager, discussion with other staff). Double-check all calculations and other high-risk medication administration process- es (e.g., patient- controlled analgesia) and verify with another nurse.

Do not interpret illegible handwriting; clarify with prescriber. Question unusually large or small doses. Document all medications as soon as they are given. When you have made an error, reflect on what went wrong and ask how you could have prevented the error. Evaluate the context or situation in which a medication error occurred. This helps to determine if nurses have the necessary resources for safe medication administra- tion. Attend in-service programs that focus on the medications commonly administered. Ensure that you are well rested when caring for patients. Nurses make more errors when they are fatigued. Involve and educate the patient when administering medications. Address patients' concerns about medications before administering them (e.g., concerns about their appearance or side effects). Follow established policies and procedures when using technology to adminis- ter medications (e.g., automated medication dispensing systems [AMDSs] and bar-code scanning). Medication errors occur when nurses "work around" the tech- nology (e.g., override alerts without thinking about them). (Potter 583)

67. When should the nurse document medication administration?: Document medications IMMEDIATELY after administration; DO NOT delay.
68. What is TOP PRIORITY when a medication error occur?: Assess the patient FIRST; patient's safety and well being is priority!
69. What is the purpose of aspirating during IM administration?: Ensure proper placement of the needle Ensure no blood return to ensure syringe is NOT in vascular space
70. If blood return appears in the syringe during aspiration of IM administra- tion, what should the nurse do?: Withdraw the needle and prepare injection again
71. What steps should the nurse follow when administering a transdermal patch?: Remove old patch before applying new.

Inject 10 mL/second DO NOT rub sit after injection to prevent bruising

75. What needles sizes are used for IM injection: Obese - 3 inch Thin - 1/2 to 1 inch
76. What is the degree of insertion for ID, IM, and SQ injections?: ID- 5 to 15 degrees IM- 90 degrees SQ- 45 degrees [1 inch of tissue or thin] or 90 degrees [2 inch of tissue or obese]
77. What are the sites for subcutaneous injections?: outer posterior aspect of the upper arms, the abdomen from below the costal margins to the iliac crests, and the anterior aspects of the thigh alternative areas: scapular area of upper back and upper gluteal areas ROTATE SITES
78. How should the nurse determine the needle length and angle of insertion for a subcutaneous injection?: Based on patient's weight and estimate about of subcutaneous tissue
79. Why do subcutaneous injections take longer to absorb than intramuscular injections?: Fewer blood vessels are found under SQ tissue SQ tissue is NOT as richly supplied with blood as muscle
80. How should the nurse properly administer oral medication?: Place all the patients medications in the same cup, except for medications with pre administration assessments Place tablets into medicine cup WITHOUT removing wrapper ALWAYS hold bottle with label against palm of hand when pouring Crush pills if the patient has difficulty swallowing and liquid medication is not an option (consult with pharmacists) Administer liquid medication packaged in single-dose cup directly from the sin- gle-dose cup. Do not pour into medicine cup.

Draw up volumes of less than 10 mL in syringe designed for oral medication use without needle

81. Which wound bed tissue is characterized as soft white or yellow tissue; a stringy substance attached to the wound bed that needs to be removed before wound can heal?: Slough
82. Which wound bed tissue is characterized asked and moist; composed of new blood vessels indicating healing progression (full thickness repair)?: - Granulation Tissue
83. Which wound bed tissue is characterized as black or brown, hard, and necrotic; needs to be removed before wound can heal?: Eschar
84. Which type of drainage is characterized as clear or watery plasma?: Serous
85. Which type of drainage is characterized as thick, yellow, green, tan, or brown indicating infection?: Purulent
86. Which type of drainage is characterized as pale, pink, watery; a combina- tion of clear and red fluid?: Serosanguineous
87. Which type of drainage is characterized as bright red indicating active bleeding?: Sanguineous
88. When a wound is healed by surgical incision (wound edges are approxi- mated or closed) this is referred to as healing by intention?: Primary Intention 89. When a wound is left open until filled by scar tissue this is referred to as healing by intention? (burn, pressure ulcer, etc) This poses a greater risk for infection: Secondary Intention
89. Scarring can be severe with primary or secondary intention?: Secondary Intention
90. What is the term for a total separation of wound layers; protrusion of visceral organs through wound opening indicating EMERGENCY surgical repair?: Evisceration
91. What is the term for a partial or total separation of wound layer during an event that increases itraabdominal pressure indicating the needed for splint- ing the area to support the healing tissue during these events?: Dehiscence
92. When a patient complains that something has given way; what should the nurse associate this finding with?: Dehiscence
93. Which actions should the nurse take if the patient experiences an eviscer- ation?: Place sterile towels soaked in sterile saline over extruding tissues to reduce bacterial invasion or tissue drying NPO

105. What device can be used to splint and support the abdomen preventing dehiscence?: Abdominal binder 106. How should the nurse properly clean a pressure ulcer or wound site?: - Clean with each dressing change Move from wound towards surrounding skin Wipe only once. Change gauze to repeat. Use careful, gentle motions to minimize trauma Use only 0.9% normal saline solution to clean wounds Report any drainage or necrotic tissue
106. Which dietary source is needed for optimal wound healing including tissue growth and repair?: Protein Others: Fluid intake (30-35 mL/day), Vitamin C (collagen), and Calories (cell energy)
107. How do pressure ulcers develop?: Prolonged pressure or unrelieved pres- sure --> obstruction of blood flow --> ischemia --> necrotic tissue Examples: prolonged bed rest (most common), decreased mobility, decreased sensory perception, incontinence, poor nutrition, altered LOC 109. What is the term for a force of two surfaces moving across one another?- : Friction mechanical force when skin is dragged across bed linens Affect epidermis [top layer] of skin = sheet burn [red and painful] Restless pt., uncontrollable movements in pt., skin dragged rather then lifted from bed surface during position changes
108. What is the term for a sliding movement of the skin and subcutaneous tissue while the muscle and bones remain stationary or the skeleton slides down by skin is stationary?: Shear HOB elevated and the patient slides down the bed therefore the skin is fixed onto bed sheets Transferring pt. from bed to stretches when skin is pulled across bed
109. How does the nurse assess the wound or pressure ulcer?: Size of wound (L x W x H cm) Depth of the wound from the deepest point

Presence of undermining, tunneling (document by clock method, starting at patients head) , or sinus tract Pain Infection: Swollen/edematous, deep red color, hot, presence of drainage, presence of odor Wound edges may be separated with dehiscence present

112. How can the nurse or patient relieve pressure regarding positioning?: El- evate HOB 30 degrees 1.5-2 hour turning intervals Use a transfer device 2 hours or LESS sedentary in a chair Shift weight q15 minutes Sit on a cushion except riding or donut shaped devices DO NOT massage reddened areas
113. What are the phases of wound healing?: Hemostasis

• vessels constrict, clots form
• vessels then dilate, leak --> exudate Inflammatory
• 4 to 6 days post injury Proliferative Remodeling or Maturation
• 3 weeks post injury ** Stages HIP consider epithelization or partial thickness repair** ALL stages are considered full thickness repair

114. What indicates a complication of wound healing?: The incision has a mass bluish in color
115. Which type of incontinence is characterized as a loss of urine associated with an increase in intra-abdominal pressure (coughing, laughing, sneezing, lifting)?: Stress Incontinence
116. Which type of incontinence is characterized as a loss of urine IMMEDI- ATELY after the urge to void?: Urge Incontinence

135. If the nurse inserts an indwelling catheter and there is an immediate loss of 500 mL or more, what should the nurse to do avoid spasms and a decreased in BP and/or HR?: Clamp the catheter
136. After catheter insertion, the nurse should be aware of proper bag place- ment to reduce the risk of acquiring a urinary tract infection. Where should the nurse NEVER place the drainage bag?: Don't place bag on bedrail or floor and never above the patients waist or bladder
137. What would you include while educating your patient about preventing a UTI?: Maintain adequate fluid intake Urinate when you feel the urge Promote Complete Emptying Proper perineal care Take showers instead of baths Avoid using feminine hygiene products (pH imbalance) Acidify the urine (drink fluids high in acidity aka cranberry juice)

• DO NOT place the Foley catheter above the waist ALWAYS below the waist

138. Decreased urine output over time indicates : Dehydration
139. What are the causes of UTI's?: Poor perineal hygiene failure to wipe back to front after defecation inadequate hand washing frequent sexual intercourse (void after intercourse) catheter insertion (e. coli pathogens transmitted during surgical or catheterizations)
140. What are the signs and symptoms of a urinary tract infection?: dysuria (painful urination), fever, chills, nausea, vomiting, and malaise (when condition worsens, concentrated and cloudy urine (increased WBC's)
141. How can the nurse assess for urinary retention?: noninvasive bladder ultrasound device (bladder scanner) or intermittent catheterization to assess
142. If the patient is experiencing oliguria, what should the nurse assess for first?: Assess for bladder distention
143. What are restorative care actions that may be implemented?: Strengthen- ing pelvic floor muscles

• Kegal exercises Bladder retraining Habit training
• Improves voluntary control of urination Self- catheterization
• Spinal cord injury Maintenance of skin integrity Promotion of comfort

144. Can an indwelling catheter be inserted by a NAP?: NO NAP can clean cauterization and site, monitor I&O, and empty drainage bag
145. What are concerns regarding urine output volumes?: < 30 mL for more than two consecutive hours

2000 - 2500 mL/day Normal = 1,200 - 1,500 mL daily

146. What are the proper steps in obtain a urine collection?: -Spread labia minora -Clean from front to back, and each side of the labia (using a different gauze each pass)

• Patient imitates stream, then collect 30 to 60 mL

147. How should ROM exercises be carried out to prevent pain and when should the exercises be stopped?: Perform exercises slowly and DO NOT push past point of resistance/pain Stop movement if client complains of pain or if there is resistance (document areas of pain verbalized) 148. range of motion is when the patient moves all joints UNASSISTED- : Active ROM
148. range of motion is when the patient is unable to move independently therefore the nurse moves each joint: Passive ROM
149. What are alternatives to restraints?: Distraction Sitter Assess of Meds Alarms Pads Equipment locked Equipment secured Call light Make sure to document the alternatives attempted before putting the patient into restraints.
150. What are the different types of restraints?: Mummy wraps Seat belt Bed restraint

*Be sure to have patient dangle at bedside to check for dizziness/lightheadedness before standing up

157. Transfer and/or Positioning Considerations: - Use assistive devices to pre- vent injury to self and patient when transferring them Patients require various levels of assistance to move up in bed, move to the side-lying position, or sit up at the side of the bed, move to bed from the chair or chair to bed, etc. Always ask the patient to help to the fullest extent possible. GAIT belts are use to help healthcare personnel move patients safely (gait belt use is further reviewed in lab)
158. What is the proper position the nurse should be standing in when lifting or moving a patient?: Feet shoulder width apart, bend at knees, keep back straight, tighten abdominal muscles Keep patient as close to your center of gravity as possible
159. What is the collapse of alveoli that prevents the normal enhance of oxygen and carbon dioxide?: Atelectasis
160. How can the patient prevent atelectasis?: - perform breathing exercises every hour with incentive spirometry
161. What is the condition characterized by low oxygen at the cellular level resulting from anemia?: Hypoxemia Anemia (low oxygen carrying capacity on Hgb because decreased RBC's)
162. What is the clinical sign of hypoxia referred to as a general difficult in breathing?: Dyspnea
163. What are the signs and symptoms of dyspnea?: Accessory muscles, retrac- tion, nasal flaring, low 02 saturation
164. What are the early and late signs of hypoxia?: restlessness (earliest sign), decreased LOC, dizziness (early signs) cyanosis (late signs)
165. What is the proper method for oxygen delivery for COPD patients?: 1-3 L administered via nasal canula COPD patients require to be a little hypoxic

166. What is the term for needing pillow support to help expand the lungs because the patient is unable to lay flat due to shortness of breath?: Orthopnea
167. What is a manual method to mobilize pulmonary secretions?: Chest phys- iotherapy
168. When administering a nasal cannula > 4 L/minute has a drying effect on nasal mucosa. What should the nurse implement?: Attach nasal cannula to a humidified oxygen source up to a maximum of 6 /min
169. Which oxygen mask is used for short-term oxygen therapy administering a flow rate of 5 L/min or more to avoid rebreathing exhaled carbon dioxide retained in the mask?: Simple Face Mask
170. Which oxygen mask has a one way valve that prevents exhaled air from re- turning to reservoir bag administer at a minimum of 10 L/min ?: Non-rebreather face mask
171. Which oxygen mask delivers high concentrations of oxygen from 4 to 12 L/min depending on the flow control meter selected for the patient?: Venturi Mask
172. What are the ranges for blood pressure?: Normal = < 120 / < Prehypertensive = 120-139/ 80- Stage I HTN = 140-159 / 90-99 Stage II HTN = > 160 / > 100
173. What are the appropriate ranges for temperature?: 96.8° F to 100.4° F or 36° C to 38° C
174. Does the temperature of the body increase or decrease depending on the time of day?: Yes Temperature is usually lowest between 1:00 and 4:00 AM During the day body temperature rises steadily until a maximum temperature value at about 4: PM and then declines to early-morning levels Referred to as Circadian rhythm
175. What are the routes to assess temperature: Oral Tympanic (newborns, infants, children < 3) Rectal (more reliable when oral cannot be taken) Axilla (newborns and unconscious patients)