UGANDA NURSES AND MIDWIVES EXAMINATIONS BOARD
Diploma in Nursing (Extension) - Paper Code: DNE 111
Foundations of Nursing III
SECTION A: OBJECTIVE QUESTIONS
30 Marks
1. For which of the following reasons do nurses place the patient undergoing lumbar puncture in a flexed position? To
Explanation: Having the patient curl into a tight fetal position (maximal spinal flexion) physically separates the spinous processes. This widens the intervertebral spaces, allowing the spinal needle to easily pass between the vertebrae into the subarachnoid space without striking bone.
2. Which of the following terms refers to passing of urine containing gas?
Explanation: Pneumaturia is the medical term for the passage of gas or air in the urine. It is typically a strong clinical indicator of a fistula (an abnormal connection) between the bowel and the bladder, or a severe urinary tract infection caused by gas-producing bacteria.
3. Which of the following positions is appropriate for passing a nasogastric tube in a patient with a Glasgow coma scale of 5?
Explanation: A Glasgow Coma Scale (GCS) of 5 indicates severe coma. An unconscious patient lacks a gag reflex and cannot protect their own airway. Placing them in a lateral/lateral decubitus position during NG tube insertion prevents catastrophic aspiration into the lungs if the procedure induces vomiting. (Sitting up is strictly for conscious, alert patients).
4. Puncturing of the chest wall into the pleural cavity to remove fluid is known as
Explanation: Thoracocentesis (also known as pleural tap) is the invasive clinical procedure where a needle or catheter is introduced through the chest wall into the pleural space to drain abnormal accumulations of fluid (pleural effusion) or air.
5. The nurse recognises that the patient's tracheostomy is blocked when there is
Explanation: While the patient will undoubtedly experience hypoxia (desaturation) and respiratory distress, the definitive, mechanical proof that a thick mucus plug has completely occluded the inner lumen of the tracheostomy tube is the physical inability of the nurse to advance a suction catheter.
6. Which of the following actions does the nurse take to facilitate cast drying, in a patient who has just had a P.O.P?
Explanation: A fresh Plaster of Paris (P.O.P) cast must dry evenly through exposure to circulating room air. Turning the patient frequently ensures all sides of the cast are exposed to air. Applying localized heat (heating pads) dries the outer shell while leaving the inside dangerously damp, which can cause thermal burns and cast structural failure.
7. After a lumbar puncture procedure is completed, the nurse instructs the patient to
Explanation: The patient must remain strictly supine (flat on their back) without a pillow for several hours post-procedure. This prevents the gravity-dependent leakage of cerebrospinal fluid (CSF) through the dural puncture hole, which is the primary cause of severe, debilitating spinal headaches.
8. Which of the following instructions does the nurse give to a patient prior to an abdominal paracentesis?
Explanation: Emptying the bladder immediately before paracentesis is a critical safety protocol. A full, distended bladder rises up out of the pelvis and into the abdominal cavity, placing it at a massive risk of being accidentally punctured and ruptured by the large trocar needle.
9. A feeding tube is recommended when a patient is
Explanation: While mouth sores or dysphagia are contributing factors, the ultimate clinical indication that triggers the insertion of a Nasogastric or PEG tube is when the patient's oral intake is physically insufficient to meet their basal metabolic and nutritional requirements for survival.
10. Which of the following nursing measures is most effective for clearing respiratory secretion from a patient with a Glasgow coma scale of 5?
Explanation: A patient with a GCS of 5 is in a deep coma and has lost their gag and cough reflexes. They cannot perform "effective coughing". Because secretions pool deeply in the respiratory tract and the patient is likely intubated to protect their airway, endotracheal suctioning is the most direct and effective method for clearance.
11. The most appropriate nursing diagnosis for a patient who states "I have lost shape because of a gastrostomy tube" is
Explanation: The patient's verbalization explicitly indicates profound dissatisfaction and distress regarding a permanent structural change to their physical appearance. "Disturbed body image" is the exact NANDA nursing diagnosis used when a patient struggles to mentally adapt to surgical modifications like stomas or feeding tubes.
12. Which of the following is an appropriate type of drain for draining an abscess?
Explanation: A Penrose drain is a soft, flat, flexible rubber tube that acts as an open, passive gravity drain. It is the standard clinical choice for draining localized pockets of thick, purulent infection (abscesses), as it keeps the wound tract open and allows pus to freely exit onto the dressing.
13. Which nursing procedure is appropriate for a patient verbalising abdominal discomfort due to flatulence?
Explanation: Severe abdominal distention and painful cramping caused by trapped intestinal gas (flatulence) that the patient cannot pass naturally is mechanically relieved by inserting a rectal tube (flatus tube) to directly vent the gas from the lower bowel.
14. The rationale for raising the foot of a bed for a patient on traction is
Explanation: Note on terminology: The physiological goal of elevating the foot of the bed (Trendelenburg) during lower limb traction is to utilize the patient's own body weight to provide counter-traction. This prevents the patient from sliding down the bed, thereby ensuring the pull of the weights provides a constant, effective traction force.
15. The hydration status of a patient on a feeding tube is monitored by
Explanation: Maintaining a strict 24-hour Intake and Output (I&O) chart—meticulously recording all enteral formula, water flushes, and IV fluids against all urine, stool, and gastric aspirate output—is the most immediate and clinically accurate method to evaluate hydration and detect fluid overload or deficit.
16. The priority nursing care intervention implemented when receiving a post operative patient in theatre is to
Explanation: Based on the universal ABC (Airway, Breathing, Circulation) life support principles, the absolute first action upon receiving an unconscious or semi-conscious patient from anesthesia is to verify they have a patent airway and are maintaining adequate, spontaneous breathing.
17. Which of the following does the nurse observe on a patient who is on Gallow's traction?
Explanation: Gallows traction suspends an infant's legs vertically using adhesive or non-adhesive skin traction bandages. It is critical that these bandages are applied completely flat without wrinkles; localized high pressure from a wrinkle will rapidly cut off circulation, causing severe skin necrosis and compartment syndrome in the fragile limbs.
18. Sometimes stitches are removed on alternative days to
Explanation: In large surgical wounds or wounds under tension (like abdominal incisions), removing all sutures at once can cause catastrophic wound dehiscence (gaping open). Removing alternate sutures (e.g., leaving every second stitch in place for a few extra days) safely tests the tensile strength of the healing tissue.
19. Which of the following measures can help a patient with urine retention pass urine?
Explanation: This is a classic non-invasive nursing intervention. The sound of running water acts as a powerful psychological and auditory sensory stimulus, which triggers parasympathetic nervous system reflexes to relax the urinary sphincter and initiate micturition.
20. When bandaging a limb, the nurse stands
Explanation: A fundamental principle of bandaging is that the nurse must stand directly in front of the patient. This positioning allows the nurse to maintain constant visual contact with the patient's face to monitor for grimaces or signs of severe pain, indicating the bandage is being applied too tightly.
21. Which of the following nurse's observations indicates that the patient's underwater seal drainage system is faulty?
Explanation: "Tidaling" (the rhythmic rising and falling of fluid in the water seal chamber with breathing) confirms the system is patent and communicating with the pleural space. A sudden absence of tidaling indicates a fault—usually that the tubing is severely kinked, blocked by a clot, or the patient is lying on it (unless the lung has fully re-expanded).
22. A good practice implemented while managing an underwater seal drainage includes
Explanation: Gravity is essential for a chest tube to drain properly. The collection chamber must always be kept significantly below the level of the patient's chest to prevent the catastrophic backflow of drained fluid or contaminated water back into the pleural cavity.
23. When is it beneficial to clamp a patient's chest tube?
Explanation: Chest tubes should rarely be clamped because it risks causing a fatal tension pneumothorax. However, doctors specifically order a temporary "clamping trial" just prior to removing the tube to test if the patient's lung can remain inflated and stable on its own without the aid of the drainage system.
24. For which of the following reasons do nurses request patients undergoing radiological exams to remove metallic objects? To
Explanation: Metal objects (jewelry, underwire bras, zippers) are highly radiopaque. On X-rays and CT scans, they cast solid white shadows (artifacts) over the image, completely obscuring underlying bones and tissues and making accurate medical diagnosis impossible.
25. For which of the following procedures do nurse request patients to fast?
Explanation: A barium enema is a fluoroscopic examination of the lower gastrointestinal tract. To achieve clear visualization of the mucosal lining, the entire colon must be completely empty of stool and food residue, requiring strict fasting (NPO) and rigorous bowel preparation beforehand.
26. During provision of stoma care, nurses apply a pseudo-cream on the surrounding skin to
Explanation: The effluent (especially from an ileostomy) is rich in highly corrosive digestive enzymes and gastric acids. Barrier creams and pastes are applied meticulously around the stoma to form a physical protective shield, completely preventing the acidic effluent from digesting and excoriating the delicate peristomal skin.
27. A client's sense of hearing is assessed using a/an
Explanation: While an otoscope is used to visually inspect the physical ear canal, a tuning fork is the diagnostic instrument struck and placed on or near the skull (Weber and Rinne tests) to specifically assess and differentiate between conductive and sensorineural hearing loss.
28. Which of the following findings reported after stoma care indicates that the stoma is healthy?
Explanation: A dry stoma, retraction, and mucocutaneous separation are all severe, unhealthy surgical complications. Conversely, observing that the appliance flange has been applied smoothly and adheres perfectly without wrinkles is an indicator of successful, healthy stoma care that will prevent leakage.
29. For which of the following reasons should range of motion exercises NOT be performed? To
Explanation: Range of Motion (ROM) exercises are low-intensity movements specifically designed to preserve joint flexibility, prevent crippling contractures, and stimulate synovial fluid production. They do not raise the heart rate or burn sufficient calories to act as a weight-loss or cardiovascular conditioning program.
30. The length of a naso-gastric tube for insertion is measured from the
Explanation: To approximate the exact distance from the nares to the stomach, the universally accepted "NEX" measurement technique is used. The nurse holds the tube at the tip of the Nose, routes it to the Earlobe, and then extends it straight down to the Xiphoid process of the sternum.
SECTION B: SHORT ESSAY QUESTIONS
10 Marks
Question 31: Nursing Roles in the Recovery Room
(5 Marks)
Outline five (5) roles of the nurse in the recovery room:
- Keeping the Airway Open: The nurse must watch the patient's breathing very closely to make sure they are getting enough oxygen. They often turn the patient on their side to prevent them from choking on saliva or vomit while they are still sleepy from the anesthesia.
- Checking Vital Signs Regularly: Nurses take blood pressure, heart rate, and oxygen levels every few minutes. This helps them quickly spot dangerous changes, such as heavy internal bleeding or heart problems, before they become life-threatening.
- Checking Wakefulness and Movement: As the anesthesia wears off, the nurse checks if the patient can wake up, answer simple questions, and move their arms and legs. This ensures the brain and nerves are recovering properly after the surgery.
- Controlling Pain and Sickness: Patients often wake up feeling sharp pain or an upset stomach (nausea). The nurse gives medicine through the IV to keep the patient comfortable and calm, which helps the body start healing faster.
- Watching the Wound and Tubes: The nurse looks at the bandages to see if there is too much blood soaking through. They also make sure all the tubes, like IV lines and urine bags, are connected and working correctly without any kinks or blocks.
- Promoting Safety and Comfort: Because patients are often confused or "loopy" when they wake up, the nurse stays nearby to prevent them from falling out of bed or accidentally pulling out their medical tubes.
Question 32: Nursing Concerns for Skeletal Traction
(5 Marks)
State five (5) nursing concerns for a patient on skeletal traction:
- High Risk for Severe Infection (Osteomyelitis): The metal pins go through the skin and directly into the bone, creating a pathway for germs. The nurse must watch for redness or pus at the pin sites to prevent a deep bone infection.
- Neurovascular Compromise: Swelling or pressure can squeeze blood vessels and nerves in the limb. The nurse checks for "the 5 Ps" (like pain, paleness, or numbness) to ensure the arm or leg is still getting enough blood and has feeling.
- Impaired Skin Integrity (Pressure Ulcers): Because the patient must stay in bed for a long time, the weight of their body can damage the skin. Nurses look for signs of skin breakdown on the tailbone, heels, and elbows caused by constant pressure.
- Thromboembolic Complications: Staying still for weeks causes blood to move slowly in the legs, which can lead to dangerous blood clots (DVT). If a clot breaks loose and travels to the lungs, it can be life-threatening.
- Psychosocial Distress and Sensory Deprivation: Being confined to a bed for a long time leads to extreme boredom, anxiety, and a feeling of having no control. This can cause the patient to become very sad or mentally exhausted during their recovery.
- Risk of Malalignment: If the traction weights or the patient's body position are not exactly right, the broken bone might not line up properly. This can lead to the bone healing in the wrong position, causing long-term physical problems.
SECTION C: LONG ESSAY QUESTIONS
60 Marks
Question 33: Lumbar Puncture Procedure and Complications (20 Marks)
Important Note on Grading Framework
In standard practical nursing examinations, full marks for procedural preparation are awarded by stating the specific Action coupled with its underlying physiological or clinical Rationale.
(a) Describe the preparation of a patient for lumbar puncture procedure (15 marks):
- Action: Review the patient's chart and ensure informed, written consent has been obtained by the physician.
Rationale: To comply with legal requirements and ensure the patient understands the risks. - Action: Clearly explain the step-by-step procedure to the patient in simple language.
Rationale: To alleviate severe anxiety and gain maximum patient cooperation during the painful procedure. - Action: Provide absolute privacy by screening the bed and closing adjacent windows/doors.
Rationale: To protect the patient's dignity during physical exposure. - Action: Offer a bedpan or instruct the patient to empty their bladder and bowels prior to positioning.
Rationale: To promote physical comfort and prevent involuntary soiling during the stressful procedure. - Action: Assemble all sterile requirements on a trolley (LP needles, syringes, local anesthetic, sterile drapes, specimen bottles, manometer).
Rationale: To ensure a smooth, uninterrupted procedure without leaving the patient's bedside. - Action: Ensure the procedure is done on a hard surface or place a fracture board under the mattress.
Rationale: A hard surface prevents the bed from sagging, maintaining perfect spinal alignment. - Action: Position the patient in a lateral decubitus position with their back resting exactly at the edge of the bed.
Rationale: Brings the spine closer to the physician, ensuring easy access to the puncture site. - Action: Instruct the patient to draw their knees tightly to their chin, fully flexing the hips and neck (fetal position).
Rationale: Severe flexion maximizes the separation between the lumbar vertebrae, opening the subarachnoid space. - Action: Explain the critical importance of remaining absolutely still during needle insertion.
Rationale: Sudden movements can cause the needle to break or inflict severe trauma to the spinal cord. - Action: Adjust the patient's gown to expose only the L3-L4 or L4-L5 lumbar region.
Rationale: To maintain strict privacy and prevent the patient from suffering hypothermia. - Action: Adjust an examination lamp to provide brilliant, direct lighting on the exposed lumbar area.
Rationale: Ensures the physician can accurately identify anatomical landmarks (iliac crests). - Action: Open the sterile packs and pour antiseptic solution (e.g., iodine) into a sterile gallipot.
Rationale: To assist the doctor in maintaining a sterile field for skin preparation. - Action: Perform meticulous hand hygiene with soap/water or sanitizer, and put on clean/sterile gloves.
Rationale: To maintain strict asepsis and prevent introducing pathogens into the spinal canal. - Action: Support and hold the patient firmly but gently in the flexed position during the entire procedure.
Rationale: To provide psychological comfort and physically prevent them from uncurling out of position. - Action: Position the prepared equipment trolley within immediate, easy reach of the physician.
Rationale: To promote ergonomic efficiency and avoid breaking the sterile field.
(b) Outline five (5) complications that may arise following lumbar puncture (5 marks):
- Severe Spinal Headache: Caused by continuous leakage of CSF through the dural defect, leading to a drop in intracranial pressure.
- Meningitis / Infection: The introduction of skin bacteria into the sterile subarachnoid space due to poor aseptic technique.
- Epidural or Subdural Hematoma: Bleeding into the spinal canal from traumatized blood vessels, potentially causing severe nerve compression.
- Tonsillar Herniation: Sudden, fatal shifting of brain tissue down through the foramen magnum if the procedure is performed while Intracranial Pressure (ICP) is excessively high.
- Transient Radicular Pain: Temporary, sharp, shooting pain or numbness in the legs caused by the needle irritating a spinal nerve root.
Question 34: Wound Dressing & Gastrostomy Nursing Diagnoses (20 Marks)
(a) Outline four (4) indications for wound dressing (4 marks):
- To absorb excess inflammatory exudate and drainage from the wound bed.
- To protect the raw, healing tissue from mechanical trauma and environmental contamination.
- To apply pressure to the wound site to promote hemostasis and prevent hematoma formation.
- To provide optimal thermal insulation and maintain a moist environment, which rapidly accelerates tissue granulation.
(b) Outline four (4) actual and four (4) risk nursing diagnoses for a patient who has undergone gastrostomy due to cancer of the oesophagus (16 marks):
Actual Diagnoses:
- Inadequate protein energy intake related to inability to ingest food orally due to complete esophageal tumor obstruction.
- Acute pain related to surgical incision through the abdominal wall and insertion of the gastrostomy tube.
- Impaired skin integrity related to the surgical stoma creation and the highly corrosive leakage of acidic gastric contents around the tube.
- Disrupted body image related to the physical presence of a permanent feeding tube protruding from the abdomen and the loss of normal eating functions.
Risk Diagnoses:
- Risk for infection related to the surgical abdominal wound, presence of a foreign body (the tube), and potential contamination during feeding.
- Risk for aspiration related to delayed gastric emptying, gastroesophageal reflux, or improper flat positioning during and immediately after tube feeding.
- Risk for inadequate fluid volume related to inadequate administration of free-water flushes through the tube combined with high metabolic demands.
- Risk for injury (tube displacement / dislodgement) related to accidental pulling by a confused patient or improper securement of the external bumper.
Question 35: Nasogastric Tube Management & Gastric Residuals (20 Marks)
(a) Outline five (5) possible causes of a poorly draining nasogastric tube indicating a solution for each (10 marks):
| Possible Cause | Nursing Solution / Intervention |
|---|---|
| 1. Tube is blocked internally: Thick mucus, crushed pill fragments, or coagulated enteral formula have clogged the lumen. | Attach a 50ml syringe and gently flush the tube using warm water, normal saline, or an approved enzymatic declogging solution to dissolve the blockage. |
| 2. Tube is kinked: The soft tubing has become twisted or bent back on itself either externally or inside the stomach. | Inspect the entire length of the external tubing and untwist it. If internal, slightly advance or withdraw the tube 1-2 cm to straighten the kink. |
| 3. Tip resting against mucosa: The distal end/eyes of the tube are stuck flat against the gastric wall, creating a vacuum seal. | Reposition the patient (e.g., turn them onto their left side) or gently rotate/pull back the tube a few millimeters to free the tip from the stomach lining. |
| 4. Tube displaced upwards: The tube has slipped backward out of the stomach fluid pool and into the esophagus. | Verify proper placement via pH testing or x-ray, then carefully advance the tube deeper into the stomach if clinically indicated and ordered. |
| 5. Suction equipment failure: The wall suction pressure is too low, the tubing is disconnected, or the collection canister is completely full. | Troubleshoot the machine: ensure all connections are airtight, adjust the suction pressure dial to the prescribed setting, and empty or replace the full drainage canister. |
(b) Outline ten (10) specific actions that nurses perform while checking the gastric residual (10 marks):
- Explain the rationale of the procedure to the patient to gain their cooperation and reduce fear.
- Perform strict hand hygiene and put on clean examination gloves to adhere to standard infection control protocols.
- Elevate the head of the bed to a semi-Fowler's or high-Fowler's position (30-45 degrees) to utilize gravity and prevent aspiration.
- Place a clean towel or disposable absorbent pad across the patient's chest to protect their clothing and bedding from accidental spills.
- Pinch or clamp the nasogastric tube securely before opening the port to prevent stomach contents from leaking out and air from rushing in.
- Firmly attach a large-bore (50ml or 60ml) Toomey or catheter-tip syringe to the proximal end of the feeding tube.
- Unclamp the tube and gently but steadily pull back on the syringe plunger to aspirate the fluid currently sitting in the stomach.
- Observe and accurately measure the total volume of fluid withdrawn, noting its specific characteristics (color, consistency, and odor).
- Slowly re-instill the entire aspirated volume back into the stomach (if within normal hospital policy limits, e.g., < 250ml) to prevent severe metabolic alkalosis and electrolyte depletion.
- Flush the tube vigorously with 30ml of tap or sterile water after re-instillation to clear the lumen, then document all findings meticulously in the Intake and Output chart.