Test 5 Questions

What vitamin deficiency causes malformation of the skeletal tissue in growing kids?

Vitamin D

Found in liver and eggs?

Vitamin K

Pressure injury

damage of the skin and the subcutaneous tissue caused by prolonged pressure

Annual, starting at age 45

guaiac fecal occult blood test (gFOBT) and Fecal immunochemical test (FIT0)

Identify the appropriate times to verify enteral tube placement by pH testing. (Select all that apply.) A. Before each intermittent feeding. B. At least once every 6 hours during continuous feedings. C. Before administration of medications through the tube. D. Immediately after administration of medications through the feeding tube. E. Upon discontinuing the feeding tube.

A, B, C

Which of the following are reasons for performing lab tests? (Select all that apply.) A. Aids in diagnosis of health care problems B. Meets requirements of third party payers (i.e., insurance companies) C. Provides information about the stage of a disease process D. Reduces the need for medication therapy E. Measures a patient's response to therapy

A. Aids in diagnosis of health care problems C. Provides information about the stage of a disease process E. Measures a patient's response to therapy

When should placement of a feeding tube be verified? (Select all that apply.) A. Before administering formula through the tube. B. Before administering medications through the tube. C. Before administering water through the tube. D. At least once every 6 hours when continuous feedings are given. E. If the patient is complaining of a sore throat. F. Only when the health care provider orders it.

A. Before administering formula through the tube. B. Before administering medications through the tube. C. Before administering water through the tube. D. At least once every 6 hours when continuous feedings are given.

Which of the following nursing actions helps reduce the risk of aspiration? A. Elevating the head of the patient's bed. B. Performing nasotracheal suctioning before instilling a tube feeding. C. Encouraging the patient to deep breathe and cough. D. Keeping the patient well hydrated.

A. Elevating the head of the patient's bed.

Which of the following is counted as output? A. emesis B. ice chips C. ice cream D. meat

A. Emesis

dentify the indicators of a UTI: (Select all that apply.) A. Fever. B. Urinary drainage. C. Complaints of pain with urination (dysuria). D. Hypothermia. E. Lower abdominal pain. F. Cloudiness of the urine.

A. Fever. C. Complaints of pain with urination (dysuria). E. Lower abdominal pain. F. Cloudiness of the urine.

The nurse is collecting supplies to perform a Gastroccult test. The nurse sees both Gastroccult and Hemoccult test slides. Which of the following indicates correct understanding by the nurse of the differences between Gastroccult and Hemoccult testing? (Select all that apply.) A. Gastroccult testing tests pH and occult blood. B. There is no difference; they are the same test. C. Hemoccult testing takes longer because it is sent to the lab. D. Hemoccult testing tests only for occult blood. E. Gastroccult results are unaffected by diet or medicine.

A. Gastroccult testing tests pH and occult blood. D. Hemoccult testing tests only for occult blood.

What is the best way to prevent pressure ulcers? A. Repositioning B. Ambulating C. Hygiene D. Wound care

A. Repositioning

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately

1,2,3,5

Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1,2,6,8

When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area

1,3

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1,3,4

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1,3,5

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder

1,4

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.

1,4,5

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.

1,5,6

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.

1

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

1

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

3

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more.

3

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan

3

The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) 1. First child at the age of 26 years 2. Menopause onset at the age of 49 years 3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

3. Have the patient relax the foot while lying supine 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? 1. The student stands at a midline position behind the patient, observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine."

3. You do not listen with the bell you listen to the lungs with the diaphragm

What should your Potassium level be?

3.5-5.0 mEq/L

Elyse Russo is a 17-year-old high-school student who struggles with obesity. She is 5 feet 4 inches and weighs 210 pounds. She goes to a weight-loss clinic to try to get her weight and eating habits under control. Josh is a nursing student who works at the weight-loss clinic two times a week while in nursing school. He took the job to help pay for nursing school and also to help him learn how to interact with various types of people since he knew that as a nurse he would have to interact with the public. At first Josh didn't enjoy his job because he couldn't understand how people allowed themselves to become obese. Over time he learned to develop compassion for his patients, and he gained an understanding of the various causes of obesity. In addition, he learned a great deal about nutrition, healthy cooking, and controlling portions. Josh calculates Elyse's body mass index (BMI). Her BMI is _________.

37.3(obsess)

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?

4

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4,3,2,5,1

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history

1. Appearance and behavior

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) 1. Change the dressing using sterile technique. 2. Change TPN containers every 48 hours. 3. Change the TPN tubing every 24 hours. 4. Monitor glucose levels to watch and assess for glucose intolerance. 5. Elevate head of the bed 45 degrees to prevent aspiration.

1. Change the dressing using sterile technique 3. Change the TPN tubing every 24 hours

A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action? 1. Have the patient turn on the left side and perform a Valsalva maneuver. 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line. 3. Have the patient take a deep breath and hold it. 4. Notify the health care provider immediately

1. Have the patient turn on the left side and perform a Valsalva Maneuver

Which action can a nurse delegate to assistive personnel (AP)? 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client's tolerance of the enteral feeding

1. Performing glucose monitoring every 6 hours on a patient

The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5. Serum BUN

1. Serum total protein 5. Serum BUN

Your diet should consist of 2/3 _______1_______ fat and 1/3 ________2_________ fat.

1. Unsaturated 2. Saturated

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. 2. Establish a toileting schedule. 3. Recommend that she be evaluated for an indwelling catheter. 4. Start a bladder-retraining program.

2

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther.

2

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.

2

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

2

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication.

2,3

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal

2,3

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2,4

Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

2,5

A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? 1. Fastening tube to the gown with new tape 2. Placing client supine while giving a bath 3. Monitoring the client's weight as ordered 4. Ambulating patient with enteral feedings still infusing

2. Placing client supine while giving a bath

The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea

2. Sepsis 3. Hemorrhage 4. Skin Breakdown

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Add salt to every meal. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

A nurse is preparing to administer medication through a feeding tube. Which of the following supplies should the nurse include, besides the medication, to perform this procedure? (Select all that apply.) MAR. Sterile gloves. Gastric test strip. Water. Appropriately sized medication syringe. Graduated container and straw.

A nurse is preparing to administer medication through a feeding tube. Which of the following supplies should the nurse include, besides the medication, to perform this procedure? (Select all that apply.) MAR. Correct Sterile gloves. Gastric test strip. Correct Water. Correct Appropriately sized medication syringe. Correct Graduated container and straw.

Identify signs and symptoms of accidental respiratory migration of a feeding tube. (Select all that apply.) A. Coughing. B. Choking. C. Decreased pulse oximetry. D. Sore throat. E. Distention.

A, B, C

Mrs. Pearl Butler is a 71-year-old Caucasian who is admitted to the medical-surgical unit after undergoing a thyroidectomy secondary to thyroid cancer. Chemotherapy and radiation were not aggressive enough in treatments; thus she opted to have her thyroid gland removed. She is resting comfortably in her room with her husband present. The nurse assigned to care for Mrs. Butler has already taken her vital signs: temperature 98.7° F, blood pressure 112/82 mm Hg, pulse = 62 beats/min, and respirations 22 breaths/min on room air. The nurse is now checking the medication administration record (MAR) to see what medications Mrs. Butler has ordered. To determine which bowel elimination methods work best for Mrs. Butler, the nurse asks which of the following pertinent assessment questions? (Select all that apply.) A. "What is your regular bowel routine?" B. "Do you use laxatives, enemas, or stool softeners at home?" C. "What is your typical daily diet?" D. "Do you take iron supplements at home?" E. "What time do you go to sleep each evening?"

A, B, C, D Rationale: Asking patients about their regular bowel routine, bowel medications used at home, diet, and use of supplements helps determine the best bowel plan for the patient.

Which of the following patients may benefit from enteral nutrition? (Select all that apply.) A. A patient who has a brain injury. B. A patient with oral cancer. C. A patient with paralytic ileus. D. A patient with burns of the lower extremities. E. A patient who had a CVA (stroke) and has dysphagia (difficulty swallowing).

A, B, D, E

Enteral feedings may be administered by: (Select all that apply.) A. Continuous feeding pump. B. Through a large vein. C. Intermittent gravity drip. D. Through a central vascular access device. E. Intravenously.

A, C

You have inserted an NG feeding tube. The patient vomited during insertion and continues to gag. What action(s) should you take? (Select all that apply.) A. Suction airway as needed. B. Place patient in high-Fowler's position. C. Position patient on side. D. Contact health care provider for possible chest x-ray. E. Have patient sip ice water.

A, C, D

A nurse is reviewing the policy for irrigating a feeding tube. What information should the nurse include that would address accurate principles of infection control when performing this procedure? (Select all that apply.) A. Change irrigation bottle every 24 hours. B. Use only sterile water for irrigation. C. Perform hand hygiene and apply clean gloves to irrigate a feeding tube. D. Tap water should not be used for feeding tube irrigation with neonates. E. Sterile water may be required for patients who are critically ill.

A,C,D,E

A nursing instructor is reviewing the skill of irrigating a feeding tube with a group of nursing students. Which statement(s), if made by the nursing student, is(are) accurate, indicating learning has occurred? (Select all that apply.) A. "Curdled enteral formula and improperly crushed medications are the most common causes of feeding tube occlusion." B. "It is unnecessary to irrigate a feeding tube if the patient's medications are in liquid form." C. "It is acceptable to delegate routine irrigation of a feeding tube to NAP." D. "It is unnecessary to irrigate nasoenteric feeding tubes; only nasogastric tubes require irrigation." E. "Bowel sounds should be present if the patient is receiving tube feedings." F. "The patient should be placed in a high Fowler's or semi-Fowler's position for feeding tube irrigation."

A,E,F

A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? A. "This is a normal occurrence after having a catheter in place for more than several days." B. "It sounds like you have a UTI. I will notify your health care provider." C. "I will need to inspect your perineal area and wash and dry the area." D. "If these symptoms continue, I will notify your health care provider to see if we can reinsert the catheter."

A. "This is a normal occurrence after having a catheter in place for more than several days."

Which of the following is the best example of documentation on a patient with a urinary catheter? A. Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag. B. Catheter care provided. 14 French catheter intact with approximately 30 mL urine in bedside drainage bag. C. Unable to palpate urinary bladder. Patent denies discomfort; indwelling catheter draining well. D. Patient instructed on signs and symptoms of UTI and how to prevent while catheterized.

A. Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag.

The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her.

4. Stop feeding her

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When the central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings

4. When 75% of the patient's nutritional needs are met by the tube feedings

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

5, 7, 2, 4, 1, 6, 3, 8, 9

Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5,8,7,2,6,3,4,1

The normal adult voiding frequency is

8 times per day

How many kcal/gm do lipids yield?

9

A group of nursing students are studying together. They are discussing the differences between parenteral and enteral nutrition. Which statement, if made by one of the students, indicates further instruction is needed? A. "Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube." B. "Enteral nutrition is preferred because it is less expensive than parenteral nutrition and maintains functioning of the gut." C. "An example of the parenteral route is subcutaneous or IM injections, or the IV route." D. "Gastric feedings may be given to patients with a low risk of aspiration. If there is a risk of aspiration, jejunal feeding is the preferred method. Parenteral nutrition is provided if the patient's GI tract is nonfunctional."

A

A nurse is preparing medications to be administered through a patient's feeding tube. The patient is to receive nifedipine XL. Which of the following would be a correct action by the nurse? A. Hold the drug and notify the health care provider. B. Crush the tablet and dissolve in 30 mL of tepid water. C. Administer the medication every 12 hours rather than every 6. D. Encourage the patient to swallow the medication whole.

A

For intestinal placement of a feeding tube, in what position should the nurse place the patient while waiting for radiological confirmation of correct placement? A. On the patient's right side B. In a high-Fowler's position C. In a left lateral position D. Lying flat

A

The nurse observes a confused patient pulling at her NG feeding tube. As the nurse retapes the tube to the bridge of the patient's nose, the nurse notices that the mark on the tube has moved away from the naris. What action should the nurse take? A. Advance the tube until the mark is even with the naris and verify correct tube placement. B. Secure the tape on the patient's nose well with the tube in the current location. C. Remove the tube. D. Restrain the patient's hands before leaving the room. E. Pull back on the tube.

A

The nurse suspects the patient's feeding tube has migrated. Which of the following would indicate the greatest risk related to tube migration? A. Dyspnea and decreased oxygen saturation. B. Pain and gastric aspirate hemoccult positive. C. Absence of bowel sounds. D. Inability to flush the feeding tube.

A

Which medication administration activity can be delegated to nursing assistive personnel (NAP)? A. Application of a skin barrier cream to the perineal area. B. Application of a transdermal patch. C. Instillation of eye drops. D. Instillation of ear drops. E. Use of MDIs. F. Inserting vaginal medications. G. Inserting rectal medications.

A

Which source is likely to have a pH test result of 1 to 5? (Select all that apply.) A. Stomach of fasting patient. B. Pleural fluid from tracheobronchial tree. C. Intestine of fasting patient.

A

The patient is presently receiving intermittent tube feedings of 120 mL every 6 hours. The health care provider's orders state: Jevity formula feeding 240 mL every 6 hours per feeding tube, increase per patient tolerance. Which of the following assessment data indicate patient intolerance of the tube feeding and therefore inability of the rate to be increased? (Select all that apply.) A. Diarrhea. B. Abdominal distention and discomfort. C. Nausea. D. Flatulence. E. Thirst. F. Residual volume greater than 500 mL.

A. Diarrhea B. Abdominal dissension and discomfort C. Nausea F. Residual volume greater than 500 mL.

The patient is receiving a continuous enteral feeding. Which of the following assessment findings would require follow-up? A. Gastric residual of 375 mL. B. Bowel sounds present in all four quadrants. C. pH of gastric contents 5.0. D. Less than 10 mL of aspirate from nasoenteric tube.

A. Gastric residual of 375 mL.

Which of the following is an appropriate nursing action to prevent a complication of nasogastric (NG) tube feedings? A. Keep the head of the patient's bed elevated at least 30 degrees. B. Leave the feeding tube unclamped and unplugged between feedings. C. Allow the syringe to empty of feeding before adding more to the syringe. D. Change the feeding tube bag and tubing every 72 hours for a continuous feeding.

A. Keep the head of the patient's bed elevated at least 30 degrees.

Which of the following is an example of a simple carb? A. Oranges B. Fiber C. Steak D. Water

A. Oranges

The nurse is inserting an NG feeding tube. Which step in the procedure is inaccurate, indicating further instruction is needed? A. Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water. B. Hand patient a cup of water with a straw. Gently insert the tube through the nostril to back of throat. Have patient flex head toward chest. Give small sips of water and advance the tube as patient swallows. Rotate tube 180 degrees while inserting. C. When tip of tube reaches carina, stop and listen for air exchange from distal portion of tube. Continue to advance tube until desired length has been passed. Check back of throat with a penlight and tongue blade. Check placement of tube. D. Mark exit site on tube with indelible ink. Apply tincture of benzoin to nose and allow to become "tacky." Remove gloves and apply stabilization device. Obtain an x-ray film to verify tube placement.

A. Perform hand hygiene and place patient in left lateral position. Determine length of tube from the xyphoid process to the tip of the patient's nose. Insert stylet into feeding tube. Inspect nares. Dip end of tube in ice water.

Which of the following pH test results on the aspirate of a patient who receives intermittent feedings indicates that the feeding tube is in the stomach? A. pH of 1 to 5. B. pH of 6 or greater. C. pH greater than 5. D. pH of 1 to 11.

A. pH of 1 to 5.

A patient just vomited and the nurse is going to test the emesis for occult blood. Which of the following may increase the likelihood of a positive Gastroccult test result? (Select all that apply.) The patient: A. takes an iron preparation. B. ten year history of steroid use. C. is on a long-term nonsteroidal anti-inflammatory drug regimen. D. consumes carbohydrates. E. complains of nausea.

A. takes an iron preparation. B. ten year history of steroid use. C. is on a long-term nonsteroidal anti-inflammatory drug regimen.

The nurse has instructed a patient on the procedure for obtaining a midstream urine specimen. The patient asks, "Why does the urine sample need to be collected in this manner?" The nurse's best response is: A."The initial stream flushes out microorganisms that accumulate at the opening of the urinary tract." B."It is performed this way in order to verify fresh urine is obtained for testing, increasing accuracy." C."This method will prevent you from developing urinary incontinence by strengthening perineal muscles." D."By catching the middle of the urine stream, it provides time to ensure the bladder is completely empty."

A."The initial stream flushes out microorganisms that accumulate at the opening of the urinary tract."

How much urine is needed to perform a urine culture? A.At least 3 mL B.At least 20 mL C.At least 1 mL D.90 to 120 mL

A.At least 3 mL

What abnormal characteristics should be reported after obtaining a urine sample? (Select all that apply.) A.Presence of sediment B.Cloudiness of urine C.Light amber color D.Slight musty odor E.Yellow color F.Blood-tinged

A.Presence of sediment B.Cloudiness of urine F.Blood-tinged

Which of the following are normal characteristics of urine? (Select all that apply.) A.pH 4.6 to 8 B.Red blood cell count greater than 2 C.Specific gravity 1.010 to 1.025 D.Protein absent E.Casts present F.White blood cells 0 to 4

A.pH 4.6 to 8 C.Specific gravity 1.010 to 1.025 D.Protein absent F.White blood cells 0 to 4

The nurse is giving report to another nurse regarding a patient who receives medications through a feeding tube. The nurse states that in order to prevent clogging of the tube, preventive measures need to be continued. The nurse knows this would include which of the following? A. Administering a pancrelipase tablet in the enteral feeding tube every 24 hours. B. Administering 60 mL of soda, such as Coke, through the tube every 4 hours. C. Administering 30 to 60 mL of tepid water following the last dose of medication. D. Using a small-bore syringe to flush the feeding tube as ordered around the clock.

C

A family caregiver is observing a nurse preparing to administer medications through her father's feeding tube. The caregiver asks, "What is the purpose of the pH paper?" Which of the following is the best response? A. "It is used to determine if the pH is low enough for medications to dissolve." B. "It is used to verify correct placement of the feeding tube in the stomach." C. "The pH paper will help us know whether your father is getting enough water." D. "I will test gastric aspirate before and after medication administration to note any change."

B

If the nurse suspects the NG feeding tube has migrated, the nurse should: A. Instill 10 mL of water into the feeding tube, reinsert the stylet, and reposition the tube. B. Stop any enteral feedings and obtain an order for a chest x-ray film to determine placement. C. Irrigate the tube with tap water. D. Reposition the patient from side to side.

B

The nurse is going to irrigate a nasogastric feeding tube. The nurse would be correct to draw up how much water into the ENFit syringe? A. 15 mL. B. 30 mL. C. 60 mL. D. The same amount as the gastric residual volume.

B

The nurse is inserting an NG feeding tube for the first time. Which action, if made by the nurse, indicates further instruction is needed? A. The nurse dips the end of the tube into a glass of water to activate the lubricant. B. The nurse has the patient flex the head as the tube is inserted into the naris. C. The nurse aims back and down toward the ear. D. The nurse advances the tube as the patient swallows.

B

The nurse is irrigating a nasogastric feeding tube after having verified tube placement by pH testing. The nurse draws up 30 mL of tap water into an ENFit syringe, removes the plug at the end of the tube, attaches the ENFit syringe, and slowly instills the irrigation solution. The nurse removes the syringe and plugs the end of the tube. What error occurred in the performance of this skill? A. There was no error; the nurse performed the skill correctly. B. The nurse failed to kink the tubing before connecting and removing the syringe from the end of the feeding tube. C. The nurse should have used sterile water from a container marked with the date and nurse's initials. D. The nurse instilled the irrigation solution at an incorrect rate.

B

The nurses are discussing feeding tube migration and prevention. Which of the following statements indicates correct understanding? A. As long as the external portion of a feeding tube is taped in place, the tube will be unable to migrate out of position. B. A feeding tube can enter the airway without causing obvious respiratory symptoms. C. The nurse should have the patient deep breathe and cough and suction the patient frequently. D. The nurse should keep the head of the bed flat to reduce the risk of tube migration.

B

The patient begins to cough and choke as the nurse is inserting the NG tube. What is the best action for the nurse to take at this time? A. Pull the feeding tube out and start over in the opposite naris. B. Pull the tube back into the posterior nasopharynx and attempt to reinsert. D. Instruct the patient to take small sips of water and swallow. E. Auscultate over the carina.

B

Which sources are likely to have a pH test result of greater than 6? (Select all that apply.) A. Stomach of fasting patient. B. Pleural fluid from tracheobronchial tree. C. Intestine of fasting patient.

B

The nurse understands that irrigating a feeding tube helps prevent it from becoming clogged and clears the tubing of fluid. At what times is it appropriate to flush a feeding tube? (Select all that apply.) A. Once a shift. B. Before medication administration. C. Before an intermittent feeding. D. Between medications. E. After medication administration.

B, C, D, E

The health care provider just left the patient's room after explaining the options of NG or NI feeding tube placement. A student asks a nurse about the differences between nasogastric and nasointestinal feedings. Which of the following are accurate statements made by the nurse? (Select all that apply.) A. Insertion of an NG tube requires clean gloves, whereas insertion of an NI tube requires sterile gloves. B. Gastric aspirate is expected to have a lower pH than intestinal aspirate. C. The advantage to an NI tube is that there is less risk for aspiration. D. NI tubes are used for patients with nasal problems such as nosebleeds or deviated septums. NG tubes are used for patients without nasal problems. E. Both NG and NI tubes are usually used for less than 30 days

B, C, E

The health care provider has ordered an enteral feeding tube for an elderly patient. Which statement, if made by the patient's family member, indicates further instruction is needed? A. "The enteral feedings will help provide additional calories." B. "The tube feedings are used to improve digestion." C. "This will help prevent her from getting pneumonia again from choking." D. "Tube feedings are less likely to cause infection than getting nutrients by IV infusion."

B.

The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed? A. "Urinary catheter care is a clean procedure; sterile gloves are unnecessary." B. "The bedside drainage bag should only be emptied when it is full." C. "The securement device that anchors the catheter should be reapplied." D. "Catheter care can be delegated to nursing assistive personnel."

B. "The bedside drainage bag should only be emptied when it is full."

The patient appears anxious about having a laboratory test. How should the nurse best respond? A. "Everyone is nervous about having laboratory tests performed. I will let you know the results as soon as I receive them." B. "What is it about the test that concerns you?" C. "There is nothing to worry about. This is routine." D. "Why are you anxious about having a laboratory test performed? I'm sure your doctor wouldn't order it unless necessary."

B. "What is it about the test that concerns you?"

The nurse is verifying placement of a nasogastric tube. Which gastric pH result would indicate the tube is properly positioned? (Select all that apply.) A. 6.0 B. 2.0 C. 3.0 D. 5.0 E. 5.5

B. 2.0 C. 3.0 D. 5.0 E. 5.5

The nurse is inserting an NG feeding tube. Which of the following supplies will the nurse need to perform the procedure? (Select all that apply.) A. Saline nasal spray. B. 8- to 12-Fr feeding tube. C. 60-mL ENFit syringe. D. Stethoscope. E. Tube fixation device. F. Tincture of benzoin. G. Sterile specimen cup. H. Cup of water/straw.

B. 8- to 12-Fr feeding tube. C. 60-mL ENFit syringe. D. Stethoscope. E. Tube fixation device. F. Tincture of benzoin. H. Cup of water/straw.

Which of the following may be delegated to nursing assistive personnel (NAP)? A. Administering medication through a feeding tube. B. Administering a tube feeding. C. Verifying feeding tube placement. D. Inserting a nasogastric (NG) feeding tube. E. Assessing for peristalsis.

B. Administering a tube feeding.

Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter? (Select all that apply.) A. Attach a 2-mL syringe to the balloon port and aspirate the fluid. B. Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. C. Attach a 10- or 20-mL syringe to the balloon port and forcibly aspirate the water. D. Cut the balloon port and allow the water to slowly drain into a sterile basin. E. Gently aspirate the syringe plunger if water remains in the balloon.

B. Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. E. Gently aspirate the syringe plunger if water remains in the balloon.

Elyse Russo is a 17-year-old high-school student who struggles with obesity. She is 5 feet 4 inches and weighs 210 pounds. She goes to a weight-loss clinic to try to get her weight and eating habits under control. Josh is a nursing student who works at the weight-loss clinic two times a week while in nursing school. He took the job to help pay for nursing school and also to help him learn how to interact with various types of people since he knew that as a nurse he would have to interact with the public. At first Josh didn't enjoy his job because he couldn't understand how people allowed themselves to become obese. Over time he learned to develop compassion for his patients, and he gained an understanding of the various causes of obesity. In addition, he learned a great deal about nutrition, healthy cooking, and controlling portions. Josh teaches Elyse about proper nutrition. Elyse states, "I can't control my eating. I vomit after I eat to try to lose weight, but I'm still fat." The adolescent suffers from which of the following? A.Anorexia nervosa B. Bulimia nervosa C. Impaired reality D. Fad dieting

B. Bulimia nervosa

A patient has a nasogastric feeding tube. The nurse is aware of the need to monitor the patient for potential complications. Which of the following symptoms, if demonstrated by the patient, would potentially indicate the greatest risk related to tube feedings? A. Diarrhea. B. Dyspnea. C. Abdominal distention. D. Throat irritation.

B. Dyspnea.

Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight catheterized several times a day. Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his bladder schedule to prevent a urinary tract infection (UTI). As Beth inserts the catheter into Mr. Kelter's penis, she feels resistance. She should use more force to guide the catheter through his urethra. A. True B. False

B. False

A patient is receiving a continuous enteral feeding by infusion pump. The nurse enters the patient's room to verify tube placement and measure residual. The nurse notices the patient's respirations are shallow and rapid and that the patient's color is ashen. The nurse notes crackles on auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should the nurse take? (Select all that apply.) A. Ask if the patient feels short of breath. B. Position patient on side. C. Turn off the tube feeding. D. Have the patient deep breathe and cough. E. Suction the patient. F. Notify the health care provider.

B. Position patient on side. C. Turn off the tube feeding. E. Suction the patient. F. Notify the health care provider.

The nurse is reviewing the patient's medical record to determine if there are any factors present that can cause a false-positive result for occult blood testing. The nurse would be correct to identify which of the following? (Select all that apply.) A. Antacids (e.g., Amphojel, Maalox, Milk of Magnesia) B. Red meats, poultry, fish C. Iron supplement. D. Spinach, collard greens E. Anticoagulants (e.g., warfarin sodium, heparin)

B. Red meats, poultry, fish C. Iron supplement. D. Spinach, collard greens

The nurse attempts to aspirate gastric contents from an established NG feeding tube and obtains no return. What action should the nurse take? A. Document the finding. B. Reposition the patient, flush tube with 30 mL air, and reattempt to aspirate. C. Get an order for a chest x-ray film to verify placement before administering the tube feeding. D. Remove the tube and insert a new one.

B. Reposition the patient, flush tube with 30 mL air, and reattempt to aspirate.

The NAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP: A. washed the perineal area with soap and water and applied a topical antimicrobial ointment at the urethral meatus around the catheter. B. stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing. C. inserted the hub of syringe into balloon port allowing the sterile water to return passively into the syringe and slid the catheter out into a waterproof pad. D. obtained a squirt bottle of warm water and had the patient squirt it over their perineum while sitting on the toilet.

B. stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing.

The nurse has instructed the male patient on how to properly clean himself in preparation for obtaining a midstream urine specimen. Which statement made by the patient indicates correct understanding? A."I should clean in a direction from the most contaminated area to the least contaminated area." B."I should begin cleaning at the opening of my penis and go outward in a circular motion." C."I should wash the area well with soap and water, and then I am ready to provide the specimen." D."I should clean in a direction from front to back in the perineal area."

B."I should begin cleaning at the opening of my penis and go outward in a circular motion."

The nurse is going to obtain a urine sample from a patient who has an indwelling urinary catheter for routine analysis. How much urine should the nurse obtain? A.At least 3 mL B.At least 20 mL C.At least 1 mL D.90 to 120 mL

B.At least 20 mL

Elyse Russo is a 17-year-old high-school student who struggles with obesity. She is 5 feet 4 inches and weighs 210 pounds. She goes to a weight-loss clinic to try to get her weight and eating habits under control. Josh is a nursing student who works at the weight-loss clinic two times a week while in nursing school. He took the job to help pay for nursing school and also to help him learn how to interact with various types of people since he knew that as a nurse he would have to interact with the public. At first Josh didn't enjoy his job because he couldn't understand how people allowed themselves to become obese. Over time he learned to develop compassion for his patients, and he gained an understanding of the various causes of obesity. In addition, he learned a great deal about nutrition, healthy cooking, and controlling portions. Josh emphasizes the importance of taking vitamins to Elyse, especially since she is malnourished as a result of the excessive vomiting. Water-soluble vitamins include vitamins A, D, E, and K. A. True B. False

B.False Rationale: Fat-soluble vitamins include A, D, E, and K. Water-soluble vitamins are C and B complex.

Red blood cell formation, protein metabolism and nervous system functioning?

B12

The normal adult fecal frequency is

BID to three times a week

Energy needed at rest too maintain life-sustain activities

BMR (Basal Metabolic rate)

Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight catheterized several times a day. Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his bladder schedule to prevent a urinary tract infection (UTI). Beth enters Mr. Kelter's room after lunch to perform straight catheterization. List in order the steps Beth takes to perform straight catheterization on Mr. Kelter. A. Lubricate the catheter. B. Clean penis with dominant hand. C. Apply sterile gloves. D. Advance catheter into penis. E. Apply fenestrated drape. F. Hold penis with nondominant hand. G. Ask patient to bear down. H. Coil catheter in dominant hand.

C, E, A, F, B, H, G, D Rationale: The steps of straight catheterization are to position the patient, apply sterile gloves, apply the fenestrated drape, lubricate the catheter, hold the penis with the nondominant hand, clean the penis with the dominant hand, coil the catheter in the dominant hand, ask the patient to bear down, and advance the catheter into the penis.

If a patient's indwelling catheter is removed at 0900, the patient should be due to void by: A. 1900 to 2100 (7:00 PM to 9:00 PM) B. 1100 to 1200 (11:00 AM to 12:00 PM) C. 1500 to 1700 (3:00 PM to 5:00 PM) D. 0930 (9:30 AM)

C. 1500 to 1700 (3:00 PM to 5:00 PM)

How many seconds after placing gastric contents on the pH paper should the results be read? A. 10 seconds B. 20 seconds C. 30 seconds D. 40 seconds

C. 30 seconds

The risk of Colorectal cancer starts at what age? A. 40 B. 45 C. 50 D. 55

C. 50

The nurse is going to administer an intermittent tube feeding. Because the patient's feeding tube has been in place for 3 days, which action is best for the nurse to take at this time? A. Obtain an order for x-ray film verification of tube location. B. Auscultate over the gastric area while instilling 30 mL of air into the feeding tube. C. Aspirate gastric contents and test on a pH strip. D. Verify the indelible ink mark on the tube is at the nares.

C. Aspirate gastric contents and test on a pH strip.

Why is it important to have the tube feeding at room temperature? A. It is unnecessary to keep the tube feeding cold because it will be hanging at room temperature anyway. B. It aids the speed of digestion. C. Cold formula can cause gastric cramping. D. Cold formula may lower the patient's body temperature.

C. Cold formula can cause gastric cramping

Which of the following could alter gastric pH test results? A. Time of day B. Intermittent enteral feedings C. Prescribed omeprazole (Prilosec) D. Aspirin therapy

C. Prescribed omeprazole (Prilosec)

The nurse is going to irrigate the patient's established feeding tube with 30 mL of tap water before instilling the tube feeding. The nurse attempts to do so without success. What should action should the nurse take? A. Notify the health care provider. B. Irrigate the tubing with soda, such as Coca-Cola. C. Reposition the patient. D. Use a smaller syringe with the plunger to push the fluid through the feeding tube.

C. Reposition the patient

Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? A. The patient states, "My bladder feels so full, it is starting to hurt!" B. The catheter has been in place for 3 days. C. The patient's urine appears cloudy with a foul odor. D. The patient is drinking less than 1500 mL of fluids daily.

C. The patient's urine appears cloudy with a foul odor.

The NAP is obtaining a midstream urine specimen from a female patient. Which action, if made by the NAP, requires correction and indicates further instruction is needed? A.The NAP cleans the patient using a new swab each time. B.The NAP cleans the patient in a front to back motion. C.The NAP cleans the patient starting at the center and xuses the same swab to clean the sides. D.The NAP cleans in a direction going from the least contaminated to most contaminated area.

C.The NAP cleans the patient starting at the center and xuses the same swab to clean the sides.

A patient had blood drawn for coagulation studies. The result is critically high. What action should take place at this time? A.The laboratory technician should notify the health care provider of the result. B.The nurse should notify the health care provider whenever they arrive on the unit. C.The nurse should call the health care provider with the result. D.The laboratory technician should repeat the test for verification.

C.The nurse should call the health care provider with the result.

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

1,4,5

What constitutes could be in fecal matter

Undigested food, dead bacteria, fat, bile, pigment, cells lining intestinal mucosa, water

________________ and _________________ deal with Urinary Stomas

Ureterostomy- placed in your ureters/upper renal tract Nephrostomy-tubes placed in renal pelvis area/ inside your kidneys

Which vitamin is important to vision, growth, cell division, reproduction and immunity?

Vitamin A

Which vitamin helps convert food to energy and keeps the body functioning. Patients that have past history of a gastric bypass or stomach ulcers must take this along with the elderly, vegetarians, and vegans.

Vitamin B/B12

Which vitamin helps to control infection and helps to heal wounds?

Vitamin C

An ileostomy is placed in the ____________ and a colostomy is placed in the ___________________.

Small intestine Large intestine

Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury

Stage 1

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serumfilled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive- related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Stage 2

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/ or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

Stage 3

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/ or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

Stage 4

serosanguineous drainage

Pale, pink, watery; mixture of clear and red fluid

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 2. Abiamu needs to weigh Ms. Ortega's son. Which device should she use to weigh the infant? A. Platform scale B. Sliding scale C. Water chamber D. Bariatric chamber

Platform Scale

Adventists church

Pork fish shellfish alcohol caffeine vegetarian diet encouraged

Judaism dietary restrictions

Pork predatory fowl Shelfish Rare meats Blood Mixing of milk or dairy products with meats kosher food preparation methods 24 hr of fasting of Yom Kippur No leavened bread eaten during Passover (8 days) No cooking from sundown on Friday to sundown on Saturday/Sabbath

which of the following dietary restrictions do Muslims have? Select all that apply A. Pork B. Alcohol C. Caffeine D. Fish

Pork, Alcohol, Caffeine

Muslim dietary restrictions

Pork, alcohol, caffeine, Ramadan fasting sunrise to sunset for month, ritualized methods of animal slaughter required for meat ingestion

What are the building blocks of body tissues?

Proteins

Serous drainage

Clear, watery plasma

A medication label states, "For Parenteral Use Only." What is the correct interpretation of this statement? A. The medication should be given orally so it is absorbed through the GI tract. B. The medication should only be used in adults. C. The medication should be administered topically. D. The medication should be administered by injection.

D

A nurse is telling a coworker that she is unable to flush a feeding tube. Which suggestion offered by the coworker would be accurate, useful information? A. "Try using Coca-Cola to flush the tubing; the carbonation will break up any blockage." B. "Cranberry juice works well because the acidity dissolves occlusions from medication." C. "Call the health care provider; the tube is going to have to be replaced." D. "Reposition the patient and see if you are able to flush the tubing with water."

D

The nurse instructed the NAP on how to collect a urine specimen from a patient. Which of the following statements, if made by the NAP, indicates further instruction is needed? A. "I should wear clean gloves while handling the specimen and transport it in a biohazard bag." B. "I should get the specimen to the lab within 20 minutes or put it in the refrigerator." C. "I should ask the patient to state their name and check their patient identification number on their armband." D. "I only need to label the lid of the cup with the patient's name, date, and source of specimen."

D. "I only need to label the lid of the cup with the patient's name, date, and source of specimen."

The nurse informs the patient the result of an occult blood test on gastric contents was negative. The patient asks what this means. The nurse's best response is: A. "A moderate amount of blood was "hidden" in the gastric contents." B. "You need to discuss your aspirin consumption with your health care provider." C. "You will need to be fasting so that we may repeat the test." D. "There was only a very small amount or no blood in the gastric secretions."

D. "There was only a very small amount or no blood in the gastric secretions."

Which step would be performed first in the sequence for obtaining a Gastroccult test from an NG tube? A. Apply two drops of commercial developer solution over sample and one drop between positive and negative performance monitors. B. Apply one drop of gastric sample to Gastroccult blood test slide. C. Observe specimen. If red blood or coffee-ground material is noted, report these findings immediately. D. Disconnect nasogastric tube from suction. Aspirate 5 to 10 mL with a catheter tip syringe.

D. Disconnect nasogastric tube from suction. Aspirate 5 to 10 mL with a catheter tip syringe.

Which of the following is an example of a complex carb? A. grapes B. steak C. water D. fiber

D. fiber

The nurse has delegated the task of obtaining a midstream urine specimen to NAP. Which of the following responsibilities does NOT remain with the nurse who delegated the task? A.Understanding the results and reporting them to the health care provider B.Determining who is capable and knowledgeable to carry out the task with accuracy C.Ensuring the task was completed and performed accurately D.Instructing the patient on the procedure to gain cooperation

D.Instructing the patient on the procedure to gain cooperation

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 4. When auscultating Ms. Ortega's heart, Abiamu notices that the heart fails to beat at regular successive intervals. This cardiac abnormality is referred to as a __________________.

Dysrhythmia Rationale: A dysrhythmia, which may be life-threatening, is the failure of the heart to beat at regular successive intervals.

Colonoscopy

Every 10 years, starting at age 45

DNA stool test

Every 3 years starting at age 45

Computed tomography, colonography

Every 5 years years, starting at age 45

Flexible sigmoidoscopy

Every 5 years, starting at age 45

A friction tear is a

Forced tear/ when a health care worker moves a patient and causes a tear

Mrs. Shirley Stone is a 56-year-old African-American who is admitted to the medical-surgical unit for management of a stage III decubitus ulcer on her right heel. She has type 2 diabetes, which is not easily managed. Although she is compliant with her medication routine and adheres to a diet to help manage her blood sugar, she still struggles with keeping her blood sugar within its normal range. Mrs. Stone works on a production line in a factory where she is on her feet all day. The excessive pressure on her feet caused a stage I decubitus that quickly progressed to a stage III ulcer. James is the nursing student assigned to Mrs. Stone. Mrs. Stone tells him, "This is all my fault. I've been doing so well with my medicine and diet, but I've gotten lazy about checking and caring for my feet. I work such long hours that, by the time I get home, I'm too tired to tend to my feet like I should. And I know I'm supposed to exercise, but after 12-hour shifts at the factory I'm just worn out." When repositioning Mrs. Stone in bed or moving her from the bed to the wheelchair, James is careful to lift her right leg as opposed to dragging it across the bed to prevent ____________ and _____________ that may lead to injuries to epidermis and tissue necrosis.

Friction and shear Rationale: Shear causes tissue capillaries to stretch, thus causing tissue necrosis deep in the tissues. Friction causes redness or a "burn" to the top layer of skin.

What color should Fecal matter be?

Infant: yellow Adult: brown

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 1. Abiamu enters Ms. Ortega's room to perform a physical assessment. Rank in order the four techniques used in a physical examination. A. Palpation B. Auscultation C. Inspection D. Percussion

Inspection(C), Palpation(A), Percussion(D), Auscultation(B)

What should Fecal matter smell like?

Malodorous- should not smell pleasant, but should also not smell too strong or unbarring.

Christianity dietary restrictions

Minimal or no alcohol some have meatless days and fasts

Hinduism dietary restrictions

all meats, fish, shellfish with some restrictions, alcohol

pressure ulcer

any lesion caused by unrelieved pressure that results in damage to underlying tissue

What is the normal Magnesium Level?

1.5-2.5 mEq/L

A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees. 3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider.

3. Continue the feedings; this is normal gastric residual for this feeding.

How many pounds are gained if a person gains one Letter of fluid?

2.2 pounds

How do you document the percentage of food eaten?

25, 50, 75, and 100 percent

Consistency of fecal matter should be ____________

soft, formed

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2

3. Respiratory rate of 8 breaths/min

The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4

The normal infant fecal frequency is

4-6 per day when or if breastfeeding 1-3 per day when bottle-fed

Which number corresponds to the area of the chest where you would auscultate for the tricuspid valve?

4.

Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a colonoscopy every 2 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 45.

4. "I'll make sure to have a fecal occult blood test annually once I turn 45.

Which statement made by the parents of a 2-month-old infant requires further education by the nurse? 1. "I'll continue to use formula for the baby until he is at least a year old." 2. "I'll make sure that I purchase iron-fortified formula." 3. "I'll start feeding the baby cereal at 4 months." 4. "I'm going to alternate formula with whole milk, starting next month."

4. "I'm going to alternate formula with whole milk, starting next month"

What is the desired Triglyceride level?

>100

What is the desired Cholesterol Level?

>200

Mrs. Pearl Butler is a 71-year-old Caucasian who is admitted to the medical-surgical unit after undergoing a thyroidectomy secondary to thyroid cancer. Chemotherapy and radiation were not aggressive enough in treatments; thus she opted to have her thyroid gland removed. She is resting comfortably in her room with her husband present. The nurse assigned to care for Mrs. Butler has already taken her vital signs: temperature 98.7° F, blood pressure 112/82 mm Hg, pulse = 62 beats/min, and respirations 22 breaths/min on room air. The nurse is now checking the medication administration record (MAR) to see what medications Mrs. Butler has ordered. The nurse notices that Mrs. Butler has been taking her as needed (prn) pain medication, hydrocodone 5mg/acetaminophen 500mg, every 4 hours as ordered. While the nurse is assessing Mrs. Butler's pain to determine if another dose of pain medication is needed, Mrs. Butler states that she hasn't had a bowel movement (BM) since her surgery 3 days ago. The nurse knows that Mrs. Butler's constipation is most likely caused by which of the following? A. Opioid use for pain management B. Mrs. Butler's age C. Too much fat in Mrs. Butler's diet D. The thyroidectomy procedure

A Rationale: Opioid medications contribute to constipation in surgical patients. The hydrocodone portion of Mrs. Butler's pain medication is an opioid analgesic. A stool softener and laxative are needed to prevent constipation after surgery.

Latter-Day Saints (Mormons)

Alcohol Tobacco Caffeine

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 3. Abiamu performs an assessment of Ms. Ortega's cardiac system. List the four anatomical sites for assessment of cardiac function, starting on the patient's upper right side and moving in a clockwise direction.

Aortic, Pulmonic, Tricuspid, and Mitral/Apical

Mr. Ryan Kelter is a 33-year-old Caucasian who lives in an acute rehabilitation center. He was injured in a motorcycle accident that caused a spinal cord injury (SCI). As a result of the SCI, he has neurogenic bladder that prevents him from fully emptying his bladder. Because of this, he needs to be straight catheterized several times a day. Beth is the student nurse assigned to Mr. Kelter. She understands the importance of keeping him on his bladder schedule to prevent a urinary tract infection (UTI). Beth should advance the catheter ________ to _______ inches or until urine flows out of it.

Answer: 7 to 9 Rationale: In an adult male the catheter should be advanced 7 to 9 inches (17-22.5 cm) or until urine flows out of it.

The nurse is reviewing medication administration through a feeding tube with the caregiver. Which of the following statements indicates further instruction is needed? A. "To verify gastric placement, the pH of aspirated gastric contents should 4 or less." B. "After crushing all medications, I will mix them together with 30 mL of tepid water." C. "Following the last dose of medication, I will flush the feeding tube with 30 to 60 mL of sterile water because he is immunocompromised." D. "After medication administration, I will clamp the feeding tube and have him sit up for 1 hour."

B

The patient has been taking an over-the-counter acid reducer. What finding would be expected in the patient's gastric pH results? A. None, since this is a nonprescription medication. B. The pH would increase. C. A positive result for gastroccult testing. D. The pH would decrease.

B. The pH would increase.

Which of the following, if exhibited by the patient, may increase the risk for spontaneous enteral tube dislocation? (Select all that apply.) A. Nausea. B. Ambulation. C. Vomiting. D. Nasotracheal suctioning. E. Altered level of consciousness, agitation. F. H2 antagonists.

C, D, E

sanguineous drainage

Bright red; indicates active bleeding

The nurse aspirates stomach contents from a newly inserted feeding tube. The nurse is aware the patient has been on the proton pump inhibitor omeprazole. The pH strip reads "3." Where should the nurse expect the x-ray film to identify placement of the feeding tube? A. In the lungs. B. In the esophagus. C. In the stomach. D. In the small intestine.

C

The nurse just inserted an NG feeding tube. The health care provider's order states to administer all meds per tube and a continuous feeding of Isocal at 30 mL per hour. The order also states to check the patient's blood glucose every 6 hours. When can the nurse begin to instill feedings, water, or medications through the feeding tube? A. Immediately after placement is verified by pH testing. B. When the patient's blood glucose is verified to be within normal limits. C. When tube placement has been verified by x-ray film. D. After administering 30 mL of water, the medications may be given, followed by another 30 mL of water, and then continuous feeding may be initiated.

C. When tube placement has been verified by x-ray film.

The patient's wife is watching as the nurse prepares to insert a small bore feeding tube. She asks the nurse, "What is the purpose of the guide wire?" The nurse correctly responds: A. "Because placement must be verified by a chest x-ray, the guide wire is used to determine correct placement when it shows up on radiography." B. "To keep the patient from pulling the tube out as readily." C. "To serve as a guide to determine when the correct length of tubing has been inserted." D. "Because feeding tubes are flexible, a guide wire or stylet is used to provide rigidity that facilitates positioning."

D

Which of the following accurately describes the greatest risk related to having a feeding tube? A. Electrolyte imbalance. B. Fluid volume overload. C. Infection. D. Aspiration.

D

The nurse aspirates gastric contents and observes a "coffee ground appearance." What priority action should the nurse take? A. Restrict coffee from the patient's diet. B. Ask the patient what he recently consumed. C. Determine if the patient has ever had this before. D. Report the finding to the health care provider.

D. Report the finding to the health care provider.

The nurse is going to administer a bolus enteral tube feeding of 240 mL. The nurse has obtained a pH of 4 and 50 mL of gastric aspirate. Based on these findings, what action should the nurse take? A. Stop the feeding and recheck the residual in 1 hour. B. Reposition the feeding tube under fluoroscopy. C. Discard the aspirate and continue with the bolus feeding as prescribed. D. Return the aspirate to the patient's stomach and administer the feeding.

D. Return the aspirate to the patient's stomach and administer the feeding.

Which of the following types of juice should be avoided in the elderly because it changes the absorption of many drugs?

Grapefruit juice

Mrs. Pearl Butler is a 71-year-old Caucasian who is admitted to the medical-surgical unit after undergoing a thyroidectomy secondary to thyroid cancer. Chemotherapy and radiation were not aggressive enough in treatments; thus she opted to have her thyroid gland removed. She is resting comfortably in her room with her husband present. The nurse assigned to care for Mrs. Butler has already taken her vital signs: temperature 98.7° F, blood pressure 112/82 mm Hg, pulse = 62 beats/min, and respirations 22 breaths/min on room air. The nurse is now checking the medication administration record (MAR) to see what medications Mrs. Butler has ordered. The nurse knows that it is important to immediately start Mrs. Butler on a bowel medication regimen to prevent fecal impaction. Unresolved fecal impaction can result in _______________ ______________.

Intestinal obstruction Rationale: Unresolved severe fecal impaction can result in intestinal obstruction that requires surgical intervention.

The shape of fecal matter should

Resemble the diameter of the rectum (not to large or pebble sized)

A sheath tear is a

Self tear/ patient gets tear by sliding down in a bed or wheelchair

Purulent drainage

Thick, yellow, green, tan, or brown drainage

Mrs. Shirley Stone is a 56-year-old African-American who is admitted to the medical-surgical unit for management of a stage III decubitus ulcer on her right heel. She has type 2 diabetes, which is not easily managed. Although she is compliant with her medication routine and adheres to a diet to help manage her blood sugar, she still struggles with keeping her blood sugar within its normal range. Mrs. Stone works on a production line in a factory where she is on her feet all day. The excessive pressure on her feet caused a stage I decubitus that quickly progressed to a stage III ulcer. James is the nursing student assigned to Mrs. Stone. Mrs. Stone tells him, "This is all my fault. I've been doing so well with my medicine and diet, but I've gotten lazy about checking and caring for my feet. I work such long hours that, by the time I get home, I'm too tired to tend to my feet like I should. And I know I'm supposed to exercise, but after 12-hour shifts at the factory I'm just worn out." James inspects Mrs. Stone's left foot, her healthy foot, to ensure there are no signs of impaired skin integrity. He knows to check for blanching, but he does not see any when checking Mrs. Stone's skin. Why may he not see blanching of Mrs. Stone's skin? A. Blanching does not occur in darkly pigmented skin. B. There is no sign of a pressure ulcer. C. Blanching only occurs in late-stage ulcers. D. Blanching is not part of the pressure-ulcer assessment.

A Rationale: The Task Force on the Implications for Darkly Pigmented Intact Skin in the Prediction and Prevention of Pressure Ulcers defined darkly pigmented skin as skin that "remains unchanged (does not blanch) when pressure is applied over a bony prominence, irrespective of the patient's race or ethnicity." Mrs. Stone's dark skin does not blanch.

Mrs. Shirley Stone is a 56-year-old African-American who is admitted to the medical-surgical unit for management of a stage III decubitus ulcer on her right heel. She has type 2 diabetes, which is not easily managed. Although she is compliant with her medication routine and adheres to a diet to help manage her blood sugar, she still struggles with keeping her blood sugar within its normal range. Mrs. Stone works on a production line in a factory where she is on her feet all day. The excessive pressure on her feet caused a stage I decubitus that quickly progressed to a stage III ulcer. James is the nursing student assigned to Mrs. Stone. Mrs. Stone tells him, "This is all my fault. I've been doing so well with my medicine and diet, but I've gotten lazy about checking and caring for my feet. I work such long hours that, by the time I get home, I'm too tired to tend to my feet like I should. And I know I'm supposed to exercise, but after 12-hour shifts at the factory I'm just worn out." Mrs. Stone's right foot decubitus is a stage III ulcer. List in order the stages of pressure ulcers. A. Full-thickness skin loss B. Nonblanchable redness or intact skin C. Full-thickness tissue loss D. Partial-thickness skin loss or blister

B, D, A, C Rationale: The stages of pressures ulcers as developed by European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) are: stage I: nonblanchable redness or intact skin; stage II: partial-thickness skin loss or blister; stage III: full-thickness skin loss (fat visible); and stage IV: full-thickness tissue loss (muscle/bone visible).