Fundamentals VSIM FINAL (ALL pre and post Q)

A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse? 1. check oxygen saturation level 2. document findings in the medical record 3. notify the provider 4. ensure a sitter is available to watch the patient

1. check oxygen saturation level

A nurse is creating a care plan for a young adult patient with a chronic illness. Which of the following nursing diagnoses might be included in the care plan? (select all that apply) 1. ineffective health maintenance 2. activity intolerance 3. Risk-prone health behavior 4. caregiver role strain 5. social isolation

1. ineffective health maintenance 2. activity intolerance 5. social isolation 3. Risk-prone health behavior

What determines the acidity of a substance like body fluids? 1. the number of existing H ions 2. the fluid's pH measurement 3. the amount of available HCO3 4. the body's ability to trigger chemical reactions

1. the number of existing H ions

Which intervention takes priority when the nurse determines that a postoperative patient has hypoactive bowel sounds? 1.Assess the abdomen for signs of distention 2.Notify the surgeon of this assessment finding 3.Advance the patient's diet to soft, solid food 4.Assess the patient for indications of hypotension

1.Assess the abdomen for signs of distention

The nurse has received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patient's specimen? (Select all that apply.) 1.Color 2.Odor 3.pH 4.Sediment 5.Clarity

1.Color 2.Odor 4.Sediment 5.Clarity

The nurse is completing an admission assessment on a patient admitted for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition? (Select all that apply.) 1.Poor circulation 2.Poor hygiene 3.Obesity 4.Diabetes Mellitus 5.Hypertension

1.Poor circulation 2.Poor hygiene 3.Obesity 4.Diabetes Mellitus

What instruction should the nurse provide to a patient concerning how often the colostomy pouch should be emptied? 1.Whenever the pouch is one-third full of fecal drainage 2.When the pouch isn't well attached to the skin 3.After each meal 4.At least four to five times daily

1.Whenever the pouch is one-third full of fecal drainage

Which statement made by the patient indicates an understanding of diet progression after surgery? 1.I know it is important to get my strength back, so I will ask for a milkshake after surgery 2.I'll start drinking water as soon this nausea subsides 3.I love coffee, so I'll have some as soon as I get back from surgery 4.I can't tolerate a soft diet, so I'll simply go back to drinking clear liquids

2.I'll start drinking water as soon this nausea subsides

The nurse is performing an assessment of Ms. Morrow's wound. What should be included in the documentation? (Select all that apply.) 1.Turgur 2.Tunneling 3.Odor 4.Drainage 5.Location

2.Tunneling 3.Odor 4.Drainage 5.Location

Which diagnostic test serves as the basis for determining acid-base imbalances 1. serum potassium 2. blood urea nitrogen 3. arterial blood gas 4. specific gravity of urine

3. arterial blood gas

Reduced skin turgor is characteristically altered among which population 1. smokers 2. infants 3. older adults 4. premenstrual female

3. older adults

A patient is placed on omeprazole 20 mg daily. When will the nurse administer the medication? 1.At bedtime 2.One hour after any meal 3.One hour before breakfast 4.With breakfast

3.One hour before breakfast

The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding? 1.Serous 2.Serosanguineous 3.Purulent 4.Sanguineous

3.Purulent

The nurse is providing education to Ms. Morrow and her daughter on management of venous stasis in the lower extremities. What would be appropriate for the nurse to include in the teaching session? 1.Keep skin surrounding the wound dry and inspect it at least once a week 2.Avoid ambulation as this may aggravate you condition 3.Put on antiembolism stockings as soon as you get up in the morning and wear them all day 4.Sit with your legs in the dependent position so that blood will drain to lower extremities

3.Put on antiembolism stockings as soon as you get up in the morning and wear them all day

What information will the nurse include when providing education for a patient scheduled for a colostomy as treatment for rectal cancer? 1.The surgeon will determine whether the ostomy can be temporary once surgery has begun 2.Permanency will depend on how much colon function has been affected by the surgery 3.The ostomy will be permanent because of the nature of the illness 4.Once the inflammation in the colon subsides, the ostomy will be reversed

3.The ostomy will be permanent because of the nature of the illness

Mr. Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session? 1.You may have to urinate more frequently while taking this medication 2.You may experience excessive saliva production while taking this medication 3.This medication helps reduce bladder spasms 4.Your urine may appear reddish-orange

3.This medication helps reduce bladder spasms

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? 1.Iron 2.Calcium 3.Albumin 4.Prealbumin

4.Prealbumin

The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history?

When did the edema start? Can you describe the edema? What were you doing just before you noticed the edema? Do you have any recent history of surgery or illness? What are your usual daily activities? Do you stand a lot? What medications do you take? Do you have heart disease or blood vessel disease?

A patient is concerned about a medication the nurse is administering. The patient states that the medication is not normally something that is administered. What is the best response by the nurse? 1. I will hold the medication and find out for you 2. it is probably a generic medication for something you normally get 3. the provider has ordered it for you 4. we should probably update your medication reconciliation forms

1. I will hold the medication and find out for you

Identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? (select all that apply) 1. acute pain 2. not able to tolerate activity 3. metabolic acidosis 4. difficulty breathing 5. ineffective respiratory gas exchange

1. acute pain 2. not able to tolerate activity 4. difficulty breathing 5. ineffective respiratory gas exchange

The nurse is recording fluid intake for Mr. Johnson. Which items on the dinner trap should the nurse include when completing this documentation? (Select all that apply.) 1.Applesauce 2.Ice cream 3.Tomato soup 4.Iced tea 5.Creamed corn

2.Ice cream 3.Tomato soup 4.Iced tea

While completing discharge instructions with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time? 1. determine if the patient has any questions 2. reassure the patient 3. listen to the patient's lungs 4. ask if the patient has support at home

3. listen to the patient's lung

Which physical finding poses the greatest safety risk for a patient diagnosed with hyponatremia? 1. dry mucous membranes 2. anxiety 3. cold, clammy skin 4. orthostatic hypotension

4. orthostatic hypotension

The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed? 1.Intact skin with nonblanchable redness of a localized area 2.Full-thickness tissue loss with exposed bone, tendon, or muscle 3.Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed 4.Full-thickness tissue loss, possibly with visible subcutaneous fat

4.Full-thickness tissue loss, possibly with visible subcutaneous fat

The nurse is preparing to irrigate a patient's wound. Upon assessment, the wound appears to be healing and the wound bed is beefy red. Which solution should the nurse select for this procedure? 1.Dakin's solution 2.Isopropyl alcohol 3.Tap water 4.Normal saline

4.Normal saline

A nurse is preparing to admit a patient with cystic fibrosis and altered nutrition status. The nurse plans to implement with precautions to be used in the patient's care? 1. droplet 2. contact 3. standard 4. airborne

3. standard

The nurse is caring for a patient experiencing the effects of paraplegia. What urinary condition is associated with this diagnosis? 1.Chronic cystitis 2.Oliguria 3.Neurogenic bladder 4.Stress incontinence

3.Neurogenic bladder

A provider orders a high-fat, high-protein, high-carb diet for a patient with cystic fibrosis. What is the best rationale for this diet order? 1. Cystic fibrosis interferes with the digestion of food and absorption of nutrients 2. thickened mucus secretions predispose the patient to anemia 3. the diet was ordered according to the patient's preferred food intake 4. cystic fibrosis is a chronic disease characterized by altered electrolytes

1. cystic fibrosis interferes with the digestion of food and absorption of nutrients

The nurse is caring for an adolescent patient who appears withdrawn and isolated. What strategy should the nurse use to work with this patient? 1. Develop a therapeutic, trusting relationship with the patient. 2. talk to the patient's parents about what is going on with the patient 3. tell the patient what the patient needs to do in order to get better 4. leave the patient alone as much as possible

1. develop a therapeutic, trusting relationship with the patient

A patient with a low body mass index is found to have low albumin and prealbumin levels. Which of the following nursing actions should be considered? (select all that apply) 1. encourage oral intake of foods and fluids as ordered 2. monitor input and output for the patient 3. request nutrition consult 4. assess for signs and symptoms of infection 5. assess gastrointestinal function

1. encourage oral intakes of foods and fluids as ordered 2. monitor input and output for the patient 3. request nutrition consult 5. assess gastrointestinal function

Mona complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond? 1. even short activities such as moving to the chair will help you cough mucus out of your lungs 2. you should wait until your breathing improves to try to get out of bed again, because it makes you short of breath 3. You really need to walk as much as possible in order to prevent your pneumonia from getting worse 4. pneumonia causes thick secretions in your lungs, making it difficult to breath

1. even short activities such as moving to the chair will help you cough mucus out of your lungs

During her hospitalization for pneumonia, the provider orders arterial blood gases for Mona. What is the best explanation for why this is ordered? 1. patient has shallow, ineffective breathing 2. patient has a history of smoking ½ pack of cigarettes per day 3. patient has fever and malaise 4. patient has a productive cough with rust colored sputum

1. patient has shallow, ineffective breathing

Hypokalemia is confirmed by what serum blood result? 1. potassium 3.0 2. potassium 5.5 3. sodium 133 4. sodium 146

1. potassium 3.0

The nurse titrates the patient's oxygen to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per provider's orders. What is the rationale for this order? (select all that applies) 1. promotes a decrease in respiratory effort 2. allows the body to meet metabolic demands 3. prevents atelectasis in a patient with pneumonia 4. promotes a decrease in myocardial workload 5. Allows the patient to receive 100% oxygen

1. promotes a decrease in respiratory effort 2. allows the body to meet metabolic demands 4. promotes a decrease in myocardial workload

Mona's blood gas results indicate respiratory acidosis. Her oxygen saturation is 95% per the pulse oximeter. Which intervention should the nurse provide? (select all that apply) 1. provide supplemental oxygen as ordered 2. ensure the patient is well hydrated 3. none; the patient has 95% oxygenation 4. promote voluntary coughing activities to clear secretions 5. assist the patient with adequate ventilation

1. provide supplemental oxygen as ordered 2. ensure the patient is well hydrated 4. promote voluntary coughing activities to clear secretions 5. assist the patient with adequate ventilation

Expected assessment findings of a patient with pneumonia may include which of the following (select all that apply) 1. tachypnea 2. use of accessory muscles 3. enuresis 4. malaise 5. fever

1. tachypnea 2. use of accessory muscles 4. malaise 5. fever

A patient states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer? 1. the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis 2. You have to use your incentive spirometer because your provider has ordered it for you. 3. The incentive spirometer will cause you to cough less because you are moving more air through your lungs 4. You should wait to use your incentive spirometer until you are not coughing up so much sputum

1. the incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis (partial or complete collapsed lung) Patient should use incentive spirometer regularly to maximize lung function through alveolar inflation, preventing complications of atelectasis. The the spirometer will likely cause patient to cough up sputum because patient is breathing deeply, but it will not decrease the amount of sputum.

The nurse is preparing to discharge Mona from the hospital. Which of the following instructions should the nurse include in the discharge education? (select all that apply) 1. use the incentive spirometer every one to two hours to move secretions out of your lungs 2. stop taking your antibiotics once you are feeling better 3. continue to focus on ambulating several times per day 4. quitting smoking will improve your recovery 5. take your antibiotics as directed, even if you are feeling better

1. use the incentive spirometer every one to two hours to move secretions out of your lungs 3. continue to focus on ambulating several times per day 4. quitting smoking will improve your recovery 5. take your antibiotics as directed, even if you are feeling better

A nurse is assessing an adolescent patient. Which of the following questions best represents therapeutic communication techniques? 1. what do you hope happens here today 2. you don't smoke, do you 3. do you know what to do to stay healthy 4. are you feeling well

1. what do you hope happens here today

Which patients have an increased risk for developing colorectal cancer? (Select all that apply.) 1.A 30 y.o. with a 13- year history of Crohn's disease 2.A 50 y.o. whose diet includes red meat daily 3.A 63 y.o. who is healthy 4.A 70 y.o. who has been diagnosed as obese 5.A 40 y.o. with a history of lupus

1.A 30 y.o. with a 13- year history of Crohn's disease 2.A 50 y.o. whose diet includes red meat daily 3.A 63 y.o. who is healthy 4.A 70 y.o. who has been diagnosed as obese

The nurse is preparing discharge education for a patient with a permanent colostomy. What information concerning diet and nutrition will the nurse include? (Select all that apply). 1.Avoid foods that previously caused diarrhea 2.Gradually add new foods into the diet 3.Drink at least two quarts of water daily 4.Avoid high fiber foods for eight weeks after the surgery 5.Be aware that colostomies are prone to develop food blockages

1.Avoid foods that previously caused diarrhea 2.Gradually add new foods into the diet 3.Drink at least two quarts of water daily 4.Avoid high fiber foods for eight weeks after the surgery

The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse? 1.Call for a co-worker to help hold the patient's legs in position 2.Instruct the patient to turn over on her side 3.Notify the provider that the procedure could not be completed because the patient is paralyzed 4.Ask a family member to assist you with the catheterization

1.Call for a co-worker to help hold the patient's legs in position

After completing an intermittent catheterization, what information concerning the procedure will the nurse include in Ms. Johnson's medical record? (Select all that apply.) 1.Characteristics of the urine obtained 2.Time procedure was performed 3.Size of catheter used 4.Description of the cleansing process preceding the procedure 5.Description of the patient's tolerance for the procedure

1.Characteristics of the urine obtained 2.Time procedure was performed 3.Size of catheter used 5.Description of the patient's tolerance for the procedure

What information should the nurse include in the documentation associated with the changing of a patient's colostomy pouch? (Select all that apply.) 1.Condition of the skin around the stoma 2.How often the process will be done 3.Description of the stoma 4.Characteristics of the fecal matter 5.Patient's response to the process

1.Condition of the skin around the stoma 3.Description of the stoma 4.Characteristics of the fecal matter 5.Patient's response to the process

The nurse is caring for a patient who is unable to urinate voluntarily since a gunshot injury. Patient data associated with which intervention will provide information regarding the patient's kidney function? 1.Daily serum creatinine levels 2.Results of precatheterization bladder scans 3.Number of times the patient requests oxybutynin over a 24-hour period 4.Urinary output over eight hours

1.Daily serum creatinine levels

The nurse is completing an admission assessment on a paitent afmitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? (Select all that apply.) 1.Do some areas of your skin seem warmer or colder than others? 2.Do you have any sores on your body? 3.What kind of activities cause you to be fatigued? 4.Have you used pads or special pants because you can't control your urine? 5.Have you noticed any swelling on your feet, ankles, or fingers?

1.Do some areas of your skin seem warmer or colder than others? 2.Do you have any sores on your body? 4.Have you used pads or special pants because you can't control your urine? 5.Have you noticed any swelling on your feet, ankles, or fingers?

Which interventions will the nurse implement to help minimize a postoperative patient's risk for surgical site complications? (Select all that apply.) 1.Following strict aseptic techniques when changing surgical dressing 2.Monitoring for elevation in body temperature 3.Providing sufficient fluids to maintain hydration 4.Advancing diet as appropriate to provide adequate nutrition 5.Encouraging deep, sustained breathing and supported coughing

1.Following strict aseptic techniques when changing surgical dressing 2.Monitoring for elevation in body temperature 3.Providing sufficient fluids to maintain hydration 4.Advancing diet as appropriate to provide adequate nutrition

Which statements will guide the nurse when preparing to educate a patient whose condition requires a permanent colostomy? (Select all that apply.) 1.Help the patient get accustomed to looking at the ostomy 2.Encourage the patient to take part in the care process 3.Assess the patient for signs of depression 4.If the patient is accepting, include family members in the teaching 5.Schedule the teaching two to three days after the surgery

1.Help the patient get accustomed to looking at the ostomy 2.Encourage the patient to take part in the care process 3.Assess the patient for signs of depression 4.If the patient is accepting, include family members in the teaching

The nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. What questions would the nurse include when assessing the patient? (Select all that apply.) 1.How often do you urinate? 2.Is there anything that you do that helps you urinate? 3.Do you ever leak urine? 4.When was your last menstrual period? 5.Have you noticed any change in your usual voiding pattern?

1.How often do you urinate? 2.Is there anything that you do that helps you urinate? 3.Do you ever leak urine? 5.Have you noticed any change in your usual voiding pattern?

Which statements best support the nurse's evaluation that a patient who recently experienced a sigmoid colostomy has begun to accept the body change? (Select all that apply.) 1.I'm anxious to get a bathing suit that accommodates my colostomy 2.My stoma continues to be red and moist 3.My ostomy nurse always has helpful suggestions about daily care routine 4.Having a colostomy is a small price to pay for being healthy 5.I really hope no one else I know has to ever deal with a colostomy

1.I'm anxious to get a bathing suit that accommodates my colostomy 2.My stoma continues to be red and moist 3.My ostomy nurse always has helpful suggestions about daily care routine 4.Having a colostomy is a small price to pay for being healthy

What assessment data will the nurse expect to find to support the assumption that Mr. Haye's surgical incision is in the inflammatory phase of wound healing? (Select all that apply.) 1.Increased white blood cell count 2.Incision is slightly edematous 3.Incisional site pain 4.Redness surrounding the incision 5.Signs of scabbing are noted at the incision site

1.Increased white blood cell count 2.Incision is slightly edematous 3.Incisional site pain 4.Redness surrounding the incision

While inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. What is the appropriate action by the nurse? 1.Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies 2.Remove the catheter and re-start the procedure using a new sterile kit 3.Allow the patient a period of rest and attempt the procedure at a later time 4.Carefully remove the catheter and reinsert it into the urethra

1.Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies

The nurse has an order to check a patient's post-void residual urine. How would the nurse carry out this order? 1.Measure the amount of urine in the bladder using a bladder scanner 2.Insert a straight catheter and measure the urinary output in two hours 3.Calculate the difference between the patient's intake and output 4.Palpate the bladder for distention and record findings in the chart

1.Measure the amount of urine in the bladder using a bladder scanner

The nurse has created a sterile field and is preparing to catheterize a patient. While using sterile cotton balls to clean the patient prior to the procedure, the nurse drops a contaminated cotton ball in the middle of the sterile field. What is the correct action of the nurse at this time? 1.Obtain a new catheter kit and restart the procedure 2.Remove the contaminated cotton ball from the field with the non-dominant hand 3.Continue with the procedure while avoiding the contaminated cotton ball 4.Ask a co-worker to remove the contaminated cotton ball from the field

1.Obtain a new catheter kit and restart the procedure

The nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this patient? (Select all that apply.) 1.Perform neurovascular checks to look for changes 2.Provide meticulous skin care 3.Maintain strict bed rest 4.Assist with range of motion exercises to lower extremities 5.Monitor patient for signs of skin breakdown

1.Perform neurovascular checks to look for changes 2.Provide meticulous skin care 4.Assist with range of motion exercises to lower extremities 5.Monitor patient for signs of skin breakdown

Which nursing interventions are implemented primarily to prevent respiratory complication in a patient after abdominal surgery? (Select all that apply.) 1.Prompting to cough 2.Assisting in early ambulation 3.Encouraging deep breathing 4.Providing pain medication as required 5.Education on incentive spirometer use

1.Prompting to cough 2.Assisting in early ambulation 3.Encouraging deep breathing 5.Education on incentive spirometer use

The nurse is preparing to catheterize a female patient and is positioning the patient. Which position(s) would be appropriate for this procedure? (Select all that apply.) 1.Side lying 2.Supine 3.Semi-Fowler's 4.Dorsal recumbent 5.Lithotomy

1.Side lying 4.Dorsal recumbent

Which statement by the nurse indicates a thorough understanding of the purpose of postoperative nursing care? 1.The goal is to ensure uneventful recovery from surgery 2.The goal is well-managed postoperative pain 3.The goal is to prevent infection 4.The goal is frequent assessment of the surgical incision site

1.The goal is to ensure uneventful recovery from surgery

With information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure? (Select all that apply.) 1.The patient's body is draped to promote modesty 2.The scan typically does not cause the patient any pain 3.The scan produces an image of the patient's bladder and the amount of urine it contains 4.The scanner is moved over the skin of the patient's lower abdomen 5.The procedure is necessary when a patient experienced difficulty voiding

1.The patient's body is draped to promote modesty 2.The scan typically does not cause the patient any pain 4.The scanner is moved over the skin of the patient's lower abdomen

What information will the nurse include when providing education for a patient who is scheduled for a sigmoid colostomy? (Select all that apply.) 1.When an ostomy is needed, intestinal mucosa is brought through the abdominal wall 2.The fecal matter that will pass through the stoma will be liquid in form 3.A healthy stoma is bright red, moist, and rounded 4.A stoma is the portion of the intestinal mucosa that is secured to the skin of the abdomen 5.The term ostomy refers to an opening from the inside of an organ to the outside of the body.

1.When an ostomy is needed, intestinal mucosa is brought through the abdominal wall 3.A healthy stoma is bright red, moist, and rounded 4.A stoma is the portion of the intestinal mucosa that is secured to the skin of the abdomen 5.The term ostomy refers to an opening from the inside of an organ to the outside of the body.

Upon entering the room, the nurse observes Mona slumped over in a semi-Fowler's position, struggling to catch her breath. What is the priority nursing action at this time? 1. obtain an oxygen saturation level 2. assist the patient into a high Fowler's position 3. Titrate her oxygen so that her oxygen is greater than or equal to 95% 4. Obtain vital signs

2. assist the patient into a high Fowler's position

A patient demonstrates correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? 1. inhales quickly and forcefully 2. inhales slowly and deeply 3. exhales slowly and deeply 4. exhales quickly and forcefully

2. inhales slowly and deeply (Place mouthpiece into mouth and inhale slowly and deeply. Then hold the breath for 5 sec before exhaling)

Which statement concerning fluid balance demonstrates a need for additional instruction concerning fluid intake and output? 1. a desirable amount of fluid intake and output in adults ranges from 1500 to 3500 mL daily 2. the balance between fluid intake and output must be achieved each day to maintain homeostasis 3. fluid output is comprised of feces, sweat and exhaled air 4. it is recommended that a healthy adult consume 1.5 quarts of water daily

2. the balance between fluid intake and output must be achieved each day to maintain homeostasis (the balance between fluid intake and output may not occur daily but should occur every two to three days)

Which statement by the nurse indicates a need for further education on the role of water as a body fluid? 1. tissue lubrication is facilitated by water 2. water is transported to cells when it is attached to electrolytes 3. waste products are removed from the cell by water 4. water helps maintain normal body temperature

2. water is transported to cells when it is attached to electrolytes

A patient has just completed a tube feeding that has run throughout the night. What is the best education the nurse can provide to the patient at this time? 1. It is important that you ambulate three times a day 2. you should remain upright for the next hour 3. you should lie down to get some sleep 4. you should wear your pneumatic compression device when you are in bed

2. you should remain upright for the next hour

When should the nurse caring for a patient with a new colostomy plan to change the pouching system? 1.After any meal 2.Before breakfast 3.Right before bed 4.Before the patient showers

2.Before breakfast

The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg? 1.Pale, white toes with decreased sensation 2.Dark discoloration of the skin surrounding the wound site 3.Shiny skin with hair loss over legs, feet, and toes 4.Scaly rash between the toes with itchiness

2.Dark discoloration of the skin surrounding the wound site

The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12? 1.Low risk 2.High risk 3.Moderate risk 4.Not at risk

2.High risk

The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? 1.I will make sure the tip of the syringe touched the wound bed while performing the irrigation? 2.I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound 3.I will use a sterile specimen cup to slowly pour irrigation solution over the entire wound bed 4.In order to debride the wound, I will use a moderate amount of force to instill the solution

2.I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound

Which statements indicate that a patient who recently required a colostomy has achieved the outcomes set for regular bowel elimination? (Select all that apply.) 1.Getting a short nap each afternoon makes me feel so much better 2.I've learned to implement the techniques I learned in stress management 3.I've gotten accustomed to drinking at least two quarts of water a day 4.My routine includes about 30 minutes of exercise daily 5.I know that what I eat has a large impact on my bowel function

2.I've learned to implement the techniques I learned in stress management 3.I've gotten accustomed to drinking at least two quarts of water a day 4.My routine includes about 30 minutes of exercise daily 5.I know that what I eat has a large impact on my bowel function

Which diagnostic test is used as a screening tool for the possible diagnosis of colon cancer? 1.Stool pinworms 2.Occult blood 3.Timed stool specimen 4.Stool culture

2.Occult blood

The nurse is completing documentation following the insertion of an intermittent urinary catheter. What should be included in the documentation? (Select all that apply.) 1.The length of time for completion of the procedure 2.Size of the catheter 3.Patient's tolerance of the procedures 4.Date the procedure was performed 5.Time the procedure was performed

2.Size of the catheter 3.Patient's tolerance of the procedures 4.Date the procedure was performed 5.Time the procedure was performed

The nurse has received an order to apply a hydrocolloid dressing to Mr. Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education? 1.Hydrocolloid dressings help to maintain a moist wound environment 2.This dressing will need to be held in place by surgical tape 3.I can leave this dressing in place for three to seven days 4.It will help protect the wound from contamination

2.This dressing will need to be held in place by surgical tape

Ms. Johnson asks: why do I need to self-catheterize at regular intervals? What would be the appropriate response by the nurse? 1.You will only need to self-catheterize once daily 2.This helps prevent your bladder from becoming over distended 3.Self-catheterization helps reduce your risk of infection 4.This allows you to accurately measure your urine

2.This helps prevent your bladder from becoming over distended

The nurse is providing education to Mr. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing? 1.Green leafy vegetables 2.Whole grain bread 3. Baked Chicken 4.Baked potato

3. Baked Chicken

A nurse is assessing a patient with cystic fibrosis. Based on a diagnosis of cystic fibrosis, the nurse expect to find which of the following common physical systems upon assessment 1. shortness of breath, headache, and vision changes 2. nausea, vomiting and hyperreflexia 3. cyanosis or pallor, dyspnea and arrhythmias 4. increased activity, diaphoresis and tachycardia

3. cyanosis or pallor, dyspnea and arrhythmias

A nurse is planning patient education about a prescribed medication for a patient. What should the nurse do first? 1. educate the patient about potential allergic reactions to the med 2. review the signs and symptoms of drug toxicity with the patient 3. find out what the patient already knows about the med 4. educate the patient about potential drug interactions

3. find out what the patient already knows about the med

A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up which of the following test results? 1. white blood cell count 2. chest x-ray 3. hemoglobin 4. gram stain

3. hemoglobin (a pulse oximeter measures the oxygen saturation of hemoglobin. A pts hemoglobin may be adequately saturated with oxygen, but if they have low hemoglobin, they might not have enough oxygen to meet demands).

A patient which cystic fibrosis has five capsules of pancrelipase (amylase, lipase and protease) ordered to be administered now with his breakfast. The patient is currently experiencing nausea and intermittent vomiting. What should the nurse do with the medication 1. crush the medication to administer to patient 2. administer the medication as ordered 3. hold the medication until the patient is able to eat again 4. call the provider immediately

3. hold the medication until the patient is able to eat again

Mona asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. What is the best response by the nurse? 1. it is ordered by your provider 2. it increases the oxygen taken in by the lungs when you inhale 3. it helps prevent atelectasis or collapsing of the alveoli in the the lungs 4. it decreases cardiac workload during inspiration

3. it helps prevent atelectasis or collapsing of the alveoli in the lungs

A nurse is teaching a patient with cystic fibrosis about nutrition in the high-fat, high-protein, high-carbohydrate diet that has been recommended. Which of the following should be included in this education? 1. it is not necessary to monitor dietary intake 2. it is important to focus on eating calorie-dense foods 3. it is important to select a variety of nutrient-dense foods 4. it is important to only eat high-fat, high-protein, high-carb foods

3. it is important to select a variety of nutrient-dense foods

In addition to regular monitoring of serum potassium level, which intervention will the nurse implement to address the safety needs of a patient prescribed intravenous potassium chloride 1. deliver the medication by slow IV push 2. shading windows to minimize sun exposure 3. screening electrocardiograms (ECG) regularly 4. monitor for hyperactivity

3. screening ECG regularly

Which statement concerning the measure of intake and output is true? 1. liquid medications are not considered when calculating intake 2. health care agencies have adopted standard volumes fro common beverage containers 3. when possible, intake and output should be measured rather than estimated 4. only foods that are consumed as liquid are included in the intake calculations

3. when possible, intake and output should be measured rather than estimated

As the nurse administer Mona's prescribed medication, guaifenesin, the patient states: "I don't like this medication. It makes me cough too much." How should the nurse respond? 1. I will let your provider know you have questions about your medications 2. This medication is given to you because of your pneumonia 3. When you cough out secretions, oxygenation is more effective 4. This medication will help make your breathing easier

3. when you cough out secretions, oxygenation is more effective

The nurse is providing patient education on self-catheterization. What statement by Mr. Johnson indicates the need for additional teaching? 1.I should store my reusable catheters in a clean, dry container 2.I should report signs and symptoms of potential complications to the provider immediately 3.I can use either an indwelling or intermittent catheter 4.I may be eligible for free catheters through Medicare

3.I can use either an indwelling or intermittent catheter

The nurse is providing Mr. Johnson with discharge education about intermittent self-catheterization. What statement, if made by the patient, would indicate the need for further instruction? 1.It is important that I self-catheterize at regular intervals 2.There are risks associated with self-catheterization, such as bleeding and infection 3.I should maintain sterile technique throughout the procedure 4.If I do not catheterize myself, I may develop urinary problems

3.I should maintain sterile technique throughout the procedure

The need for a sigmoid colostomy is generally a result of cancer at what point in the intestinal tract? 1.Anywhere in the descending colon 2.Anywhere in the transverse colon 3.Near the rectum 4.Near the ileocecal valve

3.Near the rectum

A postoperative patient is receiving enoxaparin sodium therapy. Which assessment data would the nurse report immediately to the patient's health care provider? 1.A platelet reading of 260,000 per mcL 2.Small amount of gum bleeding after completing oral hygiene 3.Patient has reported self-medicating with aspirin three times since surgery 4.Patient reports no bowel movement for two days

3.Patient has reported self-medicating with aspirin three times since surgery

A nurse is planning on administering a tube feeding to a patient with a nasogastric tube. The patient appears asleep flat in bed. What should the nurse do first? 1. administer the feeding quietly without waking the patient 2. carefully connect the nasogastric tube to the tube feeding 3. flush the nasogastric tube with 30-60 ml of water 4. assist the patient to a semi-Fowler's position or higher.

4. assist the patient to a semi-Fowler's position or higher

A nurse has just finished placing a nasogastric tube into a patient for the purpose of administering feedings. What should the nurse do first? 1. irrigate the nasogastric tube with 30-60 mL of water 2. administer the tube feeding as ordered 3. assess how much of the tube was inserted into the ient to verify placement 4. confirm the placement of the nasogastric tube per facility policy

4. confirm the placement of the NG tube per facility policy

Christopher has a low body mass index and has lost 12 pounds over the past two weeks. Which method could the nurse use to assess his overall dietary intake in order to provide nutrition education? 1. ask the patient if he has a healthy diet 2. track the percentage of food eaten at each meal while in the hospital 3. ask the patient to keep a food diary log 4. obtain a food frequency assessment

4. obtain a food frequency assessment

Hyponatremia is associated with a decrease of which electrolyte: 1. chloride 2. phosphorus 3. potassium 4. sodium

4. sodium

The nurse plans on assessing the patient's gastrointestinal system. Which statement below reflects the best prioritization of this assessment 1. the nurse should palpate and then auscultate the abdomen 2. the nurse should percuss and then auscultate the abdomen 3. the nurse should percuss and then inspect the abdomen 4. the nurse should auscultate and then palpate the abdomen

4. the nurse should auscultate and then palpate the abdomen

Mona's laboratory work indicates an elevated white blood cell count with a left shift in the differential. The nurse interprets this to mean which of the following? 1. a left shift in the differential means that there is no infection present 2. there is a high number of white blood cells, but not immature white blood cells, present in the circulation 3. there is a high number of white blood cells to fight the infection, and the red blood cells are compensating 4. there is a high number of white blood cells and immature white blood cells present to fight the infection

4. white blood cells present to fight the infection There is a high number of white blood cells and immature white blood cells present to fight the infection

The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? 1.Reapply the original dressing until a new one can be obtained 2.Pick up the dressing and use the side that did not touch the bed 3.Remove gloves and go to the supply room to obtain more supplies 4.Ask the patient to press the call bell to summon a co-worker to obtain another dressing

4.Ask the patient to press the call bell to summon a co-worker to obtain another dressing

The nurse is irrigating a patient's wound when the patient complains of pain. What is the appropriate action by the nurse? 1.Administer the ordered analgesic when the procedure is finished 2.Discontinue the irrigation and notify the provider 3.Complete a pain assessment and finish the procedure 4.Stop the procedure and administer the ordered analgesic

4.Stop the procedure and administer the ordered analgesic

Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse? 1.Irrigation helps to sterilize the wound 2.The application of fluid helps hydrate the surrounding tissue 3.The irrigation fluid contains medication for the wound 4.The procedure helps remove drainage and debris from the wound

4.The procedure helps remove drainage and debris from the wound

The nurse is providing discharge education on complications associated with intermittent self-catheterization. Which possible complication should the nurse include in the teaching session? (Select all that apply.) 1.Urinary tract infections 2.Nephrotic syndrome 3.Bladder perforation 4.Urethral strictures 5.Bladder spasms

1.Urinary tract infections 3.Bladder perforation 4.Urethral strictures 5.Bladder spasms

A patient complains of nausea after a tube feeding. What is the priority action of the nurse at this time? 1. Position the patient on left side 2. ensure the head of the bed remains elevated 3. aspirate the tube feeding contents from the patient's stomach 4. flush the tube with 30 to 60 mL water

2. ensure the head of the bed remains elevated

What pathology is responsible for metabolic acidosis 1. an increase of CO2 2. an excess of HCO3 and/or a decrease in H ions 3. a decrease of carbonic acid 4. a decrease in bicarbonate or an increase in hydrogen icons

4. a decrease in bicarbonate or an increase in hydrogen ions