114 FINAL exam review questions
A client with COPD has been ordered O2 at 3 L a minute for treatment of dyspnea. What delivery mode is most appropriate for this clients needs? A. nasal canula B. simple mask C. partial rebreather mask D. non re breather mask
A
A nurse is using a pulse oximeter to measure a clients SpO2 obtains a reading of 90%. What is the nurse's most appropriate action? A. encourage the client to do deep-breathing exercises. B. Raise the head of the clients bed slightly, if tolerated. C. review the medications that the client has taken in the past 90 minutes. D. document this expected assessment finding.
A
The nurse is proving care for a client who has a T tubule (biliary drain). The nurse should anticipate that their clients immediate medical history likey includes which of the following? A. cholecystectomy (gall bladder removal) B. debridement of an abscess C. stage 3 or 4 pressure ulcer D. prostatectomy (removal of the prostate gland)
A
A client has undergone foot surgery and will use crutches in the short term. Which of the following teaching points should the nurse provide to the client? A. If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly. B. Your elbows will be slightly bend when you are using your crutches. C. when your crutches fit right, most of your body weight will be supported by your armpits. D. we'll have the nursing assistant watch you while you walk around the unit the first time.
B
Which of the following are recommended guidelines for daily care of a client who has an indwelling urinary catheter? A. put on sterile gloves before cleaning the catheter. B. slean 6 to 8 inches of the catheter, moving from the meatus downward. C. slightly pull on the catheter during the cleaning motion to dislodge crusts. D. afte cleansing the urethral meatus with an antibacterial cleanser, inspect for drainage.
B
urinalysis and urine culture testing have been ordered for a client with an indwelling cath. The nurse observes that there is currently no urine in the clients catheter tube. What should the nurse do? A. encourage the client to increase fluid intake for the next couple of hours. B. clamped the tube below to access the port to allow urine to accumulate. C. reposition the client supine. D. attach a syringe to the access port and aspirate until a sample is obtained.
B
Which of the following statement accurately describes a recommended guideline when using venipuncture to collect a venous blood sample for routine testing? A. use the inner wrist because of the low risk for damage to underlying structures. B. draw the blood from the same extremity used for IV site access in order to preserve the other extremity. C. avoid performing venipuncture on a client with an actual or suspect diagnosis of a cerebrovascular accident (stroke). D. avoid areas that are edematous, paralyzed, or are on the same side as a mastectomy.
D
Which of the following urine collection methods produced a specimen that most closely reflects the characteristics of the urine being produced by the body? A. a voided urine specimen for culture collected midstream. B. A voided specimen collected from he bed pan C. a urine specimen collected form an indwelling urinary catheter D. all collection techniques produce similar specimen.
A
A clienti ho is recovering from a stroke has begun tube feedings. Which of the following statements accurately describes a step in administering this from nutrition? A. feeds must be warned prior to installation to reduce the risk of nausea and vomiting. B. intermittent feedings use gravity for instillation or a feeding pump to administer the formula over a set period of time. C. continuous feedings are the preferred method of introducing the formula over a set period of time via gravity. D. feeding intolerance is less likely to occur with larger volumes.
B
A nurse carefully assess the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? A. kidneys B. lungs C. adrenal glands D. blood vessels
B
A nurse is caring of t a client who has a surgical wound following a bowel resection. The nurses assessment reveals dehiscence of the wound and the nurse contacts the surgeon. What complication of surgery has this client experienced? A. the edges of the wound are misaligned. B. there is an accidental separation of the wound. C. tehre is an accumulation of fluid in the interstitial tissue surrounding the wound. D. there is redness or inflammation of an area as a result of possible wound infection.
B
A nurse is maintaining a clients continuous bladder irrigation. When apprasingin the effectiveness of this therapy, the nurse should prioritize what assessment? A. calculating the flow rate of urinary output B. monitoring the characteristics of the urinary output C. assisting PVR using a bladder scanner D. palpating the clients bladder region.
B
A nurse is teaching a group of student nurses about recommended practices for providing skin care to their clients. Which of the following practices should the nurse teach to the students? A. assess the clients skin at least twice a week B. avoid using soap and hot water, if possible. C. do not use skin barrie products. D. avoid using skin emollients whenever possible.
B
A nurse is using venipuncture to collect a venous blood sample from a client with a clotting disorder. What would be the appropriate intervention for this client? A. apply warm compresses to the site for about 10 minutes before obtaining the sample. B. maintain firm pressure on the venipuncture site for at least 5 minutes after withdrawing the needle. C. perform venipuncture without a tourniquet to minimize the risk for hematoma. D. have the client make a fist while obtaining the blood sample.
B
A nurse prepares to insert a nasointestinal tube to provide nutrition toa client. Which of the following is a recommended guideline for this procedure? A. administer otal analgesis 30 to 45 minutes prior to insertion B. begin by measuring from the tip of the nose to the ear lobe to the xiphoid process. C. add 16 to 18 inches to the measure obtained so the tube rests in the desired area. D. position the bed flat and assist the client to his or her left side.
B
A physician orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurses most appropriate action when carrying out this order? A. apply restraints to the hands or wrists, never to the ankles. B. ensure that two fingers can be inserted between the restraints and the clients extremity. C. use a quick release knot to tie the restraint to eh side rail. D. remove the restraint at least every 4 hours, or according to agency policy.
B
An NG tube has been ordered, and when the nurse attempts to pass the tube through the clients pharynx, the client begins to cough and shows signs of resp. distress. Which of the following would be the most appropriate intervention? A. ask the client to make a deep breath and continue advancing the tube B. stop advancing the tube and pull it back into the nasal area. C. immediately remove the tube and call the physician. D. if the client can tolerate another attempt, ask him or her to raise the chin and swallow as the tube is advanced.
B
Negative pressure wound therapy has been ordered for a patient who needs to be treated for a chronic wound. Which of the following would be included in this clients plan of nursing care? A. to facilitate adequate rest, disconnect NPWT each night between 2200 and 0700. B. record the quantity of drainage once prettify and document on the intake and output record. C. change the wound dressing daily, or more frequently is excessive output is noted. D. remove the transparent dressing if a leak is noted.
B
Removal of a clients NG tube has been ordered. Which of the following actions should the nurse perform during the intervention? A. place the client in the protective supine position to facilitate easy removal. B. before removing the tube, discontinue suction and separate tube from suction. C. attach a syringe and flush with 50 ml of water or normal saline before removal. D. quickly and carefully remove the tube while the client breathes out.
B
What is the maximal time to suction an adults teach tube?
10-15 seconds
Restraints are to be removed every ___ hours.
2
A rectal suppository should be inserted ___ inches into the rectum to ensure contact with rectal mucosa.
3
All visitors/people should stay __ feet away from those under a droplet precaution.
3
A client has a stroke and will require long term tube feeding. Which of the following types of feeding tubes would be most appropriate for this clients needs? A. gastronomy tube B. nasogastric tube C. naso-intestinal tube D. salem sump tube
A
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? A. remove the airway, turn the client to the side and provide mouth suction, if necessary. B. immediately remove the airway, rinse the clients mouth with sterile water, and report this to the physician. C. leave the airway in place and promptly notify the physician for further instructions. D. suction the clients mouth through the oropharyngeal airway to prevent aspiration.
A
A nurse is implementing the principles of surgical asepsis while inserting a clients inter dwelling catheter. Which of the following actions should the nurse perform? A. hold sterile objects above was it level to prevent accidental contamination. B. consider the outside of the sterile package to be partially sterile. C. consider the outer 3 inch edge of the sterile field to be contaminated. D. open the sterile packages so that the first edge of the wrapper is directed toward you.
A
A nurse is preparing to move a lucent up in bed. How can the nurse best demonstrate the principles of correct body mechanics? A. face the direction of movement. B. twist body at the wast when lifting. C. keep the body weight height than the center of gravity. D. keep feet together to provide a solid base of support.
A
A nurse is preparing a peripheral venous access device. Before admin, what should she do? Select all: A. flush the device with a small amount of normal saline B. assess the clients allergy status C. select an appropriate injection site D. identify the client according to institutional protocol E. admin 2 to 3 ml of heparin to clear lost from the device
A; B; D
A client has been having frequent watery stools (diarrhea) for an extended period of time, and has decreased skin turgor and dark urine. Based on this data, which nursing diagnosis would be most appropriate? A. imbalanced nutrition: less than body requirements B. deficient fluid volume C. impaired tissue integrity D. impaired urinary elimination
B
A client who requires intermit. urin. catheterization needs a sterile urine specimen. Which type of catheter should the nurse use? A. condom catheter B. urinary bag C. straight catheter D. retention catheter
C
A nurse is assessing a patient who is being admitted to the hospital. Which is the most important info that indicates whether the patient is at risk for physical injury? A. weakness experiences during a previous administration B. medication that increase intestinal motility C. two recent falls that occurred at home D. the need for corrective glasses
C
A nurse is inspecting a clients pressure ulcer documents the following: full thickness tissue loss; visible subcutaneous fat; no bone, tendon, or muscle visible. Th nurse should recognize what stage of pressure ulcer? A. stage 1 B. stage 2 C. stage 3 D. stage 4
C
A patinets o2 saturation by pulse ox. indicates inadequate oxygenation. Which should the nurse do first? A. notify the primary care provider B. recheck the result. C. raise the head of the bed D. administer ocygen
C
The nurse is providing care to a patient who has a sacral pressure ulcer with a wet to dry dressing. Which guideline is appropriate when caring for a patient with a wet to dry dressing? A. the wound should remain moist from the dressing B. the wet to dry dressing should be packed tightly into the wound. C. the dressing should be allowed to dry before its removed. D. a plastic sheet-type dressing should cover the wet dressing.
C
A clients plan of care specifies the nurse of cold therapy. Which of the following actions should the nurse perform during the intervention? A. fill the ice bag about half full with ice and then fill it with water. B. cover the ice bag with sterile gauze before applying. C. positiont he ice bag immediately distal to the area requiring treatment. D. remove the ice bag and assess the site for redness after 30 seconds.
D
A nurse is in charge of client care for a client who has an infection caused by a multi drug resistant microorganism. Which of the following is an accurate guideline for using Transmission-Based Precautions when caring for this client? A. place the client in a private room that has negative air pressure. B. keep visitors 3 feet from the client. C. use resp. protection when entering the room. D. wear a gown and gloves whenever entering the clients room to give care.
D
A nurse is teaching a client how to care for her dementia. Which of the following is a recommended teaching guideline? A. remove your dentures whenever possible in order to rest your gums. B. wrap your dentures in a clean napkin or facecloth when not using them. C. rinse your dentures in a dilute bleach solution at least once per week. D. store your dentures in cold water whenever they're not in use.
D
The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying the Jackson Pratt drain, the nurse should prioritize what action? A. don sterile gloves before manipulating the cap of the drain. B. cleanse the area around the cap with alcohol for 30 seconds before removing it. C. pin the drain to the clients gown after pulling the tube taught. D. recompress the drain before replacing the cap.
D
Negative air pressure rooms are used for clients under __________ caution.
airborne
An intra-dermal injection to test an allergy should be injected into the inner forearm.
allergy
Incentive Spirometer= instruct client to ________ slowly and as deeply as possible through the mouthpiece without using the nose.
inhale
______ medications are the most common prescription.
oral
