Fund. Exam 6

Match the nursing interventions on the left with the complication to be prevented on the right. An intervention may apply to more than one complication. Nursing Intervention 1. Offering glasses or hearing aid 2. Early ambulation 3. Strict aseptic technique 4. Deep breathing exercise 5. Hydration Complication a. Deep vein thrombosis b. Wound infection c. Delirium d. Atelectasis

1. c 2. a, c 3. b 4. d 5. a, d

The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 5 feet, 2 inches in height. Which factors increase this patient's risk for surgical complications? (Select all that apply.) 1. Obesity 2. Prolonged bleeding time 3. Delayed wound healing 4. Ineffective vital capacity 5. Immobility secondary to height

Answer: 1, 3. Secondary to the physiological stress of surgery that increases cortisol levels in patients with type 2 diabetes, these patients are at risk for surgical complications. This patient is also obese, which increases surgical risk.

How would the nurse position a postsurgical patient who is severely obese during incentive spirometry? 1. Supine 2. Side-lying 3. High-Fowler's 4. Semi-Fowler's

Answer: 2 •The nurse should use a side-lying position for a patient who is severely obese during incentive spirometer exercises to facilitate better movement of the diaphragm. •The supine position is not appropriate for incentive spirometer exercises. •High-Fowler's and semi-Fowler's positions are appropriate for postsurgical patients of normal weight during incentive spirometer exercises.

A patient has a stage 4 pressure ulcer on their sacral area. What type of foods would the patient most benefit from? 1. Dried beans, eggs, meats 2. Liver, spinach, corn 3. Oats, fruits, and vegetables 4. Peanuts, tomatoes, and cabbage

Answer: 1 A patient with a stage 4 pressure ulcer needs a high protein diet to promote wound healing. Dried beans, eggs, and meats are the highest protein foods of the selection.

A patient who has a colostomy is complaining about having excess gas. You ask the patient to tell you what he has ate in the past 48 hours. Which food would you suspect is causing the patient excessive gas? 1. Cherries, Radishes, and Watermelon 2. Caraway seeds, tomato soup, and eggs 3. Chicken, grapes, and raspberries 4. Squash, Spinach, and Pickles

Answer: 1 Cherries, radishes, and watermelon are gas causing foods and should be decreased in consummation if a patient is experiencing excess gas.

A patient just had a Wound Vac ® placed on her abdomen from abdominal surgery. Which foods would help promote wound healing? 1. Citrus fruit and tomatoes 2. Liver, beef, and fish 3. Corn, poultry, and grains 4. Peanuts, beans, and pork

Answer: 1 Foods high in vitamin C help promote the production of collagen which is vital for wound healing. Citrus fruits and tomatoes are high in vitamin C.

A patient is admitted for diverticulitis. The patient has been on a full liquid diet and has been tolerating it well. Now the MD has ordered the patient a new diet. You would expect to find what type of food on the patient's lunch tray? 1. Piece of white bread, skinless white potatoes, and white rice. 2. Glass of whole milk, broccoli, and cabbage 3. Peanut butter sandwich, glass of milk, and strawberries 4. French fries, chicken salad, and apple pie

Answer: 1 Patients with diverticulitis should be started on a low-residue diet after full liquids have been tolerated. A piece of white bread, skinless white potatoes, and white rice are considered low-residue foods.

Which factor may predispose a patient to unintended hypothermia during surgery? 1. Age 2. Obesity 3. Smoking 4. Nutrition

Answer: 1 •Age is an important factor that may predispose a patient to unintended hypothermia. •Pediatrics and geriatrics are at a higher risk of presenting problems relating to temperature control during surgery. •Obesity may predispose a patient to an increased risk of postoperative atelectasis, pneumonia, and death. •Smoking may lead to respiratory problems and wound healing. •Nutritional deficiency may result in poor wound healing after surgery.

The nurse is inserting a central catheter into a patient to provide parenteral nutrition (PN). The nurse places the patient in a left lateral decubitus position and instructs the patient to hold his or her breath and bear down during catheter insertion. Which rationale would explain this instruction? 1. Helping prevent an air embolism 2. Promoting the patient's comfort 3. Promoting lung expansion 4. Preventing pulmonary aspiration

Answer: 1 •An air embolism can occur when inserting a catheter for PN. •It can be prevented by placing the patient in a left lateral decubitus position because the chances of air embolism are minimal as a result of the anatomic position of the heart. •Holding the breath and bearing down is called the Valsalva maneuver. Performing the Valsalva maneuver helps increase the venous pressure and prevent air from entering the bloodstream. •The patient's position does not promote the patient's comfort nor does it promote lung expansion. It also does not help prevent pulmonary aspiration; pulmonary aspiration is a complication of enteral nutrition and is not related to PN.

Which intervention indicates a correct technique of nasogastric (NG) feedings? 1. Checking residual volume every 4 hours 2. Stimulating the gag reflex every 8 hours 3. Administering only small amounts of the feeding formula 4. Administering the feedings to the patient in a supine position

Answer: 1 •Checking the residual volume every 4 hours is an effective measure to ensure that the feedings are being absorbed without risk of delayed gastric emptying. •Stimulating the gag reflex increases the risk of aspiration. •Patients should receive the prescribed dosage of the enteral feedings as directed by the health care provider. •Enteral feedings should never be administered to a patient in a supine position because of the risk of aspiration.

Which statement is true regarding actions after surgery? 1. Coughing is contraindicated after an eye surgery. 2. Pain and redness are normal signs of arterial occlusion. 3. The side-lying position deteriorates the lung function of patients who are obese. 4. Deep breathing improves lung function in a patient with a spinal surgery.

Answer: 1 •Coughing increases the intracranial and intraocular pressure in a patient who has undergone an eye surgery; therefore coughing is contraindicated. •Redness and pain are typically observed when there is a venous thrombus. •The side-lying position helps improve lung function in a patient who is obese. •Deep breathing is contraindicated in a patient who has undergone spinal surgery.

A poststroke patient suffers from right-sided hemiplegia and dysphagia. Which complication of dysphagia might the nurse observe in the patient? 1. Aspiration pneumonia 2. Excess fluid intake 3. Improved nutrition status 4. Weight gain

Answer: 1 •Dysphagia may increase the risk of the food getting into the airway while eating. It may get aspirated and lead to aspiration pneumonia. •Difficulty in swallowing fluid leads to decreased fluid intake, resulting in dehydration. •The inability to swallow may reduce food intake and result in decreased nutrition status and weight loss.

Which factor may cause electrolyte imbalance and increase the risk of complications during surgery? 1. Fever 2. Alcohol abuse 3. Dysrhythmias 4. Thrombocytopenia

Answer: 1 •Fever may cause fluid and electrolyte imbalance that may pose a risk of complications during surgery. •Alcohol abuse may affect wound healing. •Dysrhythmias may cause a depression of cardiac function. •Thrombocytopenia increases the risk of hemorrhage during surgery.

A patient receiving total parenteral nutrition (TPN) asks the nurse why blood glucose is being checked because the patient does not have diabetes. Which response by the nurse is appropriate? 1. "TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range." 2. "The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely." 3. "Monitoring your blood glucose level helps determine the dose of insulin that you need to absorb the TPN." 4. "Checking your blood glucose level regularly helps determine if the TPN is effective as a nutrition intervention."

Answer: 1 •The TPN solution is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. • Administration of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. •Blood glucose levels should be monitored every 6 hours to assess for hyperglycemia. •Maintaining blood glucose within acceptable limits helps prevent complications from the TPN. •The high concentration of dextrose in the TPN does not cause diabetes. •Insulin aids the body in absorbing sugar not the TPN solution. •Monitoring all the patient's electrolytes, not just the blood glucose, helps determine the effectiveness of the TPN solution.

Which amino acid does the body not synthesize? 1. Lysine 2. Alanine 3. Asparagine 4. Glutamic acid

Answer: 1 •The body does not synthesize lysine, which is an indispensable amino acid that should be part of a healthy diet. •Alanine, asparagine, and glutamic acid are dispensable amino acids, which are synthesized by the body.

How often would the nurse change the feeding bag for a patient who is prescribed an intermittent enteral feeding? 1. Daily 2. Every 8 hours 3. Every 12 hours 4. Every other day

Answer: 1 •The feeding bag that is used to administer intermittent enteral feedings is changed every 24 hours or daily. •Changing the bag every 8 hours or every 12 hours is more often than necessary. •The feeding bag should be changed more frequently than every other day.

Which nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding? 1. Discarding gastric contents 2. Flushing the tube with 30 mL of air 3. Administering the feeding for a gastric volume of 425 mL 4. Pulling back slowly to aspirate the total volume of gastric contents

Answer: 1 •The inappropriate nursing action is to discard the gastric contents. This action could lead to fluid and electrolyte imbalances and should be avoided. •Flushing the tube with 30 mL of air, administering the feeding for a gastric volume of 425 mL, and pulling back slowly to aspirate the total volume of gastric contents are all appropriate nursing actions.

A patient arrives at an outpatient surgery center before a tonsillectomy. Which action is the priority during this phase of surgery? 1. Preoperative assessment 2. Intraoperative medication 3. Intraoperative assessment 4. Postoperative instructions

Answer: 1 •The patient is in the preoperative phase of surgery and must be assessed and prepared for surgery. •The patient may have laboratory work obtained, medication administered, and consent forms signed. •The intraoperative phase is the actual surgery; the patient is anesthetized, prepped, draped, and surgery performed. •The postoperative phase is the recovery phase of surgery in which the patient continues to recover until optimal health is achieved.

The nurse is feeding a patient with dysphagia. Which patient position should be avoided to reduce the risk of aspiration? 1. Supine 2. Sitting in a chair 3. High-Fowler's position 4. Chin-tucked position

Answer: 1 •The patient should not be placed in a supine position because the risk of aspiration is high. To prevent aspiration, the patient should be made to sit in a chair or in a Fowler's position. These positions helps the patient swallow properly and prevents the risk of food going into the airway. The chin-tucked position helps prevent aspiration.

The nurse documents the following complaints upon an initial assessment. Which patient need would be the nurse's priority? 1. Pain related to oral ulcers 2. Insufficient nutrition for body requirements 3. Deficient understanding of diet therapy 4. Constipation related to reduced food intake

Answer: 1 •The patient's needs should be met in the order of priority. •The pain caused by oral ulcers should be a priority because this pain could affect the patient's nutritional intake and affect all other related interventions. Once the pain is relieved, the nutritional intake can be increased. •Correcting a nutritional imbalance should be the second priority because it may affect other body systems. However, this diagnosis can only be addressed once the oral pain is relieved. •Deficient knowledge regarding the diet therapy is the third priority. This diagnosis can only be addressed once the patient is relieved of pain. •Constipation is the last priority. It can be addressed once the pain is relieved. The risk can be prevented by increasing the dietary intake and advising the patient on diet changes.

The nurse is attending to an elderly patient scheduled for a hernia operation. The nurse understands that because of aging, the patient may have rigidity of the blood vessel walls and a reduction in sympathetic and parasympathetic innervation to the heart. Which risk would be increased in this patient after a surgery? Select all that apply. One, some, or all responses may be correct. 1. Hemorrhage 2. Increased systolic blood pressure 3. Increased diastolic blood pressure 4. Increased ability to eliminate drugs 5. Increased lung expansion

Answer: 1, 2, 3 •As the body ages, the blood vessel walls become rigid, causing a reduction in sympathetic and parasympathetic innervation to the heart. •These changes may increase the risk of hemorrhage after a surgery. The patient may also develop an increase in systolic and diastolic pressures. •After a surgery, there could be a decreased ability to eliminate drugs because of reduced renal function. •Lung expansion may be reduced as a result of decreased strength of the respiratory muscles.

A patient with myasthenia gravis has difficulty swallowing. For which complication of dysphagia would the nurse be observant? Select all that apply. One, some, or all responses may be correct. 1. Aspiration pneumonia 2. Dehydration 3. Weight loss 4. Dental caries 5. Gastric ulcers

Answer: 1, 2, 3 •Dysphagia refers to difficulty swallowing. •The chewed food may become aspirated during swallowing and may cause aspiration pneumonia. •The inability to swallow may lead to a decreased intake of fluids, resulting in dehydration. •Weight loss may be caused by inadequate intake of food. •Dental caries are not a complication of dysphagia. They are caused by inadequate oral hygiene. •Gastric ulcers may be caused by infection, drugs, or stress.

Which food item suggested by the nurse contains significant amounts of fiber? Select all that apply. One, some, or all responses may be correct. 1. Oats 2. Barley 3. Cornmeal 4. Cheese 5. Milk

Answer: 1, 2, 3 •Fiber in the diet does not contribute calories because it is not broken down by the digestive enzymes. •Oats, barley, and cornmeal contain significant amounts of fiber. •Cheese and milk are easily broken down and digested.

Which nursing intervention helps ensure that a patient regains normal gastrointestinal function after general anesthesia and a surgical procedure? Select all that apply. One, some, or all responses may be correct. 1. Provide frequent oral hygiene. 2. Maintain adequate fluid intake. 3. Encourage ambulation and physical activity. 4. Provide a meal right after the patient takes pain medication. 5. Advance diet quickly to encourage the return of peristalsis.

Answer: 1, 2, 3 •Providing frequent oral hygiene as well as adequate hydration and cleaning of the oral cavity eliminates dryness and bad tastes in the mouth that may prevent the patient from eating adequately. •Fluids promote adequate hydration and keep fecal material soft for easy passage. •Promoting ambulation and exercise stimulates a return of peristalsis, and a patient who has abdominal distention and "gas pain" may obtain relief when walking. •Provide meals or snacks when the patient is rested and free from pain, not right after taking pain medication, ambulating, coughing, extensive dressing changes, or deep-breathing exercises; allow the pain medication to take effect or the patient to rest before eating to prevent feeling nauseated. •A patient's dietary intake should be advanced gradually, not quickly, based on the surgeon's orders; most surgeons rely on the return of flatus or bowel sounds to order a normal diet.

Which nursing intervention is appropriate for the nurse to implement for a patient reluctant to perform exercises because of incisional pain? Select all that apply. One, some, or all responses may be correct. 1. Report to the surgeon or pain team. 2. Increase the dose of pain medication. 3. Instruct the patient to ask for pain medications 30 minutes before exercises. 4. Involve family members when teaching exercises. 5. Assess the patient for fatigue and anxiety.

Answer: 1, 2, 3 •When a postsurgical patient is reluctant to perform exercises because of incisional pain, the nurse should tell the surgeon or pain team so that the analgesic dose can be increased or the prescription altered. •The nurse should tell the patient to ask for pain medications 30 minutes prior to exercising if he or she is in pain to preemptively provide relief. •The nurse should involve family members when teaching exercises to ensure adequate home care, but this will not improve pain. • The nurse should assess for the presence of fatigue and anxiety when the patient is unable to perform exercises correctly before, not after, surgery.

Which statement describes a responsibility of a circulating nurse in managing the care of a patient during surgery? Select all that apply. One, some, or all responses may be correct. 1. The nurse assists in positioning the patient. 2. The nurse counts the sponges and instruments. 3. The nurse reviews the preoperative assessment. 4. The nurse implements the plan of care. 5. The nurse hands instruments to the surgeon.

Answer: 1, 2, 3, 4 •The circulating nurse assists in positioning the patient, counts the sponges and instruments, reviews the preoperative assessment, and implements the plan of care. The scrub nurse is responsible for handing instruments to the surgeon.

The nurse recognizes that which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Spirituality 3. Personal beliefs 4. Previous experiences with death 5. Gender 6. Level of education

Answer: 1, 2, 3, 4. Culture, spirituality, personal beliefs and values, and previous experiences with death influence how a person approaches death.

A patient admitted to the hospital poststroke experiences right-sided hemiplegia. The nurse finds that the patient has dysphagia. Which precaution would the nurse take when feeding the patient? Select all that apply. One, some, or all responses may be correct. 1. Schedule a 30-minute rest period before eating. 2. Position the patient in an upright, seated position. 3. Have the patient flex the head slightly to a chin-down position. 4. Feed the patient thin fluids and juices. 5. Allow the patient time to empty the mouth before each spoonful.

Answer: 1, 2, 3, 5 •Feedings should be carefully performed to prevent aspiration pneumonia. •The act of chewing and swallowing may be a difficult task in a patient with dysphagia and may cause fatigue. Therefore the patient should be given a 30-minute rest period before the meal. •Positioning the patient upright in a seated position prevents the aspiration of food. •Having the patient flex the head slightly to a chin-down position prevents aspiration. •Enough time should be given to the patient to chew the food properly and swallow it. •Thin juices are difficult to swallow. Instead, thick fluids and pureed foods should be provided.

Which action would the nurse implement when feeding a patient who is prescribed aspiration precautions? Select all that apply. One, some, or all responses may be correct. 1. Telling the patient to open his or her mouth 2. Encouraging the patient to feel the food in his or her mouth 3 Asking the patient to cough to clear the airway 4. Rushing the patient to finish the meal as soon as possible 5. Teaching the patient to raise his or her tongue to the roof of the mouth when eating

Answer: 1, 2, 3, 5 •Nursing actions that are appropriate when feeding a patient who is prescribed aspiration precautions include telling the patient to open his or her mouth; encouraging the patient to feel the food in his or her mouth; asking the patient to cough to clear the airway; and teaching the patient to raise the tongue to the roof of the mouth when eating. The nurse should provide more time and rest periods as needed rather than rushing the patient through a meal.

To best assist a patient in the grieving process, which factors are most important for the nurse to assess? (Select all that apply.) 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status 5. Current medications

Answer: 1, 2, 3. Previous experiences, religious affiliation, and cultural practices help individuals develop coping and can be a source of support at the end of life.

Which patient behavior would the nurse instruct assistive personnel (AP) to report during the administration of an enteral feeding? Select all that apply. One, some, or all responses may be correct. 1, Choking 2. Gagging 3. Sneezing 4. Coughing 5. Discomfort

Answer: 1, 2, 4, 5 •During an enteral feeding, the nurse should instruct AP to report choking, gagging, and coughing because these may indicate that the patient has aspirated. The nurse should also instruct AP to report any patient discomfort. Sneezing is not of particular concern during the administration of an enteral feeding.

When planning care for a dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing the patient as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Inserting a straight catheter when the patient has difficulty voiding

Answer: 1, 2, 4, 5. A sense of dignity includes a person's positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers.

A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0 to 10. The nurse has tried repositioning with no improvement in the patient's pain report. Unmanaged surgical pain can lead to which of the following problems? (Select all that apply.) 1. Delayed ambulation 2. Reduced ventilation 3. Catheter-associated urinary tract infection 4. Retained pulmonary secretions 5. Reduced appetite

Answer: 1, 2, 4, 5. Unmanaged surgical pain can lead to delayed ambulation, reduced ventilation, retained pulmonary secretions, or reduced appetite. Unmanaged surgical pain is not associated with catheter-associated urinary tract infection.

An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? (Select all that apply.) 1. Stiffened lung tissue 2. Reduced diaphragmatic excursion 3. Increased laryngeal reflexes 4. Reduced blood flow to kidneys 5. Increased cholinergic transmission

Answer: 1, 2, 4. Older adults have stiffened lung tissue, reduced diaphragmatic excursion, and reduced blood flow to kidneys. Laryngeal reflexes are reduced, increasing risk for aspiration, and reduced cholinergic transmission puts them at risk for cognitive changes.

Which comments to a patient by a new nurse regarding palliative care needs are correct? (Select all that apply.) 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care." 5. Palliative care is only for people with uncontrolled pain.

Answer: 1, 2, 4. Palliative care is available to all patients regardless of age, diagnosis, and prognosis.

The nurse is caring for a patient who is on tube feedings. Which sign and/or symptom suggests intolerance to the feedings? Select all that apply. One, some, or all responses may be correct. 1. High gastric residual 2. Nausea 3. Vomiting 4. Constipation 5. Cramping

Answer: 1, 2, 5 •Tube feedings are usually started at slow rates. The rate is increased if there are no signs of intolerance. •The presence of high gastric residual indicates that the feedings are not being digested. •The presence of high residual volume may cause nausea, vomiting, and cramping. Intolerance may cause diarrhea, but it does not lead to constipation.

A patient who lives alone comes to the clinic for a regular checkup. Upon assessment, the nurse finds that the patient has experienced a weight loss of 5 pounds and has a poor nutrition status. The nurse decides to assess the food preferences and dietary intake of this patient. Which question would the nurse ask? Select all that apply. One, some, or all responses may be correct. 1. "How do you prepare your food?" 2. "How many meals do you have in a day?" 3. "Do you buy food from the nearby store?" 4. "How many hours after eating do you go to bed?" 5. "Do you follow any special diet because of a medical condition?"

Answer: 1, 2, 5 •When assessing the dietary and food intake of a patient, it is important to know how the patient prepares the food. Various cooking practices affect the nutritional value of food. •Asking how many meals the patient has in a day is important to assess the nutrition status. •Asking if the patient is following any special diet is important because it helps the nurse determine if the patient is lacking any nutrients. •Asking the patient about buying foods from the nearby store does not provide any information regarding the dietary intake. •Asking the patient how many hours pass between eating dinner and sleeping is not important in assessing dietary intake.

Which characteristic of vitamin A differentiates it from vitamin C? Select all that apply. One, some, or all responses may be correct. 1. Stored in the body 2. Acts as an antioxidant 3. Fat-soluble vitamin 4. Acquired through diet 5. Toxic when taken excessively

Answer: 1, 3 •Vitamin A is stored in the fatty compartments of the body, whereas vitamin C is not stored in the body at all. • Vitamin A is fat-soluble, whereas vitamin C is water-soluble. •Both are antioxidant vitamins that neutralize free radicals and prevent oxidative damage to body cells and tissues. •Both vitamins may be acquired through diet, and both are toxic when consumed excessively.

Which special precaution is required for a patient who is latex sensitive scheduled for surgery? Select all that apply. One, some, or all responses may be correct. 1. Use stopcocks to inject the medications. 2. Draw the medications from well-closed vials. 3. Remove all latex products from the operating room. 4. Use a nonlatex breathing circuit with a plastic mask and bag. 5. Schedule the surgery as the last case of the day.

Answer: 1, 3, 4 •Special care should be taken for a patient who has a latex sensitivity. •Using stopcocks to inject drugs rather than latex ports reduces the chances of a latex allergic reaction. •Removing all latex products from the operating room helps prevent severe reactions in the patient. •Using a nonlatex breathing circuit with a plastic mask and bag helps prevent latex reactions. •All of the contents must be latex free. •Medication should not be drawn from well-closed vials because they increase the chances of latex allergic reactions. •Medications should be drawn directly from opened vials. •Scheduling the surgery as the first case of the day in the operating room ensures that any latex dust has been removed from the room overnight by ventilation.

Which actions by the nurse help grieving families? (Select all that apply.) 1. Encourage involvement in nonthreatening group social activities. 2. Follow up with the family in their home. 3. Remind them that feelings of sadness or pain can return around anniversaries. 4. Encourage survivors to ask for help. 5. Look for overuse of alcohol, sleeping aids, or street drugs.

Answer: 1, 3, 4, 5. Providing education, encouraging, and monitoring for healthy and unhealthy coping responses during grief are ways to support and help families grieve. Encouraging survivors to seek available resources helps survivors cope with grief.

Which patient is at high risk of dysphagia? Select all that apply. One, some, or all responses may be correct. 1. A patient who coughs during eating 2. An individual who speaks consistently 3. A person who has abnormal lip movements 4. One who has coordinated and precise speech 5. The patient with a change in voice tone after swallowing

Answer: 1, 3, 5 •Dysphagia refers to abnormal swallowing, which can lead to aspiration. •Coughing during eating indicates that food has entered the respiratory tract. •Abnormal lip movements can indicate an abnormal swallowing reflex. •A change in voice tone after swallowing is caused by the food entering the respiratory tract. •Speaking consistently and having coordinated speech indicate a normal swallowing reflex.

The nurse is caring for a patient diagnosed with hemorrhoids and chronic constipation. Which information would the nurse share with the patient about diet? Select all that apply. One, some, or all responses may be correct. 1. Food rich in fiber relieves constipation. 2. Fiber contributes calories to the body. 3. Fluid and fiber intake should be increased. 4. Fiber is well digested by humans. 5. Fruits and vegetables relieve constipation.

Answer: 1, 3, 5 •Low fluid intake, low fiber, and physical inactivity can lead to constipation, which may cause hemorrhoids in the long term. •Fiber relieves constipation by adding bulk to the stool and helping bowel elimination. •Fluids soften the stool and help in easy passage. •Fruits and vegetables are good sources of fiber and should be included in the diet. •Fiber does not add calories to the body because it is not digested by the body.

The nurse is caring for a patient experiencing dysphagia. Which intervention helps decrease the risk of aspiration during feedings? Select all that apply. One, some, or all responses may be correct. 1. Sit the patient upright in a chair. 2. Give liquids at the end of the meal. 3. Place food in the stronger side of the mouth. 4. Provide thin foods to make it easier to swallow. 5. Feed the patient slowly, allowing time to chew and swallow. 6. Encourage the patient to lie down to rest for 30 minutes after eating.

Answer: 1, 3, 5 •Patients with dysphagia are at risk of aspiration and need assistance with feedings and swallowing. •Position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. •If the patient has unilateral weakness, teach the patient and the caregiver to place food in the stronger side of the mouth. •Feed the patient with dysphagia slowly, providing smaller-sized bites, and allow the patient to chew thoroughly and swallow the bite before taking another. •Liquids may be given at any time of the meal after the appropriate viscosity has been determined by the patient. •Thin foods increase the risk of aspiration as they are difficult for the patient to control and may enter the trachea instead of the esophagus. As with fluids, thicker foods are easier to swallow. •The patient should remain in an upright position for at least 30 minutes following eating, as lying down increases the risk for aspiration.

A patient with hypertension comes to the clinic for a checkup. On assessment, the nurse finds that the patient has experienced a weight loss of 5 pounds and has a poor nutrition status. Which physical sign is indicative of poor nutrition status? Select all that apply. One, some, or all responses may be correct. 1. Dry scaly lips 2. Pain in the chest region 3. Flaccid, wasted muscles 4. Tiredness after climbing stairs 5. Spoon-shaped and brittle nails

Answer: 1, 3, 5 •When a person has poor nutrition status, the entire body is affected. •The lips are dry and scaly; there may be cracks and fissures at the angle of the lips. •The muscles appear flaccid. The muscles lose their tone and bulk because of tissue breakdown. •Spoon-shaped and brittle nails are seen when there is deficiency of elements such as calcium. •Pain in the chest is not a symptom of poor nutrition status. Chest pain can be caused by medical conditions such as angina and myocardial infarction. The patient is known to be hypertensive; thereforetiredness after climbing stairs is common.

A patient is on enteral feedings through a nasogastric tube. Which factor increases the risk of aspiration in the patient? Select all that apply. One, some, or all responses may be correct. 1. Coughing 2. Diarrhea 3. Lying flat 4. Administration of prokinetic drugs 5. Gastroesophageal reflux disease

Answer: 1, 3, 5 •When the patient coughs, the gastric contents may aspirate into the airways. •Lying flat facilitates aspiration because gastric content can easily enter the airways because of the airway's position. •Gastroesophageal reflux is a condition in which the gastric contents flow back into the esophagus. This can increase the risk of aspiration. •Diarrhea is unrelated to the risk of aspiration. •Administration of prokinetic drugs may actually decrease the risk of aspiration by promoting gastric emptying.

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent acentral 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.

Answer: 1, 3. The central line is inserted into a large vein that leads to the superior vena cava. This increases risk for infection. Therefore to prevent infection, change the TPN infusion tubing every 24 hours. Do not hang a single container of PN for more than 24 hours or lipids more than 12 hours. Use sterile technique during central line dressing changes. Monitoring glucose levels and elevating the head of bed are not interventions that will prevent central line infections.

Correct the steps to administering an enteral feeding: 1. Elevate head of bed to at least 30 degrees 2. Check for gastric residual volume 3. Flush tubing with 30 ml of water 4. Verify tube placement 5. Initiate feeding

Answer: 1, 4, 2, 3, 5

Which vitamin is fat-soluble and is stored in the adipose tissue of the body? Select all that apply. One, some, or all responses may be correct. 1. Vitamin A 2. Vitamin B 3. Vitamin C 4. Vitamin D 5. Vitamin E

Answer: 1, 4, 5

The nurse works in a medical-surgical unit. Patients in the unit with which condition would require additional nutrients in their diets to maintain a positive nitrogen balance? Select all that apply. One, some, or all responses may be correct. 1. Severe burns 2. Backache 3. Epilepsy 4. Infection 5. Fever

Answer: 1, 4, 5 •A positive nitrogen balance in the body is needed for growth and development, for maintaining muscle mass and vital organs, and for repair of tissues and wound healing. The body uses nitrogen for all these activities. •The body is said to have a negative nitrogen balance when the body loses more nitrogen than it gains through food and internal body mechanisms. •Patients with severe burns, infections, and fevers have a negative nitrogen balance because of tissue destruction and the need for tissue repair and replacement. •Therefore these patients require additional nutrients in their diets to maintain the nitrogen balance in the body and promote healing. • Patients with a backache and epilepsy do not have a negative nitrogen balance and do not need additional nitrogen.

A patient on enteral feedings experiences diarrhea. Which factor is a possible cause of this health condition? Select all that apply. One, some, or all responses may be correct. 1. Hyperosmolar formula 2. Displacement of the tube 3. Delayed gastric emptying 4. Bacterial contamination 5. Antibiotic therapy

Answer: 1, 4, 5 •Diarrhea in patients on enteral feedings may be caused by hyperosmolar formulas, bacterial contamination, or antibiotic therapy. •Hyperosmolar formulas may not be tolerated and absorbed, causing diarrhea. •Bacterial contamination of enteral formulas may cause infection of the gastrointestinal tract, leading to diarrhea. •Diarrhea can also be a side effect of antibiotic therapy. •Displacement of the tube and delayed gastric emptying do not cause diarrhea.

Which complication is associated with conscious sedation? Select all that apply. One, some, or all responses may be correct. 1. Hypoxemia 2. Hypotension 3. Cardiac irregularities 4. Respiratory depression 5. Decreased level of consciousness

Answer: 1, 4, 5 •Hypoxemia, respiratory depression, and a decreased level of consciousness are complications observed after conscious sedation. •Hypotension is associated with regional anesthesia. •Cardiac irregularities are associated with general anesthesia.

Which complication is associated with conscious sedation? Select all that apply. One, some, or all responses may be correct. 1. Hypoxemia 2.Hypotension 3.Cardiac irregularities 4.Respiratory depression 5.Decreased level of consciousness

Answer: 1, 4, 5 •Hypoxemia, respiratory depression, and a decreased level of consciousness are complications observed after conscious sedation. •Hypotension is associated with regional anesthesia. •Cardiac irregularities are associated with general anesthesia.

Which procedure is considered a palliative surgical procedure? Select all that apply. One, some, or all responses may be correct. 1. Colostomy 2. Appendectomy 3. Repair of cleft palate 4. Resection of nerve roots 5. Debridement of necrotic tissue

Answer: 1, 4, 5 •Palliative surgery reduces the intensity of the disease or its symptoms but is not intended to be curative. •Colostomy, nerve root resection, and debridement of necrotic tissue are examples of palliative surgery. •Colostomy is done for diversion of the fecal passage because of obstruction or necrosis of the distal part of the gastrointestinal tract. •Nerve root resection is usually done to relieve symptoms related to irritation of the particular nerve. •Debridement of necrotic tissue reduces the dead tissues and promotes healing. •An appendectomy is an ablative surgery; it removes a diseased body part. • A repair of a cleft palate is a constructive surgery to restore the function lost or reduced because of congenital anomalies.

Which assessment questions should the nurse ask a preoperative patient preparing for surgery? (Select all that apply.) 1. "Are you experiencing any pain?" 2. "Do you exercise on a daily basis? 3. "When do you regularly take your medications?" 4. "Do you have any medication allergies?" 5. "Do you use drugs and/or tobacco products?"

Answer: 1, 4, 5. Although regular exercise and adherence to the medication regimen are important, for the preoperative patient, the nurse needs to focus on factors that impact the surgical experience.

A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which interventions are a priority? (Select all that apply.) 1. Notify surgeon. 2. Maintain the intravenous fluid infusion. 3. Provide 2L/min of oxygen via nasal cannula. 4. Monitor the patient's vital signs every 5 to 10 minutes. 5. Reinforce the dressing.

Answer: 1, 5. The first two priorities are for the nurse to report to the surgeon immediately and to reinforce the dressing as needed. Maintaining intravenous fluids and monitoring vital signs are routine aspects of the patient's plan of care. Providing oxygen requires a prescription; the surgeon has to be notified for a prescription for oxygen.

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

Answer: 1, 5. When a client is malnourished, he or she is in a state of negative nitrogen balance—meaning, the body is experiencing protein loss and requires more protein to maintain healing. Therefore, total protein will indicate the amount of muscle breakdown and protein loss. Albumin is a serum binding protein, and lower levels can be an indicator of malnutrition, but it is really more indicative of inflammation or kidney and liver disease. As a result, this is not the gold standard for diagnosing malnutrition. BUN is also an indicator because urea is the end product of protein metabolism, and when a patient is not getting enough protein, you will see a decreased BUN.

Which is the best intervention the nurse should implement to promote bowel function? 1. Early ambulation 2. Deep-breathing exercises 3. Repositioning on the left side 4. Lowering the head of the patient's bed

Answer: 1. Early ambulation promotes peristalsis and thus the return of bowel function. Deep-breathing activities prevent the onset of respiratory complications. Positioning on the left side and lowering the head of the patient's bed do not promote peristalsis.

A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a priority? 1. Elevate the head of the patient's bed. 2. Give ordered oxygen through a mask at 4 L/min. 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward.

Answer: 1. Elevating the head of the patient's bed is a quick intervention that does not require a prescription, but it will promote lung expansion and allow secretions to move via gravity. Administration of oxygen requires a prescription. While using the incentive spirometer expands the lungs, it would not be the first action as positioning the patient to breath effectively is necessary.

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 hasbeen verified 4. Evaluating the client's tolerance of the enteral feeding

Answer: 1. The skills of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to AP. The nurse needs to administer enteral feeding because of the risk of aspiration. The nurse is responsible for teaching the client and evaluating the tolerance to the enteral feeding.

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 Valsalvamaneuver. 2. Clamp the intravenous (IV) tubing to prevent more air fromentering the line. 3. Have the patient take a deep breath and hold it. 4. Notify the health care provider immediately.

Answer: 1. Turn the patient on his or her left side to prevent air from entering the left side of the heart. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down").

You are taking care of a patient with severe COPD. What type of diet would best suit this patient's needs? 1. Cut apples, fresh broccoli, and grilled chicken 2. Pureed sweet potatoes, ground turkey & gravy with mash potatoes 3. Green beans, boiled carrots, and steamed fish 4. Fried chicken, French fries, and pudding

Answer: 2 A patient who has COPD will have difficulty breathing and the slightest activities can cause shortness of breath. Therefore, the patient would need something that is very easy to eat and requires minimal chewing. The best option here is pureed sweet potatoes, ground turkey & gravy with mash potatoes.

A patient's potassium level is 6.0. Which food should the patient avoid? 1. 6.0 is a normal potassium level so the patient can eat whatever they want without an effect 2. Raisins 3. Rice 4. Egg yolks

Answer: 2 Normal potassium levels are 3.5-5.0. Therefore a potassium level of 6.0 is considered high so the patient should avoid foods high in potassium. In this case, raisins are the highest in potassium.

A patient is diagnosed with Congestive Heart Failure and must follow a specific diet. Which spices are okay for the patient to use daily? 1. Onion Salt & Garlic Powder 2. Ginger & Bay Leaves 3. Sea Salt & Pepper 4. Garlic Sodium & Nutmeg

Answer: 2 Patients with CHF should avoid excessive sodium. All of the options expect one contain at least one sodium spice, therefore, Ginger & Bay Leaves are okay to use.

The nurse is feeding a patient with dysphagia. Which action performed by the nurse during feedings may lead to aspiration? 1. Raising the head of the bed to 90 degrees. 2. Extending the patient's head to a chin-up position. 3. Placing the food on the stronger side of the mouth. 4. Providing the patient with thicker fluids to drink.

Answer: 2 •A patient with dysphagia is at risk of aspiration if precautions are not taken during feedings. •When positioning the patient for feedings, the nurse should keep the patient's head flexed in a chin-down position. This position promotes swallowing and prevents the food from entering the respiratory tract. •The head of the bed should be raised at 90 degrees to prevent aspiration. •The food should be placed on the stronger side of the mouth to facilitate swallowing. •Thick fluids are easier to swallow than thin fluids and prevent aspiration.

The nurse provides postoperative care 1 hour after a patient underwent surgery. The nurse assesses the patient and recognizes the need to carefully monitor which parameter? 1. Temperature of 37.6° C (99.7° F) 2. Urine output of 0.4 mL/kg/hr 3. Blood pressure of 114/70 mm Hg 4. Serous drainage on the surgical dressing

Answer: 2 •A urine output of less than 0.5 mL/kg/hr is reported to the surgeon or health care provider. The nurse will monitor this parameter carefully. •Temperature of 37.6° C (99.7° F), blood pressure of 114/70 mm Hg, and serous drainage on the surgical dressing are all considered within normal limits.

Which statement made by the nurse requires correction regarding undesirable effects that can occur postoperatively to a patient who had an endotracheal tube during surgery? 1. "You may have blurred vision." 2. "You may experience a sore throat." 3. "You may have increased salivation." 4. "You may experience pain at the surgical site."

Answer: 3 •Surgical procedures involving the use of an endotracheal tube can cause dry mouth. •Therefore the nurse's statement about increased salivation needs correction. •Blurred vision can occur because of ophthalmic ointments used in surgery. •A sore throat may occur if an endotracheal tube is used during surgery. •Pain at the surgical site may be due to prolonged positioning or as a result of the tightness of dressings during surgery.

The nurse suspects that a patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. Which action would the nurse perform first? 1. Have the patient perform the Valsalva maneuver. 2. Turn the patient to the left lateral decubitus position. 3. Notify the health care provider immediately. 4. Raise the head of the bed to 90 degrees.

Answer: 2 •An air embolism possibly occurs during insertion of the catheter or when changing the tubing or cap. •Have the patient assume a left lateral decubitus position first. •Then have the patient perform a Valsalva maneuver (holding the breath and bearing down). The increased venous pressure created by the maneuver prevents air from entering the bloodstream during catheter insertion. •Maintaining the integrity of the closed intravenous system also helps prevent an air embolism. •Notifying the health care provider is important and would need to be done, although not immediately. •The nurse would not raise the head of the bed to 90 degrees. Safety is the immediate priority, which the correct answer addresses.

For which complication would the nurse monitor a patient with hemophilia who underwent surgery? 1. Signs of infection 2. Bleeding 3. Severe hypoventilation 4. Delayed wound healing

Answer: 2 •Hemophilia is a bleeding disorder that may increase the risk of hemorrhage during and after surgery. •Therefore the nurse should monitor for signs of bleeding in the patient. A history of hemophilia does not increase the risk of infection, severe hypoventilation, or delayed wound healing. An immunocompromised patient would be at risk of infection. Patients with an underlying respiratory condition such as chronic obstructive pulmonary disease may experience breathing problems after anesthesia. Patients with diabetes mellitus who take corticosteroids and those who have a weakened immune system may have delayed wound healing.

Which priority nursing action complies with The Joint Commission's standards and promotes patient safety when administering an enteral feeding by a nasoenteric tube? 1. Explaining the procedure to the patient 2. Identifying the patient using two identifiers 3. Checking the expiration date on the patient's formula 4. Performing hand hygiene prior to touching the patient

Answer: 2 •Identifying the patient using two identifiers (such as the patient's name and birthday or name and medical record) is a nursing action that complies with The Joint Commission's standards and promotes patient safety when administering an enteral feeding by a nasoenteric tube. •It should be done first to limit mistakes of identification. The remaining actions promote safety as well but can be done after identification. •Explaining the procedure to the patient enhances cooperation and places the patient at ease. Checking the expiration date on the patient's formula reduces the patient's risk of feeding-borne gastrointestinal infections. Performing hand hygiene reduces transmission of microorganisms.

The nurse observes the assistive personnel (AP) performing the following action for a patient receiving continuous enteral feedings. Which intervention must the nurse address immediately? 1. Fastening the tube to the gown with tape. 2. Placing the patient supine while giving a bath. 3. Performing oral care for the patient. 4. Elevating the head of the bed 45 degrees.

Answer: 2 •Laying the patient supine increases the risk of aspiration of the feedings and should be avoided. This needs to be addressed to maintain patient safety. •Fastening the tube to the gown with tape reduces traction on the naris if the tube moves. •Oral care must be performed and decreases the risk of infection. •Patients receiving enteral feedings should have the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated.

Which patient is at greatest risk of experiencing inadequate nutrition? 1. A 55-year-old obese man recently diagnosed with diabetes mellitus 2. A recently widowed 76-year-old woman recovering from a mild stroke 3. A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery 4. A 46-year-old man recovering at home after coronary artery bypass surgery

Answer: 2 •Older adults who are homebound and have a chronic illness have additional nutritional risks. •Frequently, members of this group live alone with few or no social or financial resources to assist in obtaining or preparing nutritionally sound meals. •This contributes to a risk of food insecurity caused by low income and poverty. In addition, the mild stroke might cause dysphagia. •The 55-year-old man, 22-year-old woman, and 46-year-old man are also at risk of inadequate nutrition, but the risk is higher for the homebound older adult who is widowed and recovering from a stroke.

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? 1. Fat 2. Protein 3. Vitamin 4. Carbohydrate

Answer: 2 •Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue and growth, maintenance, and repair. •Collagen, hormones, enzymes, immune cells, DNA, and RNA are all made of protein. •Fat, vitamins, and carbohydrates are also important for the patient's nutrition, but they are not as essential for synthesis, maintenance, and repair of body tissues.

Which enzyme do the chief cells of the stomach secrete? 1. Secretin 2. Pepsinogen 3. Cholecystokinin 4. Intrinsic factor

Answer: 2 •The chief cells of the stomach secrete the enzyme pepsinogen. •The small intestine secretes the hormones secretin and cholecystokinin. •The parietal cells secrete intrinsic factor.

Which presurgical assessment determines dehydration? 1. Body mass index 2. Oral mucous membranes 3. Four abdominal quadrants 4. Character of the apical pulse

Answer: 2 •The nurse can assess a patient's oral mucous membranes to determine if the patient is dehydrated. •Body mass index determines if the patient is obese. •The nurse can assess the four abdominal quadrants to determine bowel sounds and evaluate bowel function. •The nurse assesses the character of the apical pulse to determine heart disease.

Which skill would the nurse delegate to assistive personnel (AP) when providing care to a patient who is receiving enteral feedings? 1. Verifying the patient's tube placement 2. Infusing the patient's feeding per prescription 3. Documenting the patient's tolerance of the procedure 4. Placing the head of the patient's bed at 25 degrees

Answer: 2 •The nurse can delegate the infusion of the patient's feeding per prescription to the AP. The nurse, not the AP, should be the one to verify tube placement or document the patient's tolerance of the procedure. Whereas patient positioning is a skill that can be delegated to the AP, the appropriate position is for the patient's head of bed to be at least 30, not 25, degrees.

Which postoperative patient would the nurse see first? 1. A 75-year-old patient after hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 beats per minute 2. A 57-year-old patient with a history of obstructive sleep apnea (OSA) who underwent hip replacement 6 hours earlier and who is receiving intravenous patient-controlled analgesia (PCA); the pulse oximeter has been going off and reads 85% 3. A 36-year-old patient after bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotics 4. A 48-year-old patient after total knee replacement who needs help repositioning in bed

Answer: 2 •The patient with OSA has a risk of airway obstruction, which takes immediate precedence. •She is symptomatic of oxygen desaturation. •The patient with moderate pain, the patient who needs a dose of antibiotics, or the patient who requires assistance repositioning in bed can be seen after the patient with oxygen desaturation.

Which statement is true regarding the role of the scrub nurse during surgical procedures? 1. Suturing the incisions 2. Ensuring the cost-efficient use of supplies 3. Providing exposure of the surgical site 4. Handling the tissues during surgical procedure

Answer: 2 •The scrub nurse is often a certified nursing professional who has thorough knowledge of each step of a surgical procedure. •Along with the circulating nurse, the scrub nurse ensures patient safety and also ensures cost-efficient use of supplies required during the surgical procedure. •A registered nurse first assistant (RNFA) has an expanded role in the operating room that includes suturing the incisions and providing exposure of the surgical site. The RNFA collaborates with the surgeon by handling and cutting tissues during a surgery.

To digest starch, which enzyme does the pancreas secrete? 1. Lipase 2. Amylase 3. Elastase 4. Carboxypeptidase

Answer: 2 •To digest starch, the pancreas secretes amylase. •The pancreas secretes lipase to break down emulsified fats, and it secretes elastase and carboxypeptidase to break down proteins. Lipase breaks down emulsified fats. •Trypsin, elastase, chymotrypsin, and carboxypeptidase break down proteins.

Which measure would the nurse follow to maintain or enhance the self-concept of the postoperative patient during wound care? Select all that apply. One, some, or all responses may be correct. 1. Keeping the windows open to allow fresh air 2. Providing privacy by draping the patient completely while exposing the dressing area 3. Maintaining hygiene by providing the patient a complete bath after the first day of surgery 4. Measuring the drainage devices once every day for output recording 5. Offering oral hygiene 3 to 4 times a day to a patient

Answer: 2, 3 •Wounds, dressing, and medical equipment can threaten the self-concept of the postoperative patient. •Providing privacy with adequate draping and maintaining hygiene with a complete bath are measures that will enhance the patient's self-concept. •The windows and curtains should be kept closed to protect the patient's privacy and prevent the opportunity for infection. •The drainage devices should be measured every 8 hours to ensure the emptying of excess drainage. •Oral hygiene may be offered every 2 hours; 3 to 4 times a day is not enough

Which nursing action would help the patient with visual deficits maintain independence during feedings? Select all that apply. One, some, or all responses may be correct. 1. Allow the patient to eat independently without any instructions. 2. Tell the patient where the beverages are located in relation to the plate. 3. Identify the food location on a meal plate as if it were a clock. 4. Ensure the other care providers set the meal tray and plate in the same manner. 5. Encourage the use of large-handled adaptive utensils.

Answer: 2, 3, 4, 5 •The patient with visual deficits should be assisted with feedings. •The patient should be told where the beverage is in relation to the plate so that he or she can drink it without assistance. •Identifying where the food is on the plate using a clockwise pattern helps the patient locate the food and eat without assistance. •The patient may be able to eat the food without assistance if the plate is always set in the same pattern. •Using large, adaptive utensils helps the patient use them effectively. •The patient should not be left alone to eat if he or she has visual deficits.

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

Answer: 2, 3, 4. Patients who are malnourished on admission are at greater risk of life-threatening complications such as arrhythmia, skin breakdown, sepsis, or hemorrhage during hospitalization.

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of inter- ventions. 3. Allow patients to have visitors at any time. 4. Provide the patient with a private room close to the nurses' station. 5. Encourage the patient to eat whenever he or she is hungry.

Answer: 2, 3, 5. Allowing patients to make choices about their care and end-of-life experience provides opportunities for them to maintain their autonomy.

Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following? (Select all that apply.) 1. Documenting assessment findings in the medical record 2. Using a standardized SBAR tool 3. Being responsive in using nonverbal communication techniques 4. Giving specific information to a transport technician 5. Listening to the OR nurse's questions

Answer: 2, 3, 5. Documentation does not ensure clear communication of all findings and does not allow the OR nurse to raise questions. Giving information to another staff member to communicate important information is not acceptable in a hand-off. Using standardized tools designed for hand-offs and using communication skills will enhance communication.

The catheter of the patient receiving parenteral nutrition (PN) becomes occluded. Place the steps for caring for the occluded catheter in the order in which the nurse would perform them. 1. Attempt to aspirate a clot. 2. Temporarily stop the infusion. 3. Use a thrombolytic agent if prescribed or per protocol. 4. Flush the line with saline or heparin.

Answer: 2, 4, 1, 3

Which question would the nurse ask a patient when performing the assessment of cardiac history? Select all that apply. One, some, or all responses may be correct. 1. "Do you include fruits in your diet?" 2. "Which medications are you taking?" 3. "Are your stools regular and normal?" 4. "Do you have any trouble breathing?" 5. "On a scale of 0 to 10, how severe would you rate your pain?"

Answer: 2, 4, 5 •In cardiac assessment, it is extremely important to know which medications the patient is taking. Many medications alter the coagulation of blood, affect the heart rate, and cause other reactions that need to be considered before surgery. Asking if the patient has trouble breathing is important while assessing the cardiac profile. In severe cardiac conditions, pulmonary function is also affected. Asking the patient to score the pain indicates the severity of the pain and is important in assessment. Asking if the patient eats fruit is a general question and is not specific to cardiac assessment. Asking about the elimination functions of the body is not directly related to cardiac function.

An older patient who has been admitted in the postsurgery care unit has decreased bladder capacity. Which action can the nurse take to help the patient avoid a urinary tract infection? Select all that apply. One, some, or all responses may be correct. 1. Determine baseline urinary output for 24 hours. 2. Keep the nurse call system and bedpan within easy reach of the patient. 3. Turn or reposition the patient every 2 hours. 4. Instruct the patient to notify the nurse immediately when he or she experiences bladder fullness. 5. Ensure that the patient attempts to void urine every 2 hours.

Answer: 2, 4, 5 •Keeping the nurse call system and bedpan within easy reach and instructing the patient to notify the nurse immediately when his or her bladder is full helps avoid urine stagnancy. •Asking the patient to void every 2 hours will also help prevent stagnation of urine and urinary tract infections. •Keeping a record of baseline urinary output and repositioning the patient will not help avoid urinary tract infection.

Which datum would the nurse document in the medical record when providing care to a patient who is receiving enteral tube feedings? Select all that apply. One, some, or all responses may be correct. 1. Goal weight 2. Patency of the tube 3. Most recent vital signs 4. Amount and type of tube feeding 5. Condition of the skin at the site of the tube

Answer: 2, 4, 5 •The nurse should document the patency of the patient's tube, the amount and type of tube feeding, and the condition of the patient's skin at the site of the tube. The goal weight and most recent vital signs are not included in the documentation for this patient.

Which food allergy indicates that a patient is susceptible to latex allergy? Select all that apply. One, some, or all responses may be correct. 1. Orange 2. Kiwi fruit 3. Pineapple 4. Chestnuts 5. Avocados

Answer: 2, 4, 5 •The patient with an allergy to kiwi fruit, chestnuts, and avocados could show a cross-sensitivity to latex. •If the patient has an allergy to these foods, then the patient needs to be assessed for a latex allergy as well. •Allergies to oranges and pineapples do not show a cross-sensitivity to latex.

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

Answer: 2, 4. Palliative care and hospice care are different. Palliative care is available to all patients regardless of age, diagnosis, and prognosis. The focus of palliative care is on management of symptoms.

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

Answer: 2. A patient receiving continuous enteral feedings should never be placed supine because it increases the risk for pulmonary aspiration. If the nurse needs to lay the patient in the supine position, the feedings should be stopped and restarted when the head of the bed is at 45 degrees.

What are the physical circulatory changes that occur as death approaches? 1. Skin irritation 2. Mottling 3. Increased urine output 4. Weakness

Answer: 2. Patients experience circulatory changes resulting in mottling. Weakness, skin irritation, and incontinence are some of the physical changes that occur as death nears but are not related to circulatory changes.

The patient is on a low potassium diet that includes food such as applesauce, green beans, cabbage, lettuce, grapes, and raspberries. What type of patient would you expect to be on this type of diet? 1. A patient with heart disease 2. A patient with osteoporosis 3. A patient with Addison's disease 4. A patient who recently had gastric bypass surgery

Answer: 3 Patient's with Addison disease secrete too much potassium so they need to be on a low potassium diet.

Which outcome of both general anesthesia and conscious sedation is considered desirable? 1. Loss of gag reflex 2. Loss of blink reflex 3. Situational amnesia 4. Localized loss of sensation

Answer: 3 Under general anesthesia, a patient loses all sensation, consciousness, and reflexes, including gag and blink reflexes. The amnesia, both total and partial, that are facilitated by general anesthesia and conscious sedation protect the patient from remembering the unpleasant events of the surgical procedure. Loss of sensation to a specific, desired site through inhibition of peripheral nerve conduction is the result of local anesthesia.

Which type of anesthesia results in temporary paralysis of the lower extremities? 1 .Conscious sedation 2. General anesthesia 3. Spinal anesthesia 4. Local anesthesia

Answer: 3 •A spinal anesthesia is a type of regional anesthesia involving a desired area. There is a loss of sensation in the lower extremities, but the patient may be conscious. •Conscious sedation is used for procedures that require a depressed state of consciousness. Complete anesthesia is not required. A general anesthetic is given through an intravenous (IV) line or by inhalation. It makes the patient immobile and quiet. The patient may not be able to recall the surgical procedure. •A local anesthetic inhibits nerve conduction to a desired site, resulting in loss of sensation.

The nurse has inserted a nasogastric tube into a patient. However, when the first feeding is administered, the patient experiences pulmonary aspiration. Which action would have prevented this complication? 1. Starting the enteral feeding at a slow rate 2. Administering a milk-based formula 3. Verifying the placement of the tube through x-ray 4. Auscultating the bowel sounds before feeding

Answer: 3 •After insertion of a tube for enteral feeding, the placement of the tube should be verified through an x-ray. •This verification helps prevent complications such as pulmonary aspiration. •Starting the enteral feeding at a slow rate helps advance the feeding based on the patient's tolerance. •Administering a milk-based formula does not help prevent aspiration. •Auscultating the bowel sounds helps determine if the gastrointestinal tract is functioning; it does not help ascertain the placement of the tube.

Which assessment is a priority in the postanesthesiacare unit (PACU) during the first few minutes after a patient is admitted for an emergency appendectomy? 1. Pain assessment 2. History and physical 3. Systems assessment 4. Medication assessment

Answer: 3 •After receiving hand-off communication from the operating room, the PACU nurse conducts a complete systems assessment during the first few minutes of PACU care. •A pain assessment is not needed during the immediate postoperative phase, as the patient is still experiencing the effects of anesthesia. •An assessment of medical history and a physical examination is not done during the postoperative phases because it is unnecessary. • A medication assessment is not necessary during the postoperative phase.

An adult patient has a body mass index (BMI) of 20 kg/m2. Which conclusion regarding the patient's nutrition status would the nurse formulate? 1. Overweight 2. Imbalanced nutrition 3. Healthy weight 4. Morbidly obese

Answer: 3 •BMI is a measurement that describes relative weight for height and is significantly correlated with total body fat content. •One can determine the BMI by dividing the weight in kilograms by the height in meters squared. •The desired range for healthy adults is 18.5 to 24.9 kg/m2, which reflects a healthy weight for height. •A patient with a BMI of 25 to 29.9 kg/m2 is considered overweight. •A patient with a BMI less than the normal range may have imbalanced nutrition. •Those with a BMI greater than 40 kg/m2 are classified as morbidly obese.

Which type of medical condition causes an increased risk of infection and delayed wound healing after surgery? 1. Thrombocytopenia 2. Obstructive sleep apnea 3. Bone marrow depression 4. Peripheral vascular disease

Answer: 3 •Bone marrow depression is an immunological disorder, therefore the nurse will expect an increased risk of infection and delayed wound healing after surgery. •A patient who has been diagnosed with thrombocytopenia has a bleeding disorder that can increase the risk of hemorrhage during and after surgery. •A patient who has been diagnosed with obstructive sleep apnea can be at an increased risk of airway obstruction after surgery, especially if opioids are administered. •A patient who has been diagnosed with peripheral vascular disease can suffer from depressed cardiac function from general anesthetic agents.

Which substance is a monosaccharide? 1. Fiber 2. Starch 3. Dextrose 4. Glycogen

Answer: 3 •Dextrose is a monosaccharide, a simple carbohydrate that does not break down into more basic carbohydrate units. •Fiber, starch, and glycogen are polysaccharides, or complex carbohydrates, that are insoluble in water and digested to varying degrees.

Which factor most inhibits a person's likelihood of make healthy living choices? 1. Genetic factors 2. Geographic area 3. Environmental factors 4. Educational level

Answer: 3 •Environmental factors such as limited access to grocery stores, the ease and widespread availability of fast food, and a lack of safe places to play or exercise may inhibit a person's likelihood of healthy eating, exercising, and making other healthy living choices. •Genetic factors, geographic area, and educational level do not necessarily limit a person's ability to choose healthy lifestyle habits.

A patient tells the nurse, "I am really nervous about my upcoming surgery." Which response by the nurse is most appropriate to encourage further discussion between the patient and the nurse? 1. "Everyone is nervous before surgery." 2. "I can explain the entire surgical procedure to you." 3. "Can you tell me what has been explained to you about your surgery?" 4. "Let me tell you about the care that you will receive after surgery and the amount of pain that you can anticipate."

Answer: 3 •Explanations should begin with the information the patient already knows. •By providing the patient with individualized explanations of care and procedures, the nurse can assist the patient in managing anxiety and fear for a smooth preoperative period. •Patients who are calm and emotionally prepared for surgery tolerate anesthesia better and experience fewer postoperative complications. •Telling the patient that everyone is nervous before surgery does not address or lessen the patient's concerns. •There is no need to provide the patient with an explanation of the entire procedure because that may increase anxiety. •Telling the patient about postoperative care and postoperative pain may increase anxiety.

Which action would be the most important nursing intervention that the nurse would perform on a patient who is diagnosed with ineffective coping related to improper nutrition? 1. Teaching the patient about dietary guidelines 2. Encouraging the patient to take a short afternoon nap 3. Using an active listening approach when talking with the patient 4. Encouraging the patient to contact a friend and take a walk every day

Answer: 3 •For ineffective coping, it is most important for the nurse to use an active listening approach when talking with a patient about improper nutrition. •The nurse can teach a patient with imbalanced nutrition who is not experiencing ineffective coping about dietary guidelines. •The nurse encourages the patient diagnosed with fatigue to take a short nap in the afternoon and to contact a friend to take a daily walk.

Which vitamin does not have antioxidant properties? 1. Vitamin A 2. Vitamin C 3. Vitamin D 4. Vitamin E

Answer: 3 •Researchers believe oxidative damage may contribute to a person's risk of cancer. Vitamin D does not have antioxidant properties, but vitamins A, C, and E do.

Which nursing action is appropriate when providing care to a patient who develops diarrhea three times or more in 24 hours as a result of enteral feedings? 1. Holding the patient's current feeding 2. Rechecking the patient's gastric residual in 1 hour 3. Instituting skin-care measures for the patient 4. Obtaining a patient prescription for pancreatic enzymes

Answer: 3 •The nurse should implement skin-care measures for the patient who is prescribed enteral feedings and develops diarrhea to decrease the risk of perianal excoriation. Enteral feedings are held for patients who have two consecutive gastric residual volumes (GRVs) greater than 250 mL, not for a patient who develops diarrhea. The nurse would recheck the patient's gastric residual for volumes greater than 250 mL and not for a patient who develops diarrhea. Pancreatic enzymes are used to unclog an enteral feeding tube, not to treat diarrhea.

Which intervention will the nurse include in the plan of care for the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the patient has not eaten for the last 24 hours. 3. Instruct the patient to void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.

Answer: 3 •The nurse would assist the patient to void immediately before surgery so that the bladder will be empty. •Oral hygiene is allowed but the patient should not swallow any water or mouthwash. •The patient usually has a restriction of food and fluids for 8 hours before surgery, instead of 24 hours. •A slight increase in blood pressure and pulse is expected during the preoperative period related to anxiety.

In renal failure, protein intake should be approximately 1 to 1.4 g/kg of body weight. Which food item is the best source of this protein? 1. Cereals 2. Peas 3. Fish 4. Beans

Answer: 3 •The use of high-biological value or high-quality proteins is recommended for renal failure. •A high-quality protein contains all essential amino acids in sufficient quantity. These proteins help growth, development, and maintaining nitrogen balance. •Fish is a source of a high-quality protein and contains all essential amino acids. •Cereals and legumes such as peas and beans are incomplete proteins and lack one or more of the nine essential amino acids.

Which clinical manifestation is an indication for enteral nutrition? Select all that apply. One, some, or all responses may be correct. 1. Severe pancreatitis 2. Severe malabsorption 3. Difficulty chewing 4. Prolonged intubation 5. Anorexia nervosa

Answer: 3, 4, 5 •Enteral nutrition is indicated in patients who have difficulty chewing, have respiratory failure with prolonged intubation, or have anorexia nervosa. • A patient who has difficulty chewing can benefit from enteral nutrition because the nutrition bypasses the oral cavity. •Patients with prolonged intubation may not be able to eat and need enteral feedings to meet their nutritional demands. •Patients with anorexia nervosa might not eat and need enteral nutrition to provide them with adequate nutrition. •Enteral nutrition is contraindicated in patients with severe pancreatitis because it can worsen the pain and inflammation. •Enteral nutrition cannot be given to patients with severe malabsorption because the feedings would not be digested and absorbed.

Which of the caregiver's statements indicates a need for further teaching regarding measures to promote normal gastrointestinal function and adequate nutrition? Select all that apply. One, some, or all responses may be correct. 1. "I will provide oral hygiene frequently." 2. "I will provide meals when he or she is free from pain." 3. "I will provide fruit juices and cold liquids." 4. "I will help him or her into a comfortable position during meal time." 5. "I will have him or her sleep on the bed when he or she has gas pain."

Answer: 3, 5 •To promote normal gastrointestinal function and adequate nutrition, the patient should consume fruit juices and warm, not cold, liquids to maintain adequate fluid intake and to keep bowel movements soft and easy. •The patient should be assisted and encouraged to walk, not sleep, when he or she has gas pain to help relieve it. •The caregiver should provide oral hygiene frequently to eliminate bad taste and dryness of the mouth. •The patient should eat when he or she is free from pain. •The caregiver should help the patient into a comfortable position during meal time.

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 nurs- ing 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 thisfeeding. 4. Hold the feeding until you talk to the primary care provider.

Answer: 3. Delayed gastric emptying is a concern if 250 mL or more remains in a patient's stomach on two consecutive assessments (1 hour apart) or if a single GRV measurement exceeds 500 mL. Therefore the best action is to continue the tube feedings at this time.

When providing postmortem care, which actions are necessary for the nurse to complete? 1. Locating the patient's clothing 2. Calling the funeral home 3. Providing culturally and religiously sensitive care in body preparation 4. Providing postmortem care to protect the family of the deceased from having to view the body

Answer: 3. A deceased person's body deserves the same respect and dignity as that of a living person and needs to be prepared in a manner consistent with the patient's cultural and religious beliefs.

Which postoperative intervention best prevents atelectasis? 1. Use of intermittent compression stockings 2. Heel-toe flexion 3. Use of the incentive spirometer 4. Abdominal splinting when coughing

Answer: 3. Use of the incentive spirometer expands the lungs, thus preventing the onset of atelectasis. Heel-toe flexion and the use of intermittent compression stockings prevent the onset of deep vein thrombosis. Abdominal splinting keeps pressure on abdominal incisions to prevent pain during coughing and wound dehiscence.

After cardiac surgery, a patient is prescribed a diet to reduce cholesterol. Which amount would be the recommended cholesterol intake in this diet? Record your answer using a whole number. __________ mg/day

Answer: 300 •According to the American Heart Association guidelines, 300 mg/day cholesterol intake is allowed in a therapeutic diet to reduce cholesterol levels.

How much energy does 1 g of carbohydrate produce? Record your answer using a whole number. _________ kcal

Answer: 4

A client is recovering from debridement of the right leg. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk. 2. Chicken. 3. Banana 4. Strawberries.

Answer: 4 Citrus fruits and juices are especially high in vitamin C.Options 1 and 2: Meats such as chicken and dairy products such as milk are high in vitamin B.Option 3: Banana is rich in potassium.

You have a patient who just had a stroke and has garbled speech. What type of diet do you expect the patient to be prescribed after a speech evaluation? 1. Soft diet 2. Full liquid diet 3. Mechanically altered diet with thin liquids 4. Mechanically altered diet with nectar thick liquids

Answer: 4 When a patient has a stroke they are at risk for aspiration due to the decrease ability to swallow. Many times a stroke with affect speech as well the patient's ability to utilize the swallowing muscles. Generally, when garbled speech is noted in a stroke victim this is a sign there is a problem with the patient's ability to use their swallowing muscles. A mechanically altered diet with nectar thick liquid will usually be prescribed. However, a speech evaluation will determine what is needed.

Which nursing intervention is beneficial for regulating body temperature in a postoperative patient? 1. Administering intravenous fluids 2. Administering higher doses of clonidine 3. Instructing the patient to take calcium supplements 4. Instructing the patient to take deep breaths and to cough

Answer: 4 •Deep breathing and coughing allow the patient to expel the anesthetic gases, which may have decreased body temperatures. •Intravenous catheters should be removed when no longer needed because they can increase the risk of infection, but this does not affect body temperature. •Clonidine decreases shivering but must only be administered in small increments. •Calcium supplements may address imbalance in the patient's blood, but they do not address body temperature needs.

The nurse in the postanesthesia care unit (PACU) notes that the patient has a heart rate of 130 beats per minute and a respiratory rate of 32 breaths/min; jaw muscle rigidity; and rigidity of limbs, abdomen, and chest. Which condition does the nurse suspect, and which intervention is indicated? 1. Infection: Notify surgeon and anticipate administration of antibiotics. 2. Pneumonia: Listen to breath sounds, notify surgeon, and anticipate prescription for chest radiography. 3. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. 4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately; prepare to administer dantrolene sodium, andmonitor vital signs frequently.

Answer: 4 •Malignant hyperthermia is a life-threatening complication of general anesthesia. •It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration; it leads to hypercarbia, tachypnea, and tachycardia. •Despite the name, an elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. •Dantrolene sodium is a skeletal muscle relaxant that is used to treat this complication.

A patient fasting for surgery forgot to take the prescribed antibiotic. Which nursing action is appropriate in this situation? 1. Replace the medicine. 2. Avoid giving the antibiotic. 3. Give the antibiotic after surgery. 4. Give the antibiotic with a sip of water.

Answer: 4 •Patients are advised to fast before surgery to prevent aspiration while receiving anesthesia. •However, important medications that may affect the outcome of surgery are allowed with a sip of water. Therefore antibiotics should be administered with a sip of water. It helps to prevent infection during and after the surgery. The medicine should not be replaced or avoided. If the antibiotic is prescribed for administration before surgery, then it is of no use if it is given after the surgery.

Which immunological disorder can occur as a result of abusing street drugs? 1. Cancer 2. Leukemia 3. Bone marrow depression 4. Acquired immunodeficiency syndrome (AIDS)

Answer: 4 •People sharing needles when abusing street drugs sometimes have human immunodeficiency virus (HIV), which causes AIDS. Because the sharing of needles is what causes HIV and AIDS in this population, street drug abuse has no association with cancer, leukemia, or bone marrow depression.

Which intervention by the nurse may increase the risk of cardiovascular complications in the patient? 1. Hydrating the patient with fluids 2. Administering heparin to the patient 3. Encouraging ambulation for the patient 4. Placing pillows or rolled blankets under the knees

Answer: 4 •Placing pillows or rolled blankets under the knees may lead to the compression of popliteal vessels in the knees, which can lead to thromboembolism. •Keeping the patient hydrated helps prevent dehydration and improves the intravascular volume. •Heparin is an anticoagulant that reduces the risk of clot formation. •Ambulation is recommended for a postoperative patient to reduce thrombi formation.

Which nursing action is appropriate prior to administering a nasoentericfeeding? 1. Monitoring the platelet count 2. Drawing a red blood cell count 3. Obtaining an arterial blood gas test 4. Assessing capillary blood glucose

Answer: 4 •Prior to implementing a nasogastric feeding, the nurse should monitor laboratory values, including electrolytes and capillary blood glucose levels. These values provide a baseline to measure the patient's response to enteral nutrition. It is not necessary for the nurse to monitor the platelet or red blood cells counts or to obtain an arterial blood gas test prior to implementing a nasoentericfeeding for a patient.

Which anesthesia was likely administered to the patient who developed respiratory paralysis because of increased levels of anesthesia? 1. Local anesthesia 2. General anesthesia 3. Conscious sedation 4. Regional anesthesia

Answer: 4 •Regional anesthesia is given through epidural, spinal, and caudal blocks. •Increased levels of anesthesia can cause respiratory paralysis. Elevating the patient's upper body during the administration of anesthesia can prevent this. •Local anesthesia is given to particular sites and may not cause serious complications. •General anesthesia is given as a protective measure to prevent patient pain during the procedure. The dose depends on the duration of the surgery. •Conscious sedation is given intravenously for moderate sedation. The complication of conscious sedation is an adverse reaction to the drug.

Which action during leg exercises helps maintain joint mobility? 1. Lifting the buttocks 2. Dorsiflexion of the feet 3. Plantar flexion of the feet 4. Rotating the ankles in complete circles

Answer: 4 •Rotation of the ankles in complete circles helps maintain joint mobility. •Lifting the buttocks can help prevent shearing with the mattress. •Dorsiflexion and plantar flexion of the feet can help with stretching and contraction of the gastrocnemius muscles to promote venous return.

Which nursing action is appropriate when administering an enteral feeding to a patient who is diagnosed with pulmonary aspiration secondary to regurgitation of formula? 1. Assessing gag reflex 2. Repositioning the tube 3. Verifying tube placement once per day 4. Placing the patient in high-Fowler's position

Answer: 4 •The appropriate nursing action for a patient diagnosed with pulmonary aspiration secondary to regurgitation of formula is to place the patient in high-Fowler's position during the feeding and for 2 hours after the feeding is complete. Assessing the gag reflex is an appropriate action for a patient who experiences pulmonary aspiration secondary to a deficient gag reflux, not regurgitation of formula. The tube should be repositioned for a patient who experiences pulmonary aspiration secondary to a displaced tube, not regurgitation of formula. Tube placement should be verified before each intermittent feeding and every 4 to 6 hours for continuous feeding, not once per day.

Which nursing action may help decrease postoperative nausea? 1. Promoting ambulation 2. Maintaining adequate fluid intake 3. Providing desired servings of food 4. Moving the patient slowly when changing positions

Answer: 4 •The patient should be moved slowly to prevent nausea because of sudden movements. •Promoting ambulation can increase peristalsis of the gastrointestinal tract, but it may not prevent nausea. •Adequate fluid intake helps soften fecal material, but it will not prevent nausea. •Providing desired servings of food enhances the patient's willingness to eat the first meal. It may not prevent nausea.

Which instruction is appropriate for a preoperational patient? 1. "Take over-the-counter nonsteroidal antiinflammatory drugs the night before surgery." 2. "Avoid fried food beginning 3 hours before surgery." 3. "Begin fasting 2 hours before surgery." 4. "Avoid any fluid intake for at least 2 hours before surgery."

Answer: 4 •The stress of surgery causes fluid and electrolyte imbalance, and sedation can cause complications; therefore the patient must refrain from drinking any liquids for 2 or more hours before the surgery. • Nonsteroidal anti-inflammatory drugs should be avoided in the weeks before surgery to reduce the risk of abnormal bleeding during surgery. The nurse should instruct the patient to avoid eating fried food 8, not 3, hours before surgery. The nurse should instruct the patient to begin fasting at least 6 hours before surgery.

The nurse is caring for a patient for whom nasogastric tube feedings have been prescribed. Which amount of gastric residual volume (GRV) indicates delayed gastric emptying? 1. 250 mL or more on two consecutive assessments 30 minutes apart 2. 150 mL or more on two consecutive assessments 1 hour apart 3. More than 350 mL in a single gastric reserve volume measurement 4. More than 500 mL in a single gastric reserve volume measurement

Answer: 4 •The stretch reflex allows the food to move from the stomach into the duodenum, and food or fluids are not allowed into the esophagus when the lower esophageal sphincter is normal. •If the reserve is greater than normal, there is a risk of regurgitation and aspiration of gastric contents into the lungs. •If the gastric reserve volume of the stomach is 500 mL in a single assessment, it indicates delayed gastric emptying. •A gastric residual volume of 250 mL on two consecutive assessments 30 minutes apart indicates that the feedings are tolerated well. •A gastric residual volume of 150 mL on two consecutive assessments 30 minutes apart also indicates tolerance of enteral feedings. •More than 350 mL in a single gastric reserve volume measurement indicates that the feedings are being accepted well.

Which action would the nurse take to prevent respiratory complications in the older adult after surgery? 1. Withhold pain medications and ambulate the patient every 2 hours. 2. Monitor fluid and electrolyte status as prescribed and vital signs with temperature every 4 hours. 3. Frequently orient the patient to the surrounding environment, and ambulate the patient every 2 hours. 4. Encourage the patient to turn, breathe deeply, cough frequently, and ensure adequate pain control.

Answer: 4 •To prevent respiratory complications, adequate pain control is important to allow participation in postoperative exercises such as turning, frequent coughing, and deep breathing. •Withholding pain mediation, monitoring fluid and electrolytes, and orienting the patient to the environment are not methods used to prevent respiratory complications.

In the postanesthesia care unit (PACU), the nurse notes that the patient is having difficulty breathing and suspects an upper airway obstruction. Which action would the nurse take first? 1. Suction the pharynx and bronchial tree. 2. Give oxygen through a mask at 4 L/min. 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.

Answer: 4 •Weak pharyngeal/laryngeal muscle tone from anesthetics can occur. • Positional change helps move the tongue forward to open the airway. The immediate intervention should be to open the airway. Suctioning the bronchial tree or providing oxygen does not alleviate an upper airway obstruction. Asking the patient to use an incentive spirometer will not alleviate an airway obstruction.

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 ayear 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 nextmonth."

Answer: 4. Infants should not have regular cow's milk during the first year of life. It is too concentrated for the infant's kidneys to manage. There is also an increased risk for developing milk-product allergies.

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.

Answer: 4. Stop feeding and then place patient on side. If choking persists, suction airway. Notify health care provider. Keep patient NPO.

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 thetube 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

Answer: 4. When meeting 75% of nutritional needs by enteral feedings or reliable dietary intake, it is usually safe to discontinue PN therapy.

After cardiac surgery, a patient is prescribed nothing by mouth (NPO). Which sequence of diet progression would the nurse follow? Arrange the steps in order. 1. Full liquid 2. Low-residue diet 3. Mechanical soft 4. Pureed diet 5. Clear liquid

Answer: 5, 1, 4, 3, 2

A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for postmortem care when there is no autopsy ordered? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

Answer: 6, 9, 2, 5, 7, 3, 1, 4, 8. This order provides dignity to the deceased and ensures that the nurse is adhering to all policies and laws concerning autopsies, organ donation, or an investigation.

The nurse is checking feeding tube placement. Place the steps in the proper sequence. 1. Draw 5 to 10 mL gastric aspirate into syringe. 2. Flush tube with 30 mL air. 3. Mix aspirate in syringe and place in medicine cup. 4. Perform hand hygiene and put on clean gloves. 5. Observe color of gastric aspirate. 6. Compare strip with color chart from manufacturer. 7. Dip pH strip into gastric aspirate.

•Perform hand hygiene and put on clean gloves. •Flush tube with 30 mL air. •Draw 5 to 10 mL gastric aspirate into syringe. •Observe color of gastric aspirate. •Mix aspirate in syringe and place in medicine cup. •Dip pH strip into gastric aspirate. •Compare strip with color chart from manufacturer.

Steps of performing incentive spirometry in order:

•Perform hand hygiene. •Instruct the patient to assume a semi- or high-Fowler's position. •Have the patient place his or her lips on the mouthpiece of the incentive spirometer. •Have the patient inhale slowly and hold the breath for 2 to 3 seconds. •Instruct the patient to breathe normally between each set of 10 breaths. •Have the patient repeat the breaths until the goals are achieved.