Lab Exam Ch. 28, 38, 40, 41

7. When providing home-going instructions for a recently discharged patient, which statement by the patient's son would indicate an understanding of methods to prevent complications from immobility? a. "We'll make sure that Dad eats plenty of lean protein foods." b. "We will limit Dad's fluid intake to prevent bladder incontinence." c. "Dad should sit more and restrict the time he walks around the house." d. "His arm sling should be kept on at all times to prevent an elbow contracture."

A Adequate protein intake will prevent negative nitrogen balance in sedentary patients. Fluid intake is essential for the promotion of skin integrity, prevention of bladder infections, and regular defecation. Ambulation prevents many of the complications of immobility. Maintaining an extremity in one position for an extended period of time may actually cause a contracture.

6. What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient? a. Early ambulation after surgery b. Administering calcium with vitamin D c. Coughing and deep breathing exercises d. Referring the patient to occupational therapy

A Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity. Calcium with vitamin D helps prevent osteoporosis. Coughing and deep breathing is important for the prevention of pneumonia associated with immobility, and occupational therapy is typically ordered to help patients regain their ability to complete activities of daily living (ADLs) independently.

1. A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. b. Reassure the patient that it is not possible to void while catheterized. c. Catheterize the patient again with a larger-gauge catheter. d. Notify the primary care provider (PCP).

A Checking the position and patency of the catheter first will determine whether the problem is mechanical or physiologic in nature. At times, the end of the catheter may become lodged up against the side of the bladder preventing the flow of urine into the tubing. Telling the patient that is impossible to void while catheterized is erroneous. Catheterizing the patient with a larger-gauge catheter is unnecessary at this point, as is contacting the PCP.

6. The nurse is inserting an indwelling catheter into a male patient. While initially passing the catheter through the urethra, resistance is met. What action should the nurse take next? a. Notify the primary care provider to place a coudé catheter. b. Straighten the penis and attempt to progress the catheter again. c. Remove the catheter and insert one with a smaller lumen. d. Inflate the balloon and wait for urine passage.

A Coudé catheters are a special type of double-lumen, indwelling catheters that are slightly stiff and bent at the end, allowing the catheter to pass more easily through a partially constricted urethra. They are used mostly in men experiencing prostate enlargement or BPH. Coudé catheters may need to be placed using a metal wire introducer. Placement using an introducer typically is performed by a physician or the patient's urologist, to avoid damaging urethral tissue.

5. The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal

A Diarrhea is associated with high risk for dehydration, so the patient should increase the fluid intake. The patient may need increased sodium and potassium intake owing to loss of these electrolytes in the frequent stools. Fiber will add bulk and help to form the stools so should be increased. Whole-grain products contain fiber.

8. Which discovery found during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone c. Decreased cardiac workload d. Orthostatic hypertension

A Joint contractures may begin within hours of immobility and cause irreparable damage to joint flexibility. Muscle tone decreases, and cardiac workload increases with immobility. Pooling of blood in the lower extremities and quickly changing position may cause a rapid drop, rather than increase, in blood pressure, known as orthostatic hypotension.

4. Nursing interventions for the patient who suffers from stress incontinence include a. kegel exercises. b. surgical interventions. c. bowel retraining. d. intermittent catheterization.

A Kegel exercises also are known as pelvic floor exercises. They improve muscle tone in the pelvic floor, which helps to prevent stress incontinence.

7. The nursing instructor is teaching information about constipation in the elderly. Which statement from the student indicates a need for further instruction on this topic? a. Patients receiving tube feedings often experience constipation. b. Poor fluid intake and inability to eat a high-fiber diet often cause constipation. c. Patients with impaired mobility may experience constipation. d. Medications commonly taken by elders often contribute to constipation.

A Patients on tube feedings often experience diarrhea, not constipation.

3. The finding of a barrel chest configuration in a patient may be related to which of the following disorders? a. Chronic obstructive pulmonary disease b. Acute asthma attack c. Cardiomyopathy d. Acute myocardial infarction

A The air trapping that occurs in chronic obstructive pulmonary disease over time causes the chest to expand, leaving a ratio of 1:1 from side to front ratio instead of the normal 1:2 ratio.

2. A patient with a history of diarrhea is seen in the clinic. Which nursing intervention is most essential to include in this patient's plan of care? a. Weighing the patient daily b. Encouraging a diet high in fiber c. Decreasing the patient's fluid intake d. Instructing the patient to increase protein in the diet

A The patient with diarrhea is susceptible to dehydration. Checking the patient's weight daily will monitor fluid status.

8. A patient with chronic pneumonia may be evaluated by a speech therapist for which cause? a. Chronic aspiration of liquids b. Hypoventilation due to smoking c. Hyperventilation due to anxiety d. Decreased respiratory effort due to scolioses

A The speech therapist can perform a swallow study to determine whether thin liquids are being aspirated into the lung and recommend a regimen of thickened liquids and swallow exercises to prevent aspiration. A speech therapist would not be consulted in cases of hypoventilation or hyperventilation. Nursing measures and consulting the primary care practitioner are proper steps for these problems. A physical therapist may be consulted if scoliosis is hampering the patient's respirations.

1. Which organism is responsible for the majority of urinary tract infections in female patients? a. Escherichia coli b. Nesseria gonorrhea c. Candida albicans d. Haemophilus influenza

A Urinary tract infections (UTIs) are the result of bacteria in the urine. Infection occurs when bacteria from the digestive tract, usually Escherichia coli, invade the urethra and multiply.

5. A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? a. Calcium should be taken with vitamin D to increase calcium absorption. b. African American women are more prone to developing osteoporosis than are Asian American women. c. Increased phosphorus metabolism may lead to bone fragility. d. Aerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis.

A Vitamin D is required for calcium metabolism. Asian American women are more prone to osteoporosis than African American women. Phosphorus deficiency may lead to malformation of bones. Weight-bearing exercise is more beneficial than aerobic exercise in the prevention of osteoporosis.

5. When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? (Select all that apply.) a. Taking the urinary tract analgesic phenazopyridine (Pyridium) b. A diet that includes a large amount of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake

A, B, C, D Urine may appear orange when a patient is taking phenazopyridine. Urine can appear red or pink with a diet including beets or blackberries and if blood is present in the urine, which may be secondary to an enlarged prostate or kidney stones. Urine often has a brownish appearance when liver disease such as hepatitis or cirrhosis is present.

7. Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.) a. Monitoring respiratory status and breathing difficulties b. Assisting with feeding and ADLs c. Developing a care plan with the patient's power of attorney d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient's waist before ambulation

A, B, D Quadriplegia is the result of a high spinal cord injury that affects a patient's ability to breathe without mechanical assistance and severely limits the patient's ability to move all extremities. Most quadriplegics are confined to a wheelchair and unable to ambulate even with assistance. Mechanical lifts should be used to safely transfer this type of patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals.

10. Which questions are included in a focused history for a cardiac patient? (Select all that apply.) a. Are you having pain? b. Where is the pain located? c. Do you attend religious services regularly? d. Do you have increased fatigue? e. Do you have any episodes of dizziness?

A, B, D, E All pain assessment is important to determine a pattern of pain. Cardiac events can contribute to fatigue, and abnormal heart rhythms may contribute to dizziness. Although knowledge of a patient's religious affiliation may be important in certain settings, it is not part of a focused assessment of a cardiac patient.

1. Prior to discharge, the nurse teaches the patient the proper techniques for applying an ostomy pouch. When evaluating the teaching, the nurse observes the patient apply a new ostomy pouch without cleansing the skin underneath. What action(s) should the nurse implement following this patient's return demonstration? (Select all that apply.) a. Repeat the demonstration to show the patient how to clean the ostomy site. b. Document that the patient performed the initial return demonstration accurately and safely. c. Offer positive reinforcement regarding the need to cleanse the site to prevent skin breakdown below the appliance. d. Discharge the patient with written instructions and illustrations that demonstrate the correct procedure. e. Notify the health care provider that a repeat demonstration of the ostomy appliance procedure is needed.

A, C, D The initial return demonstration was not performed accurately, and since it is the nurse's responsibility to complete the needed teaching, the health care provider does not need to be notified. Discomfort and damage to the skin can result from not washing the site; therefore, the nurse should repeat the demonstration, emphasizing the importance of cleansing. Positive reinforcement and the provision of written instructions are valuable teaching strategies.

3. To prevent constipation in an inactive patient, which early interventions should the nurse implement? (Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake

A, C, D, E Administering stool softeners, increasing the fiber and fluids in the diet, and increasing physical activity are all early interventions to prevent constipation. Although used to treat constipation, an enema would not be an early intervention for prevention.

10. When administering a cleansing enema, which techniques should the nurse use? (Select all that apply.) a. Assist the patient to a left side-lying (Sims) position. b. Perform hand hygiene and apply sterile gloves. c. Add room-temperature solution to enema bag. d. Lubricate 2 to 4 cm (1 to 2 inches) of tip of rectal tube with lubricating jelly. e. Raise container, release clamps, and allow solution to flow to fill tubing. f. Hang solution bag 45 to 60 cm (18 to 21 inches) above anus and instill rapidly. g. Clamp tubing after solution is instilled

A, E, G The patient should be assisted to the left side-lying (Sims) position. The container release clamps must be released and the solution allowed to flow for fill the tubing. After the solution is instilled, the tubing should be clamped. Gloves for this procedure do not need to be sterile. Solution should be warmed to slightly warmer than body temperature (or 100° to 105° F) to prevent cramping. The tip of the rectal tube should be lubricated 6 to 8 cm (3 to 4 inches). If the enema bag is hung too high and the solution is instilled too rapidly, cramping may occur.

4. Which of the following is a recommended immunization for adults yearly? a. Pneumococcal b. Influenza c. Polio d. Tetanus

B

9. The nurse is placing an indwelling catheter in a female patient. She inserts the catheter into the vagina. What is the next action for the nurse to implement? a. Collect a urine specimen and notify the PCP. b. Leave the catheter in place and insert a new catheter into the urethra. c. Remove the catheter from the vagina and place it into the urethra. d. Ask another nurse to attempt the catheterization of the patient.

B By leaving the first catheter in place in the vagina, the nurse can more accurately identify the urethra for insertion of the new catheter. This prevents misplacing the new catheter into the vagina during the second catheterization attempt. The catheter that was placed in the vagina is no longer sterile, so it should not be reused and should be discarded after the new catheter is properly placed. It is impossible to get a urine sample from the catheter placed in the vagina. Only after experiencing difficulty with proper placement of the new catheter may the nurse wish to ask for assistance from another nurse.

1. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which finding does the nurse anticipate when inspecting the chest? a. A ratio of 1:2 when comparing the side and front views of the chest b. A barrel chest c. A concave shape to the sternum d. A severe lateral curvature of the spine

B Chronic air trapping in COPD can cause a barrel-shaped chest. The intercostal spaces pull the chest out, and the accessory muscles of breathing may compensate to enlarge the chest cavity. The chest diameter ratio of 1:2 is the normal finding for a person who does not have overinflation of the lungs. A concave sternum is not an expected finding with COPD. A lateral curvature of the spine is consistent with scoliosis, which is not an expected finding for most patients with COPD.

4. A patient is scheduled for an intravenous pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out? a. Urinalysis showing negative results on testing for sugar and acetone b. History of allergies c. History of a recent thyroid scan d. Frequency of urination

B Contraindications tor IVP include an allergy to iodine, which is similar in nature to the contrast material injected during the intravenous pyelogram. Knowing this information would be critical to providing safe patient care. Frequency of urination may be an indication to perform an IVP; however, this is not critical to know before performing an IVP. The results of a urinalysis and history of a recent thyroid scan would not affect a scheduled IVP.

7. A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Altered Skin Integrity b. Risk for Imbalanced Fluid Volume c. Acute Pain d. Self-Care Deficit: Toileting

B Diarrhea can cause dehydration with loss of fluids and electrolytes. There is no statement of problems with the skin, although this patient may be at risk for skin breakdown if the diarrhea continues. In addition, no self-care deficit is stated for this patient. Although the patient has experienced cramping and the pain needs to be addressed, the main consideration would be correction of any fluid and electrolyte problems, followed by determination of the cause of the diarrhea.

7. Which situation contributes to cyanosis in the pulmonary patient? a. Increased PaCO2 levels b. Hemoglobin that is not saturated with oxygen c. Elevated white blood cell count d. Decreased PaCO2 levels

B Hemoglobin that is not saturated with oxygen causes a bluish decolorization of the skin. Increased or decreased levels of carbon dioxide (CO2) may indicate an acid-base imbalance. An elevated white blood cell count may indicate an infection.

7. An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the primary concern of the nurse performing the procedure? a. Teaching deep-breathing techniques b. Maintaining strict aseptic technique c. Medicating the patient for pain before the procedure d. Positioning the patient for comfort during the procedure

B It is most important to maintain strict aseptic technique while inserting an indwelling catheter to try to prevent a urinary tract infection. It is not necessary to medicate patients before urinary catheterization. Although comfortable positioning and deep breathing may help to relax the patient, this is not the primary concern.

2. After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly under the axilla b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 28 inches forward and then swinging both legs forward when using a three-point crutch walk

B Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The four-point crutch walk is used by only patients who can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and a three-point crutch walk is not a swing-through gait.

2. The exchange of oxygen and carbon dioxide occurs in the alveoli. How is oxygen carried in the blood? a. The white blood cells b. The hemoglobin c. The platelets d. The neutrophils

B Oxygen is carried on the hemoglobin to the tissues where some is released.

8. The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining and the patient's bladder is distended. What action should the nurse take next? a. Notify the primary care provider (PCP). b. Assess the tubing for kinks and ensure downward flow. c. Change the catheter as soon as possible. d. Aspirate the stagnant urine in the catheter for culture.

B The next action by the nurse should be to check the patency of the catheter tubing. At this point there is no need to aspirate any urine or call the PCP. The catheter should not be changed unless absolutely necessary, owing to the possibility of causing an infection.

10. After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? a. Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Bowel sounds

B The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper extremities, cardiac or respiratory status leading to circumoral cyanosis, or bowel sounds.

2. Which is a goal for a patient with the nursing diagnosis of Ineffective Airway Clearance? a. Patient's respiratory secretions will become thicker so they are not moved when coughing. b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent. c. Patient will have improved range of motion while in bed. d. Patient's respiratory rate will increase to 28 breaths/min during hospitalization.

B The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of secretions. Improved range of motion is relates to musculoskeletal problems. The normal respiratory rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired.

1. A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, it is most important for the nurse to coordinate with which member of the health care team? a. Home care nurse b. Wound ostomy continence nurse c. Registered dietitian d. Primary care provider

B The wound ostomy continence nurse (WOCN) is the most important person to contact to schedule teaching sessions and follow-up care. This nurse specialist is certified in the treatment of patients who have a bowel or bladder diversion. Although team input is important, the contribution of the WOCN is paramount to help the patient achieve competence and comfort with self-care before discharge.

5. Average urine pH is a. 4 b. 6 c. 7 d. 9

B Urine normally is slightly acidic, with an average pH of 6. Urine with a pH of 4 is very acidic. A pH of 7 is neutral, and a pH of 9 is very alkaline.

2. Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. Tell the patient to void and pour the urine into a labeled specimen container. b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container. c. Instruct the patient to discard the first void and collect the next void for the specimen. d. Have the patient keep all voided urine for 24 hours in a chilled, opaque collection container.

B Urine specimens for culture and sensitivity testing must be collected in sterile containers using the clean-catch, midstream method whenever possible. All voided urine specimens should be collected directly into the specimen container, not transferred from another potentially contaminated vessel. Discarding the entire first void and saving urine in a chilled, opaque container are both procedures for conducting a 24-hour urine collection.

1. Bones function in what important roles within the body? (Select all that apply.) a. Regulate potassium levels b. Maintain calcium balance c. Protect critical organs d. Produce blood cells e. Control motor activity

B, C, D Bones assist in the maintenance of both calcium and phosphorus balance within the body. Bones protect vital organs, such as the lungs, that are surrounded by the rib cage. The role of bone marrow is critical to blood cell formation. Potassium levels are regulated by the kidneys. The nervous system controls motor activity.

3. What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows d. Hips e. Coccyx

B, C, D The patient's ears, elbows, and hips are in contact with the bed surface in the side-lying position. Breakdown on the sternum would be a potential risk if the patient were in prone position. The coccyx experiences the most pressure when a patient is sitting or in the supine position.

2. What actions by the nurse are critical to ensure patient safety? (Select all that apply.) a. Place the call light on the patient's nightstand. b. Clean up fluid spills on the floor immediately. c. Instruct the patient to wear socks when ambulating. d. Keep linens and intravenous tubing off the floor. e. Return the bed to low position prior to exiting the room.

B, D, E Cleaning up spills, keeping items off the floor, and returning the bed to low position are all essential to prevent patient injury. The call light should be placed within reach of the patient on the bed or attached to the patient's gown. Non-skid slippers or shoes should be worn by the patient when ambulating.

9. A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe? a. Increased PaCO2 b. Decreased hemoglobin c. Decreased PaO2 levels d. Increased PaO2 levels

C A person normally uses increased PaCO2 levels as the drive to breathe. A patient with COPD has chronic elevation of PaCO2 and has lost sensitivity to it as a drive to breathe. Instead, a decreased PaO2 level becomes the drive to breathe.

6. To prevent injury to a patient during logrolling, which action by the nurse is most important? a. Place an ankle foot orthotic on the patient prior to movement. b. Remove the patient's drawsheet to avoid lower extremity entanglement. c. Position a pillow between the patient's legs to maintain body alignment. d. Raise all four side rails prior to initiating logrolling independently.

C A pillow is positioned between a patient's legs during logrolling to maintain spinal alignment. Ankle foot orthotics are used to prevent footdrop and would not be indicated during logrolling. A drawsheet is critical during logrolling to prevent potential injury to both caregivers and patients in most cases. Side rails are lowered when a caregiver is positioned next to the side of the bed so that the patient can be reached without back strain to the nurse.

1. An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient? a. A two-person lift is performed, with one person on each side of the patient. b. The patient is steadied under the arms and pivoted on his left leg. c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). d. A stand assist lift is used with the help of another nurse.

C According to safe patient handling algorithms, a full-body sling with the assistance of the nurse and UAP is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand and pivot technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative.

9. Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise

C Fiber is encouraged in patients with diarrhea to add bulk to the stools. Fluid intake and exercise should be encouraged. Cathartics would not be used because they are strong laxatives used to soften the stool and evacuate the bowels.

5. Which action does a nurse anticipate when suctioning a patient with excessive secretions? a. Decrease the patient's oxygen flow rate before beginning the deep suctioning. b. Avoid lubricating the catheter tip to prevent getting the substance in the lung tissues. c. Limit the time that the catheter is suctioning to prevent excessive loss of oxygen during the process. d. Flush the artificial airway with 3 mL of tap water to loosen secretions before suctioning.

C Oxygen is removed during the suctioning procedure, and the amount of time needs to be limited. In some cases, the nurse provides extra oxygen during suctioning procedures, and decreasing the oxygen is contraindicated. Lubrication of the catheter tip with normal saline solution (NSS) is indicated and does not damage the lungs. Tap water is not sterile and should not be introduced into the airway. Evidence-based practice show that flushing with sterile NSS has no benefit, because saline does not mix with secretions, and the procedure may have negative emotional effects for the patient.

1. To best determine the patient's competency in changing an ostomy appliance, what should the nurse ask the patient to do? a. Verbalize the procedure. b. Identify the supplies needed. c. Perform the procedure. d. List the steps in the procedure.

C Repeat performance is the best way to ensure competency.

4. Which discharge instruction should the nurse provide to the patient following a colonoscopy? a. Some discomfort and bleeding is normal postprocedure. b. Return to the emergency room if you experience mild abdominal cramping. c. Do not drive or operate heavy machinery for 12 hours postprocedure. d. Return to your normal bowel pattern immediately postprocedure.

C Since sedation is given for the procedure, the patient should not drive or operate heavy machinery.

9. Which nursing diagnosis label is most appropriate for a patient who is experiencing sensory deprivation due to a lack of interaction with others? a. Impaired Verbal Communication b. Sedentary Lifestyle c. Social Isolation d. Disturbed Personal Identity

C Social isolation is experienced by patients who are unable to be in contact with other people. Patients with impaired verbal communication have difficulty speaking. A sedentary lifestyle may constitute an appropriate nursing diagnosis for patients who have a low physical activity level. Patients who exhibit serious psychological issues concerning identity may suffer from disturbed personal identity.

7. Which of the following oxygen masks has holes at the side that allow air to enter the mask? a. Partial rebreathing mask b. Nonrebreathing mask c. Simple face mask d. Nebulizer mask

C The holes in the mask allow the CO2 to escape on expiration, and if the oxygen is turned off, room air can be breathed through the holes.

6. What should be included in teaching for a patient who will be discharged with a prescription for a laxative? a. Calling the health care provider if nausea, vomiting, or abdominal pain occurs b. Continuing use of laxatives to encourage bowel evacuation c. Adding regular exercise, sufficient fluids, and regular defecation habits to his or her routine d. Knowing the difference between laxatives and cathartics

C The patient who is discharged on laxatives should still be instructed on the nonpharmacological methods to decrease constipation and promote normal bowel patterns. Laxatives are contraindicated in patients with nausea, vomiting, or undiagnosed abdominal pain. Ongoing use of laxatives is associated with harmful side effects, such as an increase in constipation and impaction, predisposition to colorectal cancer, dependency, and electrolyte imbalance and should not be encouraged. Knowing the difference between laxatives and cathartics will not help the patient in this case.

8. A patient is scheduled for a colonoscopy. After preprocedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. "I can have coffee the morning of the procedure." b. "I should drink a red sports drink the day before to stay hydrated." c. "I should drink clear liquids for 2 days before the procedure." d. "I will be able to drive home immediately after the procedure."

C The patient will be on a clear liquid diet for 1 to 3 days before the procedure. The patient should not eat or drink anything immediately before the procedure. Drinks with red or purple dye are contraindicated because they could interfere with the exam findings. Patients are given medications during the procedure that alter the sensorium and therefore need to have someone else drive them home.

6. What self-care measure is most important for the nurse to include in the teaching plan for a patient who will be discharged with a urostomy? a. Change the appliance before going to bed. b. Cut the wafer 1 inch larger than the stoma. c. Cleanse the peristomal skin with mild soap and water. d. Use firm pressure to attach the wafer to the skin.

C The peristomal area can be washed by the patient using warm water and mild soap as needed and routinely at bath time. The collection device typically has a face plate to ensure a good fit and prevent leakage of urine. These appliances are changed less frequently than before bed each night, and neither a widely cut wafer or firm pressure is needed for their application.

6. Which of the chambers of the heart becomes enlarged when mitral valve stenosis occurs? a. Right atrium b. Right ventricle c. Left atrium d. Left ventricle

C When the mitral valve is narrowed as in mitral stenosis, the left atrium has to generate more force to empty its contents, and left atrial enlargement may occur. The other three chambers of the heart may also enlarge, depending on where in the cardiovascular system the problem is occurring.

4. Which oxygen delivery setting places a patient in danger of not receiving adequate oxygen? a. Nasal cannula at a flow rate of 2 L/min b. Nasal cannula at a rate of 5 L/min c. Simple mask at a flow rate of 5 L/min d. Non-rebreather mask at a flow rate of 5 L/min

D A non-rebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen in the reservoir bag and may result in the person developing hypoxemia. The accepted range of oxygen delivery with a non-rebreather mask is 10 to 15 L/min. The amount that can be delivered by nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the range for a face mask is 5 to 10 L/min.

5. Following hip surgery, a trochanter roll is used to prevent what type of movement? a. Supination b. Pronation c. Internal rotation d. External rotation

D A trochanter roll is placed along the greater trochanter of the femur (the outer aspect of the leg) to prevent external rotation of the hip when a patient is lying in supine position. A pillow is placed between a patient's legs when logrolling or in the side-lying position to prevent internal rotation. Supination and pronation refer to body positions of face up and face down.

4. While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, and the stoma is located in the upper right quadrant of the abdomen. What type of ostomy does the patient have? a. Descending colostomy b. Ureterostomy c. Ileostomy d. Ascending colostomy

D An ascending colostomy meets the description of fecal output of liquid consistency and with a pungent odor, as well as location of the stoma in the upper right quadrant of the abdomen. Descending colostomies produce increasingly formed stool. An ileostomy will produce liquid stool but with less odor because enzyme activity is not present. Ureterostomies drain urine, not stool.

6. Which of the following artificial airways would the nurse anticipate to have a cuff at the end? a. Nasotracheal airway b. Pharyngeal airway c. Oral pharyngeal airway d. An endotracheal tube

D An endotracheal tube enters the patient's trachea and has a cuff to prevent gastric contents from emptying into the lungs from the gastrointestinal tract.

3. The patient is ordered an ultrasound to determine the size, shape, and location of the kidneys. The nurse knows that prior to the test the patient will a. be required to have a bowel cleansing enema. b. be checked for any allergies to shellfish. c. be required to drink a large amount of fluids before the test. d. have no pretest requirements.

D An ultrasound scan may be performed to assess the size, shape, and location of the kidneys. Ultrasound studies may be safely conducted in patients who have allergies to contrast media, because no radiation or contrast dyes are used. No patient preparation such as fasting or sedation is required.

8. Which of the following conditions would be associated with a wheezing sound on inspiration in a patient's lower posterior chest? a. Myocardial infarction b. Congestive heart failure c. Pulmonary edema d. Asthma

D Asthma causes a narrowing of small airways that results in a wheezing sound.

6. The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice? a. Hot dog on a bun b. Grilled chicken c. Tuna sandwich on white bread d. Spinach salad with dressing

D Green leafy vegetables are high in fiber. None of the other options are high in fiber but could be modified by using whole-grain products.

1. Which assessment finding would indicate that a patient has hemiparesis? a. Bilateral lack of movement in the patient's lower extremities b. Complaint of pain when the patient attempts to ambulate c. Loss of sensation in both of the patient's legs d. Weakness of the patient's right arm and leg

D Hemiparesis results from a neurological brain injury that causes weakness on one side of the body. Bilateral muscle and sensory loss may be due to a spinal cord injury, the level of which determines whether the patient is paraplegic or quadriplegic. Pain with ambulation may be a neurological or musculoskeletal response to a variety of concerns or disorders.

2. A patient is experiencing acute renal failure. What is the most common cause of this critical illness? a. Hypovolemia b. Cardiogenic shock c. Nephrotoxic substances d. Urethral obstruction

D Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, can lead to an anuric state, resulting in acute or chronic renal failure.

3. What nursing intervention would be the first priority to prevent constipation in an immobile patient? a. Administration of a soap suds enema b. Decreased dietary fiber consumption c. Narcotic analgesic pain relief use d. Increased daily oral fluid intake

D Increased oral intake and ambulation are the highest priority interventions for the prevention of constipation. Promoting dietary fiber intake and administering ordered stool softeners would be the next most important strategies. The use of narcotic analgesia should be minimized in constipated patients since these types of medications actually decrease gastrointestinal (GI) motility. If none of the previous interventions result in the patient having a bowel movement, a soap suds enema may be ordered.

4. Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum

D Injury to the cerebellum directly affects a patient's ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions such as vomiting. The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain.

2. What information should the nurse include when teaching a patient about deep vein thrombosis (DVT) prevention? a. Avoid movement of the extremities to prevent potential deep vein thrombosis formation. b. Encourage use of sequential compression devices (SCDs) during ambulation. c. Utilize an ankle foot orthotic (AFO) or pressure relief orthotic (PRAFO) to stretch ligaments. d. Sit with legs uncrossed to promote circulation and venous blood flow to the heart.

D Instructing patients to sit without crossing their legs and to ambulate as much as possible are important aspects of patient education in DVT prevention. SCDs must be removed prior to ambulation to prevent patient injury. Orthotics may be helpful in preventing heel pressure and footdrop, but have little effect on DVT prevention.

10. What symptom is most likely to be exhibited by the patient who complains of voiding small amounts of urine in relation to his fluid intake? a. Nocturia b. Polyuria c. Anuria d. Oliguria

D Oliguria is reduced urine volume. Nocturia is excessive urination at night. Polyuria is an excessive amount of urine excreted each day, and anuria is excretion of 50 to 100 mL or less of urine each day.

5. Which of the following patients may need a pharyngeal airway? a. A patient who is alert and oriented b. A patient who has a tracheostomy c. A patient with a broken nose d. A patient with decreased level of consciousness

D Pharyngeal airways are needed most often when a patient has a decreased level of consciousness and loss of muscle tone.

4. Which patient care activity can be delegated by the registered nurse (RN) to unlicensed assistive personnel (UAP)? a. Completing an admission skin assessment b. Administering an ordered stool softener c. Teaching deep vein thrombosis prophylaxis d. Range of motion exercises

D Range of motion exercises is the only intervention on this list that legally can be delegated to unlicensed assistive personnel. Completing an initial patient assessment, administering medications, and patient teaching are all roles and responsibilities of the registered nurse.

1. When a person takes a breath in, what is the primary muscle of respiration? a. The intercostal muscles b. The neck muscles c. Muscles of the shoulder girdle d. The diaphragm

D The diaphragm is the primary muscle of respiration. When it contracts, the intrathoracic is increased, forcing atmospheric air into the airways.

2. The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema? a. The proper way to position the patient b. Signs and symptoms of intolerance to the procedure c. Vital signs before the procedure d. History of surgery of the anus or rectum

D The most important item in preadministration assessment data is a history of surgery to the anus or rectum, which may contraindicate enema administration. The nurse needs to know the proper patient position for an enema and must observe for signs of intolerance to the procedure, but these are done during the procedure. Vital signs are not routinely obtained before an enema.

5. Select the most appropriate goal for a patient experiencing diarrhea related to antibiotic use: a. The patient will return to previous elimination pattern. b. The patient will increase intake of grains, rice, and cereals. c. The patient will discontinue antibiotic use and contact the health care provider. d. The patient will increase fluid intake.

D The patient will increase fluid intake since diarrhea can lead to dehydration.

3. A patient is scheduled for an upper GI series. Which information is most important to obtain from him before the procedure? a. Allergy to lasix b. Last bowel movement c. Time the enema was administered d. Any difficulty swallowing

D The patient will need to drink barium for this x-ray; therefore, swallowing ability should be assessed prior to the start of the procedure.

3. Which position is the priority for a patient experiencing acute shortness of breath? a. Supine position b. Reverse Trendelenburg position c. Face-down position d. Upright position

D When a person is having difficulty breathing, placing her or him in an upright position helps to increase the effectiveness of breathing. The supine position may decrease respiratory efficiency, place pressure on the chest wall from the bed, and cause increased anxiety for the patient. The reverse Trendelenburg position increases the workload of breathing. The face-down (prone) position may inhibit the patient's ability to breathe.

3. A female patient has had frequent urinary tract infections. Which statement by the patient indicates that the nurse's teaching on prevention has been effective? a. "I will limit my fluid intake to 40 ounces per day." b. "I will use bubble bath when bathing." c. "I will wait to wear my tight jeans until after my urine is clear." d. "I will wipe from the front to back after voiding."

D Wiping the female perineal area from front to back after voiding is crucial in the prevention of microorganisms, which lead to infection, being transferred from the rectum or vagina to the urethral meatus. Limiting fluid intake, using bubble bath, and wearing tight-fitting clothing all may contribute to the promotion of urinary tract infections, rather than their prevention.