NURS 226 Final Exam
During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? Select all that apply. A. Increase fiber intake. B. Increase water consumption. C. Decrease physical exercise. D. Refrain from alcohol. E. Refrain from smoking.
A and B
The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) A. Serum total protein B. Potassium C. Lipids D. Albumin E. Serum BUN
A and E
The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking ver- bal or telephone orders? (Select all that apply). A. Only authorized staff may receive and record verbal or tele- phone orders. The health care agency identifies in writing the staff who are authorized. B. Clearly identify patient's name, room number, and diagnosis. C. Read back all orders to health care provider. D. Use clarification questions to avoid misunderstandings. E. Write "VO" (verbal order) or "TO" (telephone order), includ- ing date and time, name of patient, and complete order; sign the name of the health care provider and nurse.
A, B, C, D, and E
Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) A. How to change the pouch B. How to empty the pouch C. How to open and close the pouch D. How to irrigate the colostomy E. How to determine whether the ostomy is healing appropriately
A, B, C, and E
Which of the following are appropriate measures taken to help the patient with dysphagia to swallow and prevent aspiration? (Select all that apply) A.Add thickener to thin liquids. B.Place food on the unaffected side of the mouth. C.Provide the patient with a lap protector. D.Place the patient in the high-Fowler's position. E.Provide verbal coaching. F.Talk about other matters while feeding the patient.
A, B, D, & E
When conducting a health history assessment, the nurse would want to know what most important information about the patient's elimination status? Select all that apply. A. Recent changes in elimination patterns. B. Changes in color, consistency, or odor of stool or urine. C. Time of day patient defecates. D. Discomfort or pain with elimination. E. List of medication taken by patient. F. Patient's preferences for toileting.
A, B, D, and E
Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) A. Change in bowel habits B. Blood in the stool C. A larger-than-normal bowel movement D. Fecal impaction E. Muscle aches F. Incomplete emptying of the colon G. Food particles in the stool H. Unexplained abdominal or back pain
A, B, F, and G
An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) A. Provide a dispensing system for each day of the week. B. Provide larger, easier-to-read labels. C. Tell the patient what is in each container. D. Have a family caregiver administer the medication. E. Use teach-back to ensure that the patient knows what medica- tion to take and when.
A, B, and E
A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.) A. Immediately phone in to the hospital alert system the exact loca- tion of the fire. B. Direct the nurse technician to place empty stretchers behind the fire doors. C. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. D. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. E. Close the room doors of patients who cannot get out of bed, and keep them in their rooms.
A, C, and D
After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) A. Assess the injection site. B. Administer an oral medication for pain. C. Notify the patient's health care provider of assessment findings. D. Document assessment findings and related interventions in the patient's medical record. E. This is a normal finding, so nothing needs to be done. F. Apply ice to the site for relief of burning pain.
A, C, and D
Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) A. Increase fiber and fluids in the diet. B. Use a low-volume enema daily. C. Avoid gluten in the diet. D. Take laxatives twice a day. E. Exercise for 30 minutes every day. F. Schedule time to use the toilet at the same time every day. G. Take probiotics 5 times a week.
A, E, and F
The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response? A. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel." B. "Some people have a slower bowel than others, and this is nothing to be concerned about." C. "The foods you eat contribute to peristalsis, so you should eat more fiber in your diet." D. "Bowel peristalsis is slow because you are not walking. Get more exercise during the day."
A. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel."
A client who is receiving parenteral nutrition (PN) through a cen- tral venous catheter (CVC) has an air embolus. What should be the nurse's priority action? A. Have the patient turn on the left side and perform a Valsalva maneuver. B. Clamp the intravenous (IV) tubing to prevent more air from entering the line. C. Have the patient take a deep breath and hold it. D. Notify the health care provider immediately.
A. Have the patient turn on the left side and perform a Valsalva maneuver.
Which action can a nurse delegate to assistive personnel (AP)? A. Performing glucose monitoring every 6 hours on a patient B. Teaching the client about the need for enteral feeding C. Administering enteral feeding bolus after tube placement has been verified D. Evaluating the client's tolerance of the enteral feeding
A. Performing glucose monitoring every 6 hours on a patient
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? A. Stop the instillation. B. Ask the patient to take deep breaths to decrease the pain. C. Tell the patient to bear down as he would when having a bowel movement. D. Continue the instillation; then administer a pain medication.
A. Stop the instillation.
Which of the following promotes child safety for adolescents? A. Teach children proper techniques for specific sports. B. Teach children not to operate electric toothbrushes while unsupervised. C. Teach children not to talk to or go with a stranger. D. Teach children not to eat items found in the grass.
A. Teach children proper techniques for specific sports.
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) A. Lift the patient's hips off the bed and slide the bedpan under the patient. B. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. C. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. D. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. E. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
B and E
A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment. A. Clean eye, washing from inner to outer canthus. B. Assess patient's level of consciousness and ability to follow instructions. C. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. D. Have patient close eye and rub lightly in a circular motion with a cotton ball. E. Ask patient to look at ceiling, and explain the steps to patient.
B, A, E, C, D
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.) A. Heart disease B. Sepsis C. Hemorrhage D. Skin breakdown E. Diarrhea
B, C, and D
A nurse working the night shift is assigned a patient who has a his- tory of having fallen in the hospital during a previous admission. The nurse wants to review the admission assessment completed by the nurse on the day shift. Which of the following sections in the assess- ment are most likely to provide information about the patient's cur- rent fall risks? (Select all that apply.) A. Allergy history B. Medication history C. Patient age D. Patient's occupation E. Physical exam of neuromuscular function
B, C, and E
Which of the following are safe practices to follow in the safe prepa- ration and storage of food? (Select all that apply.) A. Always use a single cutting board to prepare foods for cooking. B. Refrigerate leftovers as soon as possible. C. Always buy vegetables in packages marked "prewashed." D. Cook meats to the proper temperature. E. Wash hands thoroughly before food preparation.
B, D, and E
A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? A. Get three fecal smears from one bowel movement. B. Obtain one fecal smear from an early-morning bowel move- ment. C. Collect one fecal smear from three separate bowel movements. D. Get three fecal smears when you see blood in your bowel movement.
C. Collect one fecal smear from three separate bowel movements.
A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? A. Assess bowel sounds. B. Raise the head of the bed to at least 45 degrees. C. Continue the feedings; this is normal gastric residual for this feeding. D. Hold the feeding until you talk to the primary care provider.
C. Continue the feedings; this is normal gastric residual for this
What is a primary prevention tool used for colon cancer screening? A. Abdominal x-rays B. Blood, urea, and nitrogen (BUN) testing C. Serum electrolytes D. Occult blood testing
D. Occult blood testing
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? A. Suction her mouth and throat. B. Turn her on her side. C. Put on oxygen at 2 L nasal cannula. D. Stop feeding her.
D. Stop feeding her.
Which of the following promotes child safety for preschoolers? A. Teach children proper bicycle and skate board safety. B. Teach children how to cross streets and walk in parking lot. C. Teach children proper techniques for specific sports. D. Teach children not to operate electric toothbrushes while unsupervised.
D. Teach children not to operate electric toothbrushes while unsupervised.
A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? A. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. B. The second patient is very drowsy, loses attention span when the nurse asks questions, and mumbles when speaking. C. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume. D. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient.
D. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient.
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? A. When 25% of the patient's nutritional needs are met by the tube feedings B. When bowel sounds return C. When the central line has been in for 10 days D. When 75% of the patient's nutritional needs are met by the tube feedings
D. When 75% of the patient's nutritional needs are met by the tube feedings
A nurse is assess the pain level of a client who has come to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following? a. Presence of associated symptoms b. Location of the pain c. Pain quality d. Aggravating and relieving factors
a. Presence of associated symptoms
A patient admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft restraints. Which nursing action is most appropriate? a. Perform circulation checks to bilateral upper extremities each shift b. Attach the ties of the restraints to the bed frame c. Reevaluate the needs for restraints and document weekly d. Ensure the restraint prescription has been signed by the health care provider (HCP) within 72 hours
b. Attach the ties of the restraints to the bed frame
A nurse is working with a newly hired nurse who is administering medications to patients. Which of the following actions by the newly hired nurse indicates an understanding of medication error prevention? a. Taking all medications out of the unit-dose wrappers before entering the patient's room. b. Checking with the provider when a single dose requires administration of multiple tablets. c. Administering a medication, then looking up the usual dosage range. d. Relying on another nurse to clarify a medication prescription.
b. Checking with the provider when a single dose requires administration of multiple tablets.
The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner? a. Call another nurse to assist with the procedure b. Gather all supplies and equipment before entering the patient room c. Instruct and explain the procedure to the patient d. Check the patient's schedule for the day for the most convenient time
b. Gather all supplies and equipment before entering the patient room
Total parenteral nutrition (TPN) is prescribed for the patient who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? a. Administer TPN through a nasogastric or gastrostomy tube b. Handle TPN using strict aseptic technique c. Auscultate for the presence of bowel sounds prior to administration of TPN d. Designate a peripheral IV site for TPN administration
b. Handle TPN using strict aseptic technique (b/c it is given in a central line)
Which of the following is an example of a problem that nurses can treat independently? a. Hemorrhage b. Nausea c. Fracture d. Infection
b. Nausea
Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surger? a. Age over 75 years b. Poorly controlled diabetes c. History of one myocardial infarction d. Chronic peripheral vascular disease
b. Poorly controlled diabetes
A nurse is reviewing the laboratory findings for urinalysis (UA) of a client who reports urgency and nocturia. Which of the following findings should the nurse report to the provider? a. Positive for casts b. Positive leukocyte esterase c. Positive for epithelial cells d. Positive for crystals
b. Positive leukocyte esterase
While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a. Sanguineous b. Serosanguineous c. Serous d. Purosanguineous
b. Serosanguineous
The nurse is assessing a hospitalized older patient for the presence of pressure ulcers. The nurse notes that the patient has a 1" by 1" (3cm by 3cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a. Stage I pressure ulcer b. Stage 2 pressure ulcer c. Stage 3 pressure ulcer d. Stage 4 pressure ulcer
b. Stage 2 pressure ulcer
A nurse is caring for an older adult client in an extended care facility. Which of the following indicates the client has a stool impaction causing a large intestine obstruction? a. The client reports he had a bowel movement yesterday b. The client is having small, frequent liquid stools c. The client is flatulent d. The client indicates he vomited once this morning
b. The client is having small, frequent liquid stools
The nurse is assessing a client with dark skin for the presence of a stage 1 pressure ulcer (injury). Which is the best approach to making this assessment? a. Use a fluorescent light source to assess the skin b. Inspect the skin only when the Braden score is above 12 c. Look for skin color that is darker than the surrounding tissue d. Avoid touching the skin during inspection
c. Look for skin color that is darker than the surrounding tissue
What is the correct method for turning an adult patient brought to the ER with a suspected spinal cord injury? a. Ask the patient to assist with the turn by holding the siderails of the bed b. Place a draw sheet under the patient to assist with turning c. Request help from another nurse to perform logrolling technique d. Use a mechanical lift for safe turning and protecting the nurse's bac
c. Request help from another nurse to perform logrolling technique
The nurse has determined that the goal for a particular nursing diagnosis on the client's plan of care has not been met. It will be most important for the nurse to a. Report this finding to the provider b. Note this finding in the client's record c. Revise the plan of care d. Remove the nursing diagnosis from the plan
c. Revise the plan of care
A nurse is completing discharge teaching with a client who is 3 days post operative for a transverse colostomy. Which of the following should be included in the teaching? a. Mucus will be present in stool for 5 to 7 days after surgery b. Expect 500 to 1,000 mL of semi-liquid stool after 2 weeks c. Stoma should be pink and moist d. Change the ostomy bag when it is ¾ full
c. Stoma should be pink and moist
Which patient has an naturally acquired active immunity? a. The adult who received immunizations b. The infant whose immunity was transferred from the mother to the infant. c. The child is recovering from a childhood disease that conferred immunity. d. The adult who received gamma globulin after exposure to Hepatitis.
c. The child is recovering from a childhood disease that conferred immunity.
A nurse is preparing to feed a patient via NG tube. Which of the following is the nurse's highest priority before initiating the feeding? a. Check the feeding container for expiration b. Confirm the patient does not have diarrhea c. Make sure the client is alert and oriented d. Verify placement of the NG tube
d. Verify placement of the NG tube
The nurse is caring for a patient with bacterial pneumonia. The effectiveness of the patient's oxygen therapy can be best determined by which indicator of oxygenation? a. Absence of cyanosis b. Patient's respiratory rate c. Arterial blood gas (ABG) values d. Patient's level of consciousness
c. Arterial blood gas (ABG) values
Place the steps for an ileostomy pouch change in the correct order. 1 A. Close the end of the pouch. B. Measure the stoma. C. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. D. Press the pouch in place over the stoma. E. Remove the old pouch. F. Trace the correct measurement onto the back of the wafer. G. Assess the stoma and the skin around it. H. Cleanse and dry the peristomal skin.
E, H, G, B, F, C, D, A
It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? A. Logging on to automated dispensing system (ADS) or unlock- ing medicine drawer or cart. B. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. C. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. D. Comparing MAR or computer printout with names of med- ications on medication labels and patient name at patient's bedside.
B. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR.
The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action? A. Speak with the patient's family about food choices. B. Establish a bowel and bladder program for the patient. C. Speak with the patient about past elimination habits. D. Establish a bedtime ritual for the patient.
B. Establish a bowel and bladder program for the patient.
What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? A. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. B. Initiate bowel or habit training program to promote continence. C. Help the patient to toilet once every hour. D. Use sanitary pads in the patient's underwear.
B. Initiate bowel or habit training program to promote continence.
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? A. Fastening tube to the gown with new tape B. Placing client supine while giving a bath C. Monitoring the client's weight as ordered D. Ambulating patient with enteral feedings still infusing
B. Placing client supine while giving a bath
Place the following steps for applying a wrist restraint in the correct order: A. Pad the skin overlying the wrist. B. Insert two fingers under the secured restraint to be sure that it is not too tight. C. Be sure that the patient is comfortable and in correct anatomical alignment. D. Secure restraint straps to bedframe with quick-release buckle. E. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.
C, A, E, B, D
In the change of shift report, you are told that a patient requires minimal assistance with meals. What would you expect to do for the patient at mealtime? (Select all that apply.) A.Place the meal tray in the room, leave the room, and return in 30 minutes to remove the tray. B.Feed the patient. C.Open packages and cartons. D.Assist the patient to an upright position. E.Ask the patient if he or she wants you to cut up the food or butter the bread. F.Document the patient's intake
C, D, E, & F
A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) A. Verifying tube placement after medications are given B. Mixing all medications together to give all at once C. Using an enteral tube syringe to administer medications D. Flushing tube with 30 to 60 mL of water after the last dose of medication E. Checking for gastric residual before giving the medications F. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given
C, D, E, and F
A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.) A. A current safety inspection sticker is on the IV fluids pump. B. A walker is positioned near the patient's bedside. C. The hospital bed is in the high position. D. There is no gait belt at the bedside. E. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.
C, D, and E
The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patients says she is looking for the bath- room. Which interventions are appropriate for this patient? (Select all that apply.) A. Ask the health care provider to order a restraint. B. Recommend insertion of a urinary catheter. C. Provide scheduled toileting rounds every 2 to 3 hours. D. Institute a routine exercise program for the patient. E. Keep the bed in high position with side rails down. F. Keep the pathway from the bed to the bathroom clear.
C, D, and F
A patient is receiving a continuous enteral feeding by infusion pump. You enter the patient's room to verify tube placement and measure residual. You notice that the patient's respirations are shallow and rapid and that the patient's color is ashen. You assess rhonchi upon auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should you take? (Select all that apply) A.Ask the patient whether she feels short of breath. B.Administer oxygen. C.Turn off the tube feeding. D.Have the patient deep breathe and cough. E.Position the patient in Fowler's position, and suction the patient. F.Position patient on the left side, and suction the patient. G.Notify the physician. H.Prepare for chest x-ray examination.
C, E, G, & H
You receive an order to begin enteral tube feedings. The first step is to: A.Place the patient in a prone position. B.Irrigate the tube with normal saline. C.Check to see that the tube is properly placed. D.Introduce a small amount of fluid into the tube before feeding.
C. Check to see that the tube is properly placed.
The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? A. Large intestine B. Stomach C. Small intestine D. Pancreas
C. Small intestine
A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct quantities of nutrients. Which statement reflects that she understands the dietary guidelines? A. "I am not concerned with what I am eating." B. "I am taking vitamin doses based on TV." C. "I am taking a daily MVI." D. "I am making eating choices according to the recommended dietary allowances and intakes."
D. "I am making eating choices according to the recommended dietary allowances and intakes."
Which statement made by the parents of a 2-month-old infant requires further education by the nurse? A. "I'll continue to use formula for the baby until he is at least a year old." B. "I'll make sure that I purchase iron-fortified formula." C. "I'll start feeding the baby cereal at 4 months." D. "I'm going to alternate formula with whole milk, starting next month."
D. "I'm going to alternate formula with whole milk, starting next month."
A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? A. Have you eaten more high-fiber foods lately? B. Have you taken antibiotics recently? C. Do you have gluten intolerance? D. Have you experienced frequent, small liquid stools recently?
D. Have you experienced frequent, small liquid stools recently?
The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? A. A food allergy B. Irritable bowel syndrome C. Increased peristalsis D. Lactose intolerance
D. Lactose intolerance
A nurse is preparing to administer a medication to a patient. The medication was scheduled for administration at 0900. Which of the following are acceptable administration times for this medication? (Select all that apply) a. 0905 b. 0825 c. 1000 d. 0840 e. 0935
a and d
A nurse is caring for a client with dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply) a. Have suction equipment available for use b. Use thickened liquids c. Place food on the client's unaffected side of her mouth d. Assign an assistive personnel to feed the client slowly e. Teach the client to swallow with her neck flexed
a, b, c, and e
A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select all that apply) a. Poor wound healing b. Dry hair c. Blood pressure 130/80mg Hg d. Weak hand grips e. Impaired coordination
a, b, d, and e
When the health care provider orders a medication, which components are required to be present in all orders before the nurse can safely administer the medication? Select all that apply. a. Medication name b. Medication dose c. Exact time of day d. Injection site e. Medication route f. Medication Frequency
a, b, e, and f
A nurse is teaching a client about high-fiber foods that can assist in lowering LDL. Which of the following foods should be included in the teaching? (Select all that apply) a. Beans b. Cheese c. Whole grains d. Broccoli e. Yogurt
a, c, and d
Which items can contribute to medication errors. Select all that apply. a. A lack of communication between the nurse and the patient b. Placing a "Do Not Disturb" sign when dispensing medications. c. Lack of patient knowledge regarding the discharge medications d. A new graduate nurse anxious about giving medications for the first time.
a, c, and d
Which are complications of bed rest? Select all that apply. a. Extremity contractures b. Decreased dependency c. Diarrhea d. Pneumonia e. Pressure ulcers f. Thrombi g. Urinary Calculi
a, d, e, f, and g
A nurse is teaching a patient how to administer medications through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? a. "Flush the tube before and after each medication." b. "Administer your medications with your enteral feeding." c. "Administer tablets through the tube slowly." d. "Mix all the crushed medications prior to dissolving in water."
a. "Flush the tube before and after each medication."
Which needle size is most appropriate for administering an intradermal injection? a. 28 G- 1/2 inch b. 25 G - 1 inch c. 21 G - 5/16 inch d. 18 G - 1 1/2 inch
a. 28 G- 1/2 inch
A nurse is caring for a client who is to receive a full liquid diet due to dysphagia. Which of the following nursing actions is the highest priority? a. Add thickener to liquids b. Educate the client about acceptable liquids c. Perform a calorie count of consumed liquids d. Offer high- protein liquid supplements
a. Add thickener to liquids
A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? a. Ask a colleague for help because the nurse cannot safely perform the procedure alone. b. Gather the equipment and prepare it before informing the client about the procedure. c. Obtain an order to restrain the client before inserting the urinary catheter. d. Inform the primary provider that the nurse cannot perform the procedure because the client is confused
a. Ask a colleague for help because the nurse cannot safely perform the procedure alone.
TPN is prescribed for a patient with Chron's disease. What indicates to the nurse that the TPN has been effective? a. Has met nutritional needs b. Is not in metabolic acidosis c. Is hydrated d. Is in negative nitrogen balance
a. Has met nutritional needs
What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a. Judgmental b. Too complex c. Legally questionable d. Without supportive data
a. Judgmental
A nurse prepares an injection of morphine (Duramorph) to administer to a patient who reports pain. Prior to administering the medication, the nurse is called to another room to assist another patient onto a bedpan. She asks the second nurse to give the injection. Which of the following actions should the second nurse take? a. Offer to assist the patient needing the bedpan. b. Administer the injection prepared by the other nurse. c. Prepare another syringe and administer the injection. d. Tell the patient needing the bedpan she will have to wait for her nurse.
a. Offer to assist the patient needing the bedpan.
Which of the following describes the difference between dehiscence and evisceration? a. With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b. Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent c. Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d. Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue
a. With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.
What is the name for a greater response when two meds are given together rather than alone? a. synergistic effect b. adverse effect c. idiosyncratic reaction d. side effect
a. synergistic effect
The nurse should perform passive range-of-motion (ROM) exercises on which patients? Select all that apply Multiple answers: Multiple answers are accepted for this question a. Has septic joints b. Has temporary loss of consciousness c. Is unconscious d. Has plantar flexion of the foot e. Has supination of the hand
b and c
A nurse is providing teaching to an older adult patient to promote adherence with medication administration. Which of the following instructions should the nurse include? (Select all that apply) a. Adjust the dose according to daily weight. b. Place pills in daily pill holders. c. Provide liquid forms if the patient has difficulty swallowing pills. d. Ask a relative/friend to assist periodically e. Request child-guard caps on medication containers
b, c, and d
What should the nurse do to prevent catheter-associated urinary tract infection? Select all that apply. a. Change the catheter daily b. Provide perineal care at least once a day c. Maintain a closed drainage system d. Encourage the patient to drink 3000 mL fluids daily e. Recommend health care provider prescribe antibiotics
b, c, and d
When teaching the patient with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the patient to report which symptoms to the health care provider (HCP)? Select all that apply. a. Cloudy urine for the first few days b. Blood in the urine c. Rash d. Mild nausea e. Fever above 100 degrees F (37.8 degrees C) f. Urinating every 3 to 4 hours
b, c, and e
The nurse is reviewing hand hygiene with UAPs. Which statement by the UAP requires further instructions? a. "I will wash my hands before and after care and I wear gloves with each patient." b. "I wash my hands when they are visible soiled." c. "I will not wear artificial nails when providing care." d. "It is OK to use the alcohol based products outside of the patient's room when entering and leaving the area."
b. "I wash my hands when they are visible soiled."
The nurse is teaching the patient how to care for an ileostomy. The patient asks the nurse how long to wear the pouch before changing it. What should the nurse tell the patient? a. "The pouch is changed only when it leaks" b. "You can wear the pouch for about 4 to 7 days>" c. "You should change the pouch every evening before bedtime." d. "It depends on your activity level and your diet."
b. "You can wear the pouch for about 4 to 7 days>"
A patient using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA? a. Reassure the patient the pain will be relieved b. Document the patient's response to pain medication c. Instruct the patient to continue pressing the system's button whenever pain occurs d. Titrate pain medication until the patient is free from pain
b. Document the patient's response to pain medication
A provider is discharging a patient with a prescription for home oxygen therapy via nasal cannula. Which of the following should be included in the instructions? a. Apply petroleum jelly around the nares b. Assure the patient and their family that the patient can still smoke c. Check the position of the nasal cannula frequently d. Remove the nasal cannula during meal time
c. Check the position of the nasal cannula frequently
A nurse is caring for a patient with a Foley catheter. What should the nurse do to reduce the risk of infection? a. Clean the perineum with peroxide after each void b. Decrease oral fluids. c. Empty the Foley bag every 4 to 8 hours. d. Open the bag and Foley system to check for kinks
c. Empty the Foley bag every 4 to 8 hours.
The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? a. Tell the charge nurse that the nurse is going to lunch b. Verify that the charge nurse has assigned someone to take care of the patient c. Give the charge nurse information about what care should be given while the nurse is at lunch d. Remind the charge nurse about the patient's history and current medicaitons
c. Give the charge nurse information about what care should be given while the nurse is at lunch
A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to: a. Avoid returning to the use of an ostomy appliance if he becomes ill. b. Call the primary care provider if the stoma becomes pale, dusky, or black. c. Irrigate the stoma to produce a bowel movement on a schedule. d. Limit the intake of gas-forming foods such as cabbage, onions, and fish
c. Irrigate the stoma to produce a bowel movement on a schedule.
Which mental status change may occur when a patient with pneumonia is first experiencing hypoxia? a. Coma b. Apathy c. Irritability d. Depression
c. Irritability
Which of the following is an example of an active listening behavior? a. Taking frequent notes b. Asking for more details c. Leaning toward the patient d. Sitting comfortably with legs crossed
c. Leaning toward the patient
The nurse is called to the patient's room by another nurse. When the second nurse arrives at the room, she discovers that a fire has occurred in the patient's waste basket. The first nurse has removed the patient from the room. What is the second's nurse next action? a. Evacuate the unit b. Extinguish the fire c. Confine the fire d. Activate the fire alarm
d. Activate the fire alarm (RACE)
A nurse is discussing foods that are high in Vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? a. Tacos and Rice b. Hamburgers and fried potatoes c. Ham and Brussels Sprouts d. Eggs and Fortified Milk
d. Eggs and Fortified Milk
The nurse must transfer a dependent patient from a bed to a gurney. Which action by the nurse will be safest for the patient and nurse? a. Adjust the height of the bed b. Avoid movements that twist the spine c. Keep the patient close to the nurse's body when lifting d. Obtain an appropriate mechanical lift device
d. Obtain an appropriate mechanical lift device
Which intervention should the nurse take first to promote the start of urination in a patient who is having difficulty voiding? a. Insert an intermittent, straight catheter b. Insert an indwelling urinary catheter c. Notify the provider immediately d. Pour warm water over the patient's perineum
d. Pour warm water over the patient's perineum
During meal time the nurse notices the patient's hands are holding the throat. Which patient situation requires immediate action by the nurse? a. The patient has a high-pitched inspiratory stridor b. The patient is talking and gagging c. The patient is coughing d. The patient is not making any sounds
d. The patient is not making any sounds
A patient is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the patient to exert control over physiologic processes by which mechanism? a. Regulating the body processes through electrical control b. Shocking the patient when an undesirable response is elicited c. Monitoring the body processes for the therapist to interpret d. Translating the signals of body processes into observable forms
d. Translating the signals of body processes into observable forms
The nurse is planning the care of a frail, immobile, elderly patient. Which of the following is the best treatment or prevention to protect the patient's skin? a. Administer fluid boluses as directed by the healthcare provider b. Assisting the patient to sit in a chair three times a day c. Offering the patient six small meals a day d. Turning the patient at least every 2 hours
d. Turning the patient at least every 2 hours
