Nursing Assistant Module 3
What is the blood pressure range?
100-140 ---------- mmHg 60-90
What is the respiration range?
12-20 bpm
How many mililiters is in 1 oz.
30 ml
What is the pulse range?
60-100 bmp
The large lines on the blood pressure gauge are in increments of 20 mm of Hg pressure.
False
The liquid column in a glass oral thermometer should register below 96°F at the beginning of the procedure.
False
The lower bar on the scale indicates pounds in increments of 25.
False
URI stands for underrated respiratory injections.
False
Use hot water forWhen washing used glass thermometers., use hot water.
False
Mucus in the air passages causes crackles.
True
Odor control can be a problem when a patient has an ostomy.
True
Insert the rectal suppository: a. 2 to 3 inches above the rectal sphincter. b. 3 to 5 inches above the rectal sphincter. c. 1 to 2 inches above the rectal sphincter. d. 6 inches above the rectal sphincter.
a. 2 to 3 inches above the rectal sphincter.
The normal capillary refill is: a. 2 to 3 seconds b. 5 to 10 seconds. c. 3 to 6 seconds d. 15 to 20 seconds
a. 2 to 3 seconds
The reaction time for a Hemoccult test is a. 30 to 60 seconds. b. 2 to 3 minutes. c. 2 to 4 seconds. d. 90 to 120 seconds.
a. 30 to 60 seconds.
Removal of the gallbladder and stones is: a. Cholecystectomy. b. Cholecystitis. c. Gastrectomy. d. Cholelithiasis.
a. Cholecystectomy.
The fluids used for enemas include all of the following except: a. Milk of Magnesia. b. Phosphosoda c. Tap water d. Salt solution
a. Milk of Magnesia.
An asthma attack is usually triggered by: a. an allergen. b. cold. c. heat. d. the pillow.
a. an allergen.
The Yankauer catheter is a/an a. sterile endotracheal catheter. b. oral suction device. c. nasal airway. d. three-way urinary catheter.
b. oral suction device.
Which of these positions will enable the patient to inhale the most air? a. Fowler's position. b. orthopneic position. c. semiprone position. d. supine position.
b. orthopneic position.
The external skin opening for the tracheostomy is the: a. flange. b. stoma. c. ventilator. d. cannula.
b. stoma.
As compared to a colostomy, an ileostomy: a. has a larger stoma. b. tends to be more irritating. c. has more formed stool. d. has drainage containing blood clots.
b. tends to be more irritating.
The most common sign of respiratory problems in a patient with emphysema is: a. pain. b. nausea. c. moist cough. d. headache.
d. headache.
If the skin around an ileostomy stoma is broken, you should a. seal it with appliance adhesive. b. wipe it with alcohol. c. wash it with soap and water. d. inform the nurse.
d. inform the nurse.
When your patient is receiving oxygen, you should a. check the flow rate once each shift. b. check the flow rate every 3 hours. c. monitor intake and output. d. know the ordered rate.
d. know the ordered rate.
When administering oxygen by mask, in addition to routine care and precautions, you should a. remove the mask for bathing and meals. b. make sure the mask covers only the mouth. c. pull the straps until they are very tight. d. provide emotional support and reassurance.
d. provide emotional support and reassurance.
What are the celcius temperature ranges?
A- 36.0 37.0 O- 36.5 - 37.0 - 37.5 R- 37.0 38.1
What are the farenheit temperature ranges?
A- 96.6 - 97.6 - 98.6 O- 97.6 - 98.6 - 99.6 R- 98.6 - 99.6 - 100.6
96.8°F is an average oral temperature.
False
A freezing temperature registered in Celsius readings would be 32°.Hold the temporal artery thermometer in place for 3 minutes.
False
A herniorrhaphy is the surgery performed when there for bowel malignancy.
False
A patient who cannot get out of bed cannot be measured.
False
A pulse is best counted using the thumb placed over the artery.
False
A stool with occult blood will appear bloody.
False
Always apply gloves before taking a temporal artery temperature.
False
Blood pressures taken over arteries closer to the heart will be lower than those taken over arteries farther from the heart.
False
Check My Work Readings taken with a plastic thermometer may not be entirely accurate.
False
Cheyne-Stokes respirations are deep and regular.
False
Clinical thermometers can be identified by the shapes of their bulbs.
False
Depressant drugs elevate the blood pressure.
False
Disconnect the catheter bag before weighing the patient.
False
Drainage from a colostomy is always watery.
False
Drugs to reduce fever fight infection.
False
Each long line on the stem of a clinical thermometer indicates a change of 2 degrees of temperature.
False
Exercise decreases blood pressure.
False
Gastric ulcers are located in the esophagus.
False
Gently pull the ear pinna back and down before inserting the tympanic thermometer in an adult.
False
If safely placed, rectal thermometers need not be held. The temporal artery is deep within the body core.
False
Ill fitting dentures have no effect on weight.
False
In the high Fowler's position, the patient leans forward across the overbed table.
False
It would be unsafe to use a glass oral thermometer with a 2-year-old child.
False
Measuring the temperature in the groin area gives the most accurate indication of body temperature.
False
Only temperature variations of more than 5°F should be reported to the nurse.
False
Orthostatic hypotension is most common in middle age adults.
False
Pulses differ when counted at different pulse sites.
False
The Hemoccult test is used to determine the presence of bile in the feces.
False
The axillary temperature of a patient will register approximately one degree higher than his oral temperature.
False
The forearm is a good alternate location for taking blood pressure.
False
The most accurate temperature is taken with the tympanic thermometer.
False
The normal temporal artery temperature reading is 97.2°F.
False
The oral thermometer should remain in place for 1 minute.
False
The proper amount of time to observe a Hemoccult packet after placing a fecal smear and adding the developer is 5 minutes.
False
The pulse site used most often is the carotid artery.
False
The tympanic temperature reading is the most accurate.
False
To measure a patient confined to bed, first help her assume the left Sims' position.
False
Wait 5 minutes after the patient has taken hot liquids to measure an oral temperature.
False
When giving a soap-solution enema, approximately 2,000 mL are used.
False
When oxygen is administered by mask, make sure the straps are very tight.
False
To measure a rectal temperature, the patient is best positioned on her back.
Fasle
What are the four things that are measured in vital signs?
Temperature, pulse, respiration, blood pressure
A blood pressure below 100/60 suggests hypotension.
True
A flatus tube is used to reduce abdominal distention from gas.
True
A pulse deficit results when there is a difference between the apical and radial pulses.
True
All rectal thermometers should be lubricated before insertion.
True
Always check the overbed scale for needed repairs before use.
True
Always post a sign when oxygen is in use.
True
Always wipe the axillary area before placing a thermometer.
True
An allergen causes a sensitivity reaction.
True
An apical pulse should be counted in children.
True
An enema may be given only upon direction from the nurse.
True
Apply the principles of standard precautions when caring for an ostomy.
True
Be sure the bathroom is free before giving an enema.
True
Each short line on the stem of the clinical thermometer indicates a 0.2-degree change in temperature.
True
Gloves must be used when doing tests on feces or urine.
True
Immobility is a risk factor for hypoxemia.
True
In asthma, there is increased production of mucus, which blocks the respiratory tract.
True
Many health care professionals depend on the accuracy of patients' weight and height measurements.
True
Patients and residents can and do develop malnutrition during a stay in a health care facility.
True
Stethoscope earpieces should be cleaned both before and after use.
True
Temperature is the measurement of body heat.
True
The drainage from a new cholecystectomy incision is normally yellowish-green.
True
The most common method of measuring the temperature of a cooperative adult is by mouth.
True
The oxygen flow rate is ordered by the physician.
True
The patient is positioned on the left side, if possible, for enema administration.
True
The probe of an electronic thermometer is covered with a red sheath for rectal use.
True
The pulse is the pressure of blood against the arterial wall.
True
The pulse rate of an infant is 110 to 130 bpm.
True
The respiratory system rids the body of excess carbon dioxide.
True
The scale used most often to weigh ambulatory patients in care facilities is the upright scale.
True
The temporal artery and tympanic thermometers are ideal for taking temperatures on patients using oxygen.
True
The volume of blood in the circulatory system affects the blood pressure.
True
There may be times when a temperature has to be measured in the groin area.
True
To accurately measure blood pressure, you will need both a sphygmomanometer and a stethoscope.
True
To obtain a proper reading, the scale balance bar must hang freely.
True
Use of the incentive spirometer can help prevent pneumonia.
True
Using a blood pressure cuff of the wrong size will give an inaccurate reading.
True
Waste products from ostomy care are discarded in the biohazardous trash.
True
Weight loss is a common problem in health care facilities because of physical and mental conditions.
True
When a prepackaged enema is administered, approximately 4 ounces are given.
True
When charting an axillary temperature, always print AX after the reading.
True
When measuring a blood pressure, always keep the gauge at eye level.
True
When using an electronic thermometer, you should not allow your fingers to touch the tip of the probe sheath with your fingers.
True
When using an overbed scale, the patient's body must be free of the bed.
True
An artificial opening in the colon is known as a/an a. colostomy. b. proctostomy. c. ileostomy. d. tracheostomy.
a. colostomy.
You are giving routine stoma care to a patient with a colostomy and find the area surrounding the stoma red and irritated. You should a. cover the area and notify the nurse. b. apply powder and attach the ostomy bag. c. clean the area with alcohol. d. complete the procedure.
a. cover the area and notify the nurse.
The nasal airway: a. may be used for conscious patients. b. is molded from hard plastic. c. is needed when a ventilator is used. d. is be used during anticoagulant therapy.
a. may be used for conscious patients.
The pulse oximeter measures: a. saturation of the hemoglobin with oxygen. b. the pulse and level of oxygen in lungs. c. how much oxygen is in the venous blood. d. the amount of blood in the fingertip.
a. saturation of the hemoglobin with oxygen.
The oil-retention enema is usually a. softens the feces so they are easier to expel. b. preceded by a soap-solution enema. c. given in the semi-Fowler's position. d. retained for 1 hour.
a. softens the feces so they are easier to expel.
Which of the following is true about oxygen humidifiers? a. Fill the humidifier bottle with normal saline. b. Oxygen may be given without humidification. c. Oxygen from a concentrator needs a humidifier. d. Persons with COPD need humidified oxygen.
b. Oxygen may be given without humidification.
Pleural effusion is a. a complication of a laryngectomy. b. a collection of fluid around the lungs. c. part of the chest tube water suction. d. a treatment for cancer.
b. a collection of fluid around the lungs.
Your patient has removed her oral airway and handed it to you with a smile. After this, she went back to sleep. Your first action should be to: a. check the vital signs. b. check the pulse oximeter. c. put the airway back in. d. run and find the nurse.
b. check the pulse oximeter.
Capillary refill is used to evaluate a. cyanosis and changes in color. b. how well oxygen gets to body tissues. c. how much oxygen is in the venous blood. d. the strength of the pulse.
b. how well oxygen gets to body tissues.
Chronic obstructive pulmonary disease (COPD) is caused by: a. narrowing and clogging of the bronchi. b. loss of elasticity of the alveoli. c. normal aging changes in the trachea. d. prolonged inflammation in the bronchi.
b. loss of elasticity of the alveoli.
Which of the following pulse oximeter values suggests the patient is becoming hypoxemic? a. 98% b. 96% c. 89% d. 90%
c. 89%
Inform the nurse if the patient does not have a bowel movement: a. In 5 days. b. Daily. c. In 3 days. d. In 2 days.
c. In 3 days.
Make sure your patient who is mechanically ventilated: a. condensation in the tubing at all times. b. is restrained if he may try to pull the tube out. c. a means of communicating his needs. d. heel protectors at all times to relieve pressure.
c. a means of communicating his needs.
The primary purpose of the Passy-Muir is to: a. keep foreign bodies out of trachea. b. reduce the risk of dyspnea. c. enable the person to speak. d. prevent uncontrolled coughing.
c. enable the person to speak.
Urgency is a term that means a. inability to have a BM. b. need to vomit. c. need to eliminate. d. pain from flatus.
c. need to eliminate.
A change in mental status in a person with a tracheostomy suggests: a. patient is having shortness of breath. b. patient needs suctioning. c. patient not getting enough oxygen. d. something is wrong with the tube.
c. patient not getting enough oxygen.
Nursing care for a male patient who is using oxygen includes a. covering the patient with a wool blanket. b. keeping the head of the bed elevated 10°. c. providing frequent mouth care. d. shaving the patient with an electric razor.
c. providing frequent mouth care.
Your patient has just returned from surgery for gallstones. She will be most comfortable in the a. dorsal recumbent position. b. lithotomy position. c. semi-Fowler's position. d. left Sims' position.
c. semi-Fowler's position.
A patient with a laryngectomy can: a. blow his nose. b. smell. c. swallow. d. suck on a straw.
c. swallow.
C. difficile spores can exist on hard surfaces for: a. one year. b. 24 hours. c. 30 days. d. 5 months.
d. 5 months.
Aging changes to the respiratory system include all of the following except: a. decreased ability to inflate lungs. b. Loss of elasticity in the lungs. c. decreased risk of hypoxia. d. Size of the trachea increases.
d. Size of the trachea increases.
Persons who are elderly often put extra sugar on their food because: a. They need to prevent weight loss. b. A craving for sweets is normal. c. They need extra calories. d. Taste buds have been lost.
d. Taste buds have been lost.
Jaundice is: a. Strangulation of the intestine. b. A malignancy of the lower bowel. c. Abnormal appearance of stools. d. Yellow skin and whites of the eyes.
d. Yellow skin and whites of the eyes.
The port of a closed urinary drainage system should be cleaned before urine withdrawal with a. a sterile 4 X 4 gauze pad. b. a paper towel. c. soap and water. d. alcohol.
d. alcohol.
During routine care, the area around a colostomy should a. be cleaned with an antiseptic. b. be cleaned with an alcohol sponge. c. be covered with petroleum jelly. d. be washed with soap and water.
d. be washed with soap and water.
Enemas are given a. at bedtime. b. after surgery. c. after the patient showers. d. before diagnostic testing.
d. before diagnostic testing.
When tank oxygen is in use: a. attach the tank to the patient's bed. b. make sure additional tanks are available. c. store empty tanks in the patient's room. d. chain the tank or secure it to a base.
d. chain the tank or secure it to a base.
A sign of possible gastrointestinal malignancy is a. good appetite. b. nausea. c. weight gain. d. change in stool color.
d. change in stool color.
Patients with respiratory disease should: a. turn the face toward others when sneezing. b. carry a plastic bag to dispose of soiled tissues. c. wash their hands only after toileting. d. cover the nose and mouth when coughing.
d. cover the nose and mouth when coughing.
A mechanical ventilator is used with a: a. nasopharyngeal airway. b. refillable humidifier. c. CPAP device. d. endotracheal tube.
d. endotracheal tube.