NURS 220 Exam 2 Video Questions, Evolve quiz questions, and prep work quiz questions and v | Exams Nursing | Docsity (2024)

Download NURS 220 Exam 2 Video Questions, Evolve quiz questions, and prep work quiz questions and v and more Exams Nursing in PDF only on Docsity! NURS 220 Exam 2 Video Questions, Evolve quiz questions, and prep work quiz questions and verified answers. 1. The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do? a. Return the patient to the bed or chair (whichever is closer) b. Encourage the patient to complete the distance of ambulation c. Help him to the restroom d. Ease him to the floor - Correct answer A 2. The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk? a. Ask the patient how far she would like to go b. Review the health care provider's order c. Review the medical record to see how far the patient has walked during the past several therapeutic ambulations d. Review records of other patients who are at a similar point in their stroke rehabilitation - Correct answer B 3. The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up? a. "I will be sure to put nonskid slippers on the patient before getting him up to ambulate" b. "I will use the under-axillae technique to help him up to a standing position" c. "rocking the heavier patient into a standing position seems to work really well for me" d. "I will grasp the gait belt in the middle of the patient's back - Correct answer B 4. The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response? a. Slowly lower the patient to the floor b. Attempt to sit the patient down on a chair just a few steps away c. Try to hold the patient up until the dizziness passes d. Call for assistance in a loud but calm voice - Correct answer A 5. The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient? A. On the patient's strong side B. On the patient's weak side C. Behind the patient D. In front of the patient - Correct answer B 6. In which position will the nurse place the patient to move him or her up in bed? a. Supine with the head of the bed flat b. Sitting in the bed c. Supine with the head of the bed at a 30-degree angle D. Prone with the head of the bed flat - Correct answer A P a g e 1 | 39 7. When preparing to move a patient in bed, what will the nurse do first? a. Assemble adequate help to move the patient b. Assess the patient's ability to help with moving c. Determine the patient's weight d. Decide on the most effective means of moving the patient - Correct answer B 8. When preparing to move a patient in bed with the help of an assistant, which posture will give caregivers use to ensure their own safety? a. Stand with the knees locked b. Stand with the feet together c. Flex the hips and knees d. Shift the body weight from the back leg to the front leg - Correct answer C 9. A patient will be moved in bed with the use of a fracture-reducing device. How will the nurse place this device under the patient? a. Lift the patient to place the device directly under him or her b. Remove the draw sheet, and replace it with the device c. Sit the patient up in the bed, and place the device behind the shoulders. d. Roll the patient from side to side, and place the device under the draw sheet - Correct answer D 10. A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction- reducing device. The nurse will prepare for this move by assembling how many caregivers a. A minimum of 2 b. None, since the device does all the lifting during the move c. At least 3 d. The nurse can carry out this move without assistance - Correct answer C 11. When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? a. Apply therapeutic boots to the feet. b. Place sandbags along the legs c. Place a small pillow at the lumbar region of the back. d. Place a pillow under the calves. - Correct answer B 12. The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned? a. To position the pillows b. To ease the patient back onto the support pillows c. To keep the spine in alignment d. To roll the patient as a unit - Correct answer D 13. When positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs? a. To reduce the risk of a fall while the side rails are down b. To reduce the risk of contracture c. To control pain P a g e 2 | 39 27. The nurse has applied the SCD to a postoperative patient. The most appropriate way for the nurse to confirm proper fit is to do what? a. Ask the patient if the device is caused any pain b. Ensure that two fingers will fit between the patient's leg and the device c. Follow the manufacturer's instructions for the application of the device d. Ask another nurse to check the patients for proper application of the device - Correct answer B 28. The nurse is preparing to delegate the application of a SCD to nursing assistive personnel (NAP). Which statement by the NAP requires follow-up by the nurse? a. "I will check for a green light on the mechanical unit" b. "I will remove the SCD before ambulating the patient c. "I will tell you if I see any signs of itching, redness, or irritation on the patient’s legs" d. "I will measure the patient's legs to determine what size SCD sleeve to use" - Correct answer D 29. Why might a sequential compression device (SCD) be applied to the legs of an immobile patient? a. To stimulate circulation in the deep arterial vascular system b. To help prevent deep vein thrombosis (DVT) C. To aide peripheral circulation to reduce the risk of skin breakdown d. To assist in passive range-of-motion exercise of the patient's lower extremities - Correct answer B 30. While preparing to apply a SCD for a postoperative patient, the nurse realizes that which assessment observation contraindicates the application of the device? a. Have a low-grade fever b. Taking a prescribed anticoagulant c. Having dermatitis on the legs d. Wearing elastic stockings - Correct answer C 31. Which condition is not associated with venous stasis, part of Virchow's triad? a. Pregnancy b. Obesity c. Anxiety d. Immobility - Correct answer C 32. When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? a. To identify the potential risk of DVT b. To identify improper patient positioning c. To select the proper stocking size d. To determine whether a sequential compression device is needed - Correct answer A 33. After determining the proper size stocking and assessing the patient's circulatory status, a nurse delegates the application of elastic stockings to nursing assistive personnel (NAP). The nurse discovers that the NAP has been using moisturizer on the patient's legs before applying the stockings. What is the best action by the nurse? P a g e 5 | 39 a. Explain that moisturizer may cause excessive skin softening, which can lead to skin breakdown. b. Instruct NAP to use a small amount of cornstarch or powder c. Ask the patient if he or she is allergic to the moisturizer d. Inspect the patient's skin for color variations - Correct answer B 34. Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs? a. The patient will have a scheduled bath in a few hours. b. The patient says they are too tight. c. The patient's skin is irritated d. The patient has become fully ambulatory - Correct answer C 35. Why does the nurse remove the patient's elastic stockings at least once per shift? a. To permit the skin to breathe b. To wash the legs with a disposable bath product C. To air out the stockings and allow sweat to evaporate d. To check the skin for irritation or breakdown - Correct answer D 36. The nurse is performing passive shoulder and elbow exercises for a patient who is revering from surgery to remove a soft-tissue tumor in her upper arm. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercise? a. To keep the arm above the level of the heart b. To assess the patient's muscle tension c. To listen for crepitus in the joint d. To ensure stability while exercising the joint - Correct answer D 37. Which of the following are basic guidelines when assisting a patient with passive range of motion? a. Exercises should be continued until the point of fatigue and pain b. Exercises should be done frequently to lessen pain for the patient c. Each joint is exercised to the point of resistance but not pain d. Exercises should be performed without the support to each joint - Correct answer C 38. Why would the nurse as a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash? a. The patient is an older adult or has a chronic condition b. The patient is reluctant to perform the exercises because he is worried about reinjure c. The patient has orthopedic trauma d. The patient has pain exacerbated by exercise - Correct answer A 39. Which patient is most at risk of developing permanently impaired mobility? a. A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) b. A 55-year-old woman with mental illness who had become malnourished c. An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house P a g e 6 | 39 d. A 79-year-old man recovering from surgery to release a contracture of the connective tissue in her hand - Correct answer B 40. The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action? a. Move the joint through the full range of motion exercises b. Perform range of motion to the left elbow until resistance is met c. Omit all the range of motion exercises until the health care provider is notified d. Inform the health care provider that the patient is uncooperative with exercising. - Correct answer B 41. The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, "Enemas until clear." Which statement made by NAP requires the nurse to follow-up? a. "I'll need help to turn her onto her side" b. "It may take three or four enemas to achieve a clear return" c. "I'll test the water temperature on the inside of my own wrist." d. "The enema will wear her out, so I'll wait until after she ambulates." - Correct answer B 42. The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? a. Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube b. Place the patient in a side-lying position with the right knee flexed. c. Flush the tube with the solution. d. Hold the tube in the rectum until all of the fluid has been instilled. - Correct answer A 43. Which action would the nurse take to in ensure the safety of an older adult patient who has received an enemy? a. Assess for the presence of external hemorrhoids. b. Provide assistance to the bathroom for expulsion of fluid and stool. c. Document the patient's physical response to the enema. d. Instruct the patient to attempt to retain the fluid for 2 to 5 minutes. - Correct answer B 44. Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? a. Lubricate the tip of the rectal tube. b. Pad the patient's bed thoroughly c. Perform hand hygiene before donning globes d. Help the patient onto a bedpan to expel the enema fluid and stool - Correct answer C 45. The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up? a. "I'll warm up the solution before instilling it." b. "I'll place the patient in the left side-lying position with the right knee bent." c. "I'll put a waterproof pad under the patient before I start." d. "I'll instill the solution and then check in on my other patients until I get the call signal." - Correct answer D P a g e 7 | 39 58. Which statement best illustrates correct interpretation of a positive gastric occult blood test? a. "We don't need to retest the patient right now, because the sample turned green after about 60 seconds." b. "If the test sample turns blue, it is positive for blood." c. "The monitor area needs to turn blue within 30 seconds." d. "Because it was positive, I notified the patient's physician." - Correct answer B 59. Why might the nurse delegate to nursing assistive personnel (NAP) the skill of performing a gastric occult blood test for a patient who has vomited? a. The task is easy to demonstrate to NAP b. The likelihood of a positive result is minimal c. This skill may be delegated if performed on vomited stomach contents d. The agency transit NAP to perform only NG tube testing - Correct answer C 60. What is the initial step in preparing to perform a gastric occult blood test for a patient with recurrent vomiting? a. Determine the patient’s ability to help obtain the specimen b. Gather a gastro cult slide and developing solution c. Review the medications the patient is currently taking d. Perform hand hygiene, and apply treatment gloves. - Correct answer C A patient has consumed three 100-mL cups of ice chips and 4 ounces of ginger ale. What will nursing assistive personnel (NAP) document as this patient's oral intake? A. 120 mL B. 170 mL C. 220 mL D. 270 mL - Correct answer D 62. A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first? a. Supply a urine hat b. Explain to the patient why I&O has been ordered. c. Assess the patient's ability to self-monitor and record me&O. d. Provide the patient's family with instructions. - Correct answer B 63. A patient is admitted to your unit for dehydration. Which of the following assessments would the nurse identify as a possible sign of fluid imbalance? a. Heart rate at 80 beats per minute b. Capillary refill of less than 2 seconds c. Reduced turgor of the skin d. B/P of 118/78 mmHg - Correct answer C 64. Which statement reflects the nurse's understanding of the importance of accurate urinary output measurement for a patient with acute renal failure? a. "If the output begins to decrease, I will notify the physician immediately." b. "Increasing his fluid intake both orally and intravenously should boost his urine output." c. "I will use a collecting system with an hourly measurement device added." P a g e 10 | 39 d. "I will explain to the patient and family why I&O is being measured and recorded." - Correct answer C 65. What output will the nurse direct nursing assistive personnel (NAP) to measure for a hospitalized patient for whom I&O measurement is prescribed? a. Nasogastric tube drainage b. Chest tube drainage c. Urine collection drainage d. Ileostomy bag drainage - Correct answer C 66. Which statement made by a nurse best illustrates an understanding of the role of nursing assistive personnel (NAP) in administering a rectal suppository? a. "Find out whether the patient is capable of inserting the suppository" b. "Please tell the patient to report if any rectal bleeding occurs." c. "Be sure to let me know if the patient has a bowel movement." d. "Remember to lubricate the suppository." - Correct answer C 67. After administering a rectal suppository for constipation, the nurse will monitor for all of the following responses except which one? a. Low platelet count b. Rectal pain c. Bradycardia d. Evacuation of stool - Correct answer A 68. A female nurse is preparing to administer a rectal suppository to a male patient. The patient says, "This is so embarrassing. Is this really necessary?" What is the most appropriate response? a. "I can see if the doctor with order an oral medication" b. "How about if I show you how to insert the suppository yourself?" c. "I will make sure that you are well covered. I promise." d. "This will make you feel so much better." - Correct answer B 69. The nurse is preparing to administer a rectal suppository to an elderly patient. Which step best protects the patient's safety? a. Ask the patient to take deep, slow breaths as the suppository is being inserted. b. Insert the suppository 2 inches into the rectum. c. Place the patient in the left side-lying position with the top leg flexed. d. Instruct the patient to use the call light for assistance to the bathroom - Correct answer D 70. The nurse should question a provider's order to insert a suppository into the rectum of a patient with which condition? a. Watery diarrhea b. Rectal inflammation c. External hemorrhoids d. Internal hemorrhoids - Correct answer A 71. What instruction might the nurse give to nursing assistive personnel (NAP) regarding postoperative exercises? P a g e 11 | 39 a. "Find out if the patient has any language barriers." b. "Let me know when the patient actually begins exercising." c. "Please review a copy of the preoperative literature with the patient." d. "Assess the method of learning the patient would prefer." - Correct answer B 72. The nurse is concerned that a patient will not be able to turn independently in bed after having surgery. What must the nurse do to help this patient? a. Reinstruct the patient in proper turning techniques. b. Document that the patient refuses to turn independently. c. Communicate that the staff must turn the patient after surgery. D. Restrict turning unless absolutely necessary. - Correct answer C 73. Why might a nurse teach a patient scheduled for surgery how to do postoperative exercises? a. To maximize a sense of well-being b. To minimize postoperative complications c. To identify cultural factors that reflect the patient's perception of pain d. To evaluate the patient's ability to participate in postoperative activities - Correct answer B 74. Before teaching a patient postsurgical exercises, the nurse premeditates the patient for pain. What benefit does this have specific to the patient's learning? a. Reduced pain b. Improved focus c. Decreased relaxation d. Decreased irritability - Correct answer B 75. Which instruction might a nurse give a patient in order to protect a surgical incision when turning in bed? a. Hold your breath when turning. b. Use a pillow to splint the incision. c. Take pain medication 30 minutes before turning. d. Keep both legs straight when turning. - Correct answer B 76. What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? a. Ask another nurse to attempt the insertion. b. Document the attempts in the patient's medical record. c. Notify the physician that the attempts were unsuccessful. d. Allow the patient to rest for 30 minutes before resuming the process. - Correct answer C 77. What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? a. Examine each naris for patency and skin breakdown. b. Place the patient in the high-Fowler's position. c. Anesthetize the throat. d. Have the patient take a few sips of water. - Correct answer A P a g e 12 | 39 c. Avoiding unnecessary changes of the pouching system d. Wearing clean gloves - Correct answer C 92. Which initial nursing action would best help the patient learn self-care of a colostomy pouching system? a. Giving the patient handouts on self-care of a colostomy b. Allowing the patient to examine a stormy device c. Identifying a family member who can participate in the stormy appliance process d. Giving the patient a mirror to watch the nurse provide care - Correct answer D 93. What is the nurse's initial action when preparing to change a patient's colostomy pouching system? a. Applying clean gloves b. Draping the patient appropriately c. Emptying the colostomy d. Assessing the surrounding skin for signs of irritation. - Correct answer A 94. Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy? a. "Be sure to pat-dry the skin surrounding the stoma before applying the new pouch." b. "Alert me immediately if you see any blood in the fecal matter in the pouch." c. "Using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the stoma." d. "Remember to change your gloves after cleaning the stoma and the surrounding skin." - Correct answer B 95. When pouching a patient's colostomy, which action reduces the patient's risk for injury? a. Measuring output when emptying the contents of the pouch b. Maintaining the patient's bowel elimination function c. Promoting the patient's autonomy with bowel elimination care d. Protecting the skin from irritation caused by fecal drainage - Correct answer D 96. After unsuccessfully attempting to flush a nasogastric (NG) tube with water, what is the most appropriate action for the nurse to take? a. Flush the tube with ginger ale. b. Use apple juice to flush the tube. c. Obtain a product designed to unclog NG tubes. d. Force-flush the system with sterile normal saline - Correct answer C 97. How could the nurse assess the patency of a nasogastric (NG) tube being used for enteral nutrition? a. Elevate the head of the patient's bed to at least 30 degrees. b. Use an intravenous fluid infusion set. c. Check the gastric residual volume. d. Monitor the amount of intake the patient tolerates in an 8-hour period. - Correct answer C P a g e 15 | 39 98. What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr.? a. Recalculate the present drip factor for accuracy. b. Terminate the fluid, and prepare to hang a new bag of formula. c. Plan to check the feeding for completion within the next 3 hours. d. Check with the pharmacy to see if the formula has been hanging too long. - Correct answer C 99. Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? a. Elevating the head of the bed reduces the risk for aspiration. b. Proper elevation of the head of the bed promotes the patient's digestion. c. Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. d. Nutrients are absorbed more efficiently when the head of the bed is elevated. - Correct answer A 100. Which nursing action is appropriate when feeding gastric residual is 50 mL? a. Return it to the stomach via the feeding tube. b. Dispose of the residual contents down the commode. c. Discard the stomach contents as a liquid biohazard. d. Return half of the volume to the stomach, and discard the rest - Correct answer A 101. What would the nurse do first when preparing to begin oxygen therapy for a patient? a. Educate the NAP about the oxygen orders. b. Review the medical prescription for delivery method and flow rate. c. Place a "No Smoking" sign outside of the hospital room. d. Ensure that suction equipment is present in the room. - Correct answer B 102. When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? a. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room. b. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. c. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. d. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method. - Correct answer C 103. Which statement by the patient would indicate that he or she understands the safe use of oxygen? a. "The nurse told me that my oxygen saturation must be maintained at 85% or above." b. "I know that oxygen is a medication I can adjust whenever I need to." c. "I'll alert the nurse immediately if I have any increased difficulty breathing." d. "I often experience difficulty breathing for no apparent reason, but that is expected." - Correct answer C 104. When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? P a g e 16 | 39 a. Increase the oxygen level as needed for the patient's comfort. b. Store extra oxygen cylinders horizontally. c. Place a "No Smoking" sign at the entrance to the house. d. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark. - Correct answer C 105. What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? a. Evaluate the patient's understanding of the combustible nature of oxygen. b. Arrange for a capable family member to be present during the initial discussion. c. Collect written information to present to the patient as supplemental instructional materials. d. Assess the patient's emotional readiness and physical ability to provide autonomous care. - Correct answer D 106. The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in expanding the affected lung? a. Placing the patient in a right side-lying position b. Encouraging the patient to deep breathe and cough every hour c. Regularly assessing the patient's ability to breathe comfortably d. Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale - Correct answer A 107. What would the nurse do first to ease breathing for a patient with mild dyspnea? a. Administer oxygen at 2 L/min by nasal cannula. b. Help the patient into an upright sitting position. c. Monitor the patient's pulse oximetry level. d. Determine if the patient has a history of respiratory pathology. - Correct answer B 108. During an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? a. Notify the health care provider of the patient's complaint. b. Request that the health care provider prescribe oxygen therapy. c. Interview the patient concerning the onset of this problem. d. Instruct the patient to use two bed pillows when lying supine - Correct answer D 109. What is the purpose of splinting the abdomen with a small pillow during controlled coughing? a. To minimize chest discomfort caused by the coughing b. To expand lung capacity during the inspiratory phase of the cough c. To maximize Trans diaphragmatic pressure during the expiratory phase of the cough d. To focus the patient's attention on the abdominal muscles used during the cough - Correct answer C 110. What would the nurse do routinely to monitor oxygenation in a patient receiving Bopp? a. Assess the patient's level of consciousness every 4 hours. b. Monitor the patient's pulse oximetry readings. P a g e 17 | 39 Match the definition with the term: 1. Isometric exercises 2. Friction 3. Resistive isometric exercises 4. Shear A. Those in which an individual contracts the muscle while pushing against a stationary object or resisting the movement of an object B. Tightening or tensing muscles without moving body parts C. A force that occurs in a direction to oppose movement D. The force exerted against the skin while the skin remains stationary and the bony structures move - Correct answer 1. B 2. C 3. A 4. D In order to maintain proper body alignment and posture you must: (select all that apply) -Bend at the hips and lift using the muscles in your back for added support -Widen the base of support by separating the feet to a comfortable distance -Ensure the bed is at its lowest to prevent the risk of falls -Increase balance by bringing the center of gravity closer to the base of support - Correct answer -Widen the base of support by separating the feet to a comfortable distance -Increase balance by bringing the center of gravity closer to the base of support You are teaching your patient with decreased mobility to the right leg how to use a cane. Which action indicates proper cane use by the patient? The patient keeps the cane on the right side of the body The patient slightly leans to one side while walking The patient keeps two points of support on the floor at all times. After the patient places the cane forward, he or she then moves the left leg forward to the cane - Correct answer the patient keeps two points of support on the floor at all times. A nursing assistive personnel asks for help to transfer a patient who is 125 Ibis (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response? "The two of us can lift the patient easily." "Call the lift team for additional assistance." P a g e 20 | 39 "As long as we use proper body mechanics, no one will get hurt." "The patient only weighs 125 Ibis, You don't need my assistance.” - Correct answer "Call the lift team for additional assistance." In order to maintain proper body alignment and posture you must: (Select all that apply) Ensure the bed is at its lowest to prevent the risk of falls Increase balance by bringing the center of gravity closer to the base of support Widen the base of support by separating the feet to a comfortable distance Bend at the hips and lift using the muscles in your back for added support - Correct answer Increase balance by bringing the center of gravity closer to the base of support Widen the base of support by separating the feet to a comfortable distance Fill in the blanks by typing your responses in the text box below: Current evidence shows that many nurses frequently transfer to different positions and leave the profession because of __ (A) ___. Implementing evidence-based interventions and programs reduces the number of ___ (B) ___, which improves the health of the nurse and reduces ____(C) ___ to the health care agency. - Correct answer A) Work-related injuries B) Work-related injuries C) Indirect costs You are assisting a toddler during ambulation. You notice that as he walks, his legs and feet are far apart and slightly averted. You recognize that this: May be corrected with isometric exercises Is a sign of likely a result of underdeveloped muscle tone, requiring aggressive physical therapy? Is normal in toddlers Is usually seen in older adults - Correct answer is normal in toddlers You are transferring a patient from the bed to the chair. In order to prevent abnormal twisting of the spine you should: Face the direction of movement Align your body towards the chair and away from the patient before you begin to lift. Maintain a narrow base of support to allow for greater stability P a g e 21 | 39 Avoid using antigravity muscles while lifting - Correct answer Face the direction of movement Mr. Doe has a nasogastric (NGT) tube and is receiving enteral nutrition and reports he is constipated, what intervention would most likely help? Add water flushes Increasing the rate of the tube feeds Adding protein to the formula Decreasing the rate of the tube feed - Correct answer Add water flushes What important intervention must be done to alleviate diarrhea in a patient receiving enteral feedings? Administer antibiotic per M.D. order Fill the bag all the way to the top Do nothing it is normal to have diarrhea when receiving enteral feedings Avoid contamination of formula by changing the feeding bag every 24 hours - Correct answer Avoid contamination of formula by changing the feeding bag every 24 hours A colostomy or ileostomy stoma should be all the following except. Black Red Moist Pink - Correct answer Black Mrs. Doe a confused patient has a nasogastric (NGT) tube and is receiving enteral nutrition, you notice that she starts to have respiratory distress. What could be the reason for respiratory distress? Electrolyte imbalance NGT tube displacement Dehydration Occlusion of NGT tube - Correct answer NGT tube displacement P a g e 22 | 39 A patient's gastric residual volume was 250 ml at 0800 and 350 ml at 0900. What is the appropriate nursing action? Do no reinstall aspirate and hold the feeding until you talk to the primary care provider Raise the head of the bed to at least 45 degrees Assess bowel sounds Position the patient on his or her tight side to promote stomach emptying - Correct answer do no reinstall aspirate and hold the feeding until you talk to the primary care provider A colostomy pouch should be changed every Every 3 to 7 days Other day Once a month Every day - Correct answer every 3 to 7 days During the administration of an enema a patient reports abdominal cramping, what do you need to do? Stop the installation Ask the patient to take deep breaths to decrease the pain Add soap suds to the enema Tell the patient to bear down Ask the patient to take deep breaths to decrease the pain - Correct answer Stop the installation In what position, should the patient be for the insertion of a nasogastric tube? High fowlers At 30 degrees Lateral Supine - Correct answer High fowlers What is the gold standard to confirm NGT tube placement? P a g e 25 | 39 Oxygen saturation X-ray PH Gastric residuals - Correct answer X-ray In what part of the digestive system is where nutrients are absorbed? Stomach Colon Pancreas Small intestine - Correct answer Small intestine When performing a guaiac fecal occult blood test, the stool samples are: Placed on all over the guaiac (card) Taken from the same area of the stool sample Placed in only one small box of the guaiac (card) paper Placed in both small boxes of the guaiac (card) test paper - Correct answer placed in both small boxes of the guaiac (card) test paper The effluent from an ileostomy is: Type 1 like pebbles Clear in color Solid Different from that of a colostomy - Correct answer Different from that of a colostomy Cleansing enemas help with _____________. Dyspepsia Flatulence Increase appetite Complete evacuation of feces - Correct answer complete evacuation of feces P a g e 26 | 39 Enteral nutrition is indicated for what condition? Small bowel resection Intestinal obstruction Extended bowel rest Cerebrovascular accident - Correct answer Cerebrovascular accident 1. A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: a. Decreased peristalsis b. Decreased heart rate c. Increased blood pressure D. Increased urinary output - Correct answer A 2. A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? a. Encouraging use of an overhead trapeze for positioning and transfer. b. Frequent family visits c. Assisting the patient to a wheelchair once per day d. Ensuring that there is an order for physical therapy - Correct answer A 3. An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? a. Loss of appetite b. Gum soreness c. Difficulty swallowing d. Left-ankle joint stiffness - Correct answer D 4. The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? a. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert b. Hot dog on whole wheat bun with a side salad and an apple for dessert c. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert d. Turkey salad on toast with tomato and lettuce and honey bun for dessert - Correct answer A 5. A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: a. Myoclonus b. Pathological fractures c. Pressure ulcers d. Pruritus - Correct answer C P a g e 27 | 39 c. Two-point d. Swing-through - Correct answer A 17. Which of the following most motivates a patient to participate in an exercise program? a. Providing a patient with a pamphlet on exercise b. Providing information to the patient when he or she is ready to change behavior c. Explaining the importance of exercise at the time of diagnosis of a chronic disease d. Providing the patient with a booklet with examples of exercises e. Providing the patient with a prescribed exercise program - Correct answer B 18. The nurse recognizes that the older adult's progressive loss of total bone mass and tendency to take smaller steps with feet kept closer together will most likely: a. Increase the patient's risk for falls and injuries. b. Result in less stress on the patient's joints. c. Decrease the amount of work required for patient movement. d. Allow for mobility in spite of the aging effects on the patient's joints. - Correct answer A 19. A nurse assistive personnel asks for help to transfer a patient who is 125 lbs. (56.8 kg) from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response? a. "As long as we use proper body mechanics, no one will get hurt." b. "The patient only weighs 125 lbs. You don't need my assistance." c. "Call the lift team for additional assistance." d. "The two of us can lift the patient easily." - Correct answer C Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age? a. "You are never too old to begin an exercise program." b. "My granddaughter and I walk together around the high school track 3 times a week." c. "I purchased a subscription to a runner's magazine for my grandson for Christmas." d. "When I was a child, I exercised more than I see kids doing today." - Correct answer B 21. Which is the correct gait when a patient is ascending stairs on crutches? a. A modified two-point gait (The affected leg is advanced between the crutches to the stairs.) b. A modified three-point gait (The unaffected leg is advanced between the crutches to the stairs.) c. A swing-through gait d. A modified four-point gain. (Both legs advance between the crutches to the stairs.) - Correct answer B 22. A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient? A. Two-point gait B. Three-point gait C. Four-point gait d. Swing-through gait - Correct answer B P a g e 30 | 39 23. Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? a. The patient is 5 feet 6 inches and weighs 120 lbs. b. The patient speaks and understands English. c. The patient received an injection of morphine 30 minutes ago for pain. d. You feel comfortable handling a patient of this size and level of cooperation - Correct answer C 24. The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's: a. Gastric motility, thereby facilitating glucose digestion. b. Respiratory effort, thereby decreasing activity intolerance. c. Overall cardiac output, thereby resuming resting heart rate d. Use of glucose and fatty acids, thereby decreasing blood glucose level. - Correct answer D 25. Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. To reduce the risk for these injuries, the American Nurses Association is advocating which of the following? a. Mandate that physical therapists do all patient transfers b. Require adequate staffing levels in health care organizations c. Require the use of assistive equipment and devices d. Require an adequate number of staff to be involved in all patient transfers - Correct answer C 26. The body alignment of the patient in the tripod position includes the following: (Select all that apply.) a. An erect head and neck b. Straight vertebrae c. Extended hips and knees d. Axillae resting on the crutch pads E. Bent knees and hips - Correct answer A, B, C 27. Which of the following is a principle of proper body mechanics when lifting or carrying objects? (Select all that apply.) a. Keep the knees in a locked position. b. Bend at the waist to maintain a center of gravity. c. Maintain a wide base of support. d. Hold objects away from the body for improved leverage. e. Encourage patient to help as much as possible. - Correct answer C, E 28. Before transferring a patient from the bed to a stretcher, which assessment data do the nurse need to gather? (Select all that apply.) a. Patient's weight b. Patient's level of cooperation c. Patient's ability to assist d. Presence of medical equipment e. Nutritional intake - Correct answer A, B, C, D P a g e 31 | 39 29. Which of the following diagnosis is a patient who started smoking in adolescence and continues to smoke for 40 years at this risk for? a. Alcoholism and hypertension b. Obesity and diabetes c. Stress-related illnesses d. Cardiopulmonary disease and lung cancer - Correct answer C 30. A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation? a. Increased breathlessness but increased activity tolerance b. Decreased breathlessness and decreased activity tolerance c. Increased activity tolerance and decreased breathlessness d. Decreased activity tolerance and increased breathlessness - Correct answer D 31. A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though her color is ruddy not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon Monoxide does which of the following: a. Stimulates hyperventilation causing respiratory alkalosis b. Forms a strong bond with hemoglobin thus preventing oxygen binding in the lungs c. Stimulates hypoventilation causing respiratory acidosis d. Causes alveoli to overinflate leading to atelectasis - Correct answer B 32. An 86 year old woman is admitted to the unit with chills and a fever of 104 degrees F. What physiological process explains why she is at risk for dyspnea? a. Fever increases metabolic demands requiring increased oxygen need. b. Blood glucose stores are depleted and the cells do not have energy to use oxygen. c. Carbon dioxide production increases due to hyperventilation. d. Carbon dioxide production decreases due to hypoventilation - Correct answer A 33. A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? a. Sonorous wheezes in the left lower lung b. Rhonchi mid sternum c. Crackles only in apex of lungs d. Inspiratory crackles in lung bases - Correct answer D 34. The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? a. Antibiotics b. Frequent change of position c. Oxygen humidification d. Chest physiotherapy - Correct answer B 35. A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? a. Coughing up thick sputum only occasionally P a g e 32 | 39 47. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? a. When 25% of the patient's nutritional needs are met by the tube feedings b. When bowel sounds return c. When central line has been in for 10 days d. When 75% of the patient's nutritional needs are met by the tube feedings - Correct answer D 48. The nurse is inserting a small-bore mesenteric tube before starting enteral feedings. What is the correct order of steps to perform this procedure? a. 1. Place patient in high-Fowler's position. b. 2. Have patient flex head toward chest. c. 3. Assess patient's gag reflex. d. 4. Determine length of the tube to be inserted. e. 5. Obtain radiological confirmation of tube placement. f. 6. Check pH of gastric aspirate for verifying placement. g. 7. Identify patient with two identifiers. I. 7, 1, 3, 4, 2, 5, 6 ii. 1, 3, 4, 7, 2, 6, 5 iii. 7, 1, 3, 2, 4, 6, 5 iv. 1, 7, 3, 2, 4, 5, 6 - Correct answer I 49. A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 1200. What is the appropriate nursing action? a. Assess bowel sounds b. Raise the head of the bed to at least 45 degrees c. Position the patient on his or her right side to promote stomach emptying d. Do not reinstall aspirate and hold the feeding until you talk to the primary care provider - Correct answer D 50. The patient's blood glucose level is 330 mg/LD. What is the priority nursing intervention? a. Recheck by performing another blood glucose test. b. Call the primary health care provider. c. Check the medical record to see if there is a medication order for abnormal glucose levels. d. Monitor and recheck in 2 hours. - Correct answer C 51. Which statement made by a patient of a 2-month-old infant requires further education? a. I'll continue to use formula for the baby until he is a 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. - Correct answer D 52. The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? a. Fastening tube to the gown with new tape P a g e 35 | 39 b. Placing patient supine while giving a bath c. Hanging a new container of enteral feeding d. Ambulating patient with enteral feedings still infusing - Correct answer B 53. A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? a. Institute isolation precautions b. Clean the central line port through which the TPN is infusing with alcohol c. Change the TPN tubing every 24 hours d. Monitor glucose levels to watch and assess for glucose intolerance - Correct answer B 54. The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: (Select all that apply.) a. Heart disease. b. Sepsis. c. Pleural effusion. d. Cardiac arrhythmias. e. Diarrhea. - Correct answer B, C.D 55. The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to include? (Select all that apply.) a. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids. b. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection. c. The fat emulsion will help control hyperglycemia during periods of stress. d. The parenteral nutrition will help your wounds heal. e. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours. - Correct answer A, C, D 56. The nurse would delegate which of the following to nursing assistive personnel (NAP)? (Select all that apply.) a. Repositioning and reaping a patient's nasogastric tube b. Performing glucose monitoring every 6 hours on a patient c. Documenting PO intake on a patient who is on a calorie count for 72 hours d. Administering enteral feeding bolus after tube placement has been verified E. Hanging a new bag of enteral feeding - Correct answer B, C 57. The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) a. Avoid grapefruit and grapefruit juice, which impair drug absorption. b. Increase the amount of carbohydrates for energy. c. Take a multivitamin that includes vitamin D for bone health. d. Cheese and eggs are good sources of protein. e. Limit fluids to decrease the risk of edema - Correct answer A, C, D P a g e 36 | 39 58. Which patients are at high risk for nutritional deficits? (Select all that apply.) a. The divorced computer programmer who eats precooked food from the local restaurant b. The middle-age female with celiac disease who does not follow her gluten-free diet c. The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly d. The 25-year-old patient with Cohn’s disease who follows a strict diet but does not take vitamins or iron supplements e. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal - Correct answer B, D 59. The nurse should do which of the following when placing a bedpan under an immobilized patient? 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 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 - Correct answer B 60. A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what should the nurse suspect? a. An intestinal obstruction b. Irritation of the intestinal mucosa c. Gastroenteritis d. A fecal impaction - Correct answer A 61. During the administration of a warm tap-water enema, the patient complains of cramping abdominal pain that he rates 6 out of 10. What is the first thing the nurse should do? a. Stop the instillation b. Ask the patient to take deep breaths to decrease the pain c. Add soapsuds to the enema d. Tell the patient to bear down as he would when having a bowel movement - Correct answer A 62. The nurse is teaching the patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? a. Three fecal smears from one bowel movement b. One fecal smear from an early-morning bowel movement c. One fecal smear from three separate bowel movements d. Three fecal smears when blood can be seen in the bowel movement - Correct answer C 63. When a patient has fecal incontinence as a result of cognitive impairment, it may be helpful to teach caregivers to do which of the following interventions? a. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks b. Use diapers and heavy padding on the bed P a g e 37 | 39