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

Download NURS 220 Exam 2 Video Questions, Evolve quiz questions, and prep work quiz questions and v and more Exams Sociology of Work and Employment 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 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 drawsheet, 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 drawsheet - 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 25. The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? a. 4 b. 2 c. 1 d. none - Correct answer B 26. When preparing to delegate the application of the SCD to NAP, the nurse must do what first? a. Ask the NAP to demonstrate the proper application of the SCD. b. Assess the patient's lower extremities for signs and symptoms of impaired circulation c. Assess the patient's need for a SCD d. Explain that the device is not to be removed - Correct answer B 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 patients 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 ot 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 nruse? 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 reinjury 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 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 d. Instruct him to use the call light when he is finished - Correct answer A 55. The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, "I'll call you when I'm done." What is the nurse's best response? a. "All right, my name is Robin, and I'll be right across the hall. Just call me when you're finished" b. "Fine. Recap the urinal, hang it on your side rail, and use your call light toilet me know you're finished." c. "I'll check on you as soon as I get a chance." d. "I'll be back in 15 minutes. That should be enough time for you to finish up." - Correct answer B 56. Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) is carrying out a gastric occult blood test for a patient with a low hemoglobin and hematocrit? a. "Have you used the new Gastroccult testing system?" b. "The next time the patient vomits, please test it for occult blood." c. "Is the patient capable of assisting with the specimen collection?" d. "Remember to tell me the results of the test immediately." - Correct answer B 57. Which nursing action addresses the risk for infection related to gastric occult blood testing? a. Maintaining aseptic techniques while handling the Gastroccult slide b. Perform the test in the patient's bathroom c. Assessing the patient's history of previous gastrointestinal (GI) bleeding d. Ensuring appropriate hand hygiene before and after testing - Correct answer D 58. Which statemtn best illustrates correct interpretation of a postitive 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 transin 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 patients ability to help obtain the specimen b. Gather a gastroccult 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 I&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 collectin system with an hourly measurement device added." 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 isso 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? 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 d. Pull back on the tube - Correct answer C 86. What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? a. Arterial blood gas (ABG) levels b. Oxygen flow meter setting c. Respiratory rate d. Temperature - Correct answer B 87. What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? a. Encourage oral fluids. b. Restrict fluids. c. Ensure that humidification is present. d. Measure blood pressure every hour - Correct answer C 88. Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? a. To provide the correct amount of oxygen to the patient b. To ensure the therapeutic effects of oxygen therapy c. To prevent any adverse reaction to the prescribed oxygen therapy d. To minimize the risk of combustion during oxygen delivery - Correct answer A 89. What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? a. Regularly measure and trend the patient's pulse oximetry (SpO2) values. b. Evaluate venous blood levels every morning. c. Monitor the patient's arterial blood gas (ABG) levels hourly. d. Assess the patient for compliance with the prescribed therapy. - Correct answer A 90. What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? a. Advising the patient to call for assistance before getting out of bed. b. Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed. c. Observing the six rights of medication administration. d. Monitoring the patient for signs of hypoxia. - Correct answer C 91. When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma? a. Using adhesive remover b. Emptying the ostomy bag only when full 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 an ostomy device c. Identifying a family member who can participate in the ostomy 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 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." Early ambulation Skin integrity - Correct answer Venous return The individual of average weight and height without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of _____ % a day. - Correct answer Three The provider has ordered for you to teach Mr. Jones ROM exercises to the left elbow. Describe how you would instruct him to perform flexion and extension ROM exercises. - Correct answer Flexion: Go ahead and bend your elbow forward so that your arm moves toward the shoulder joint and your hand becomes level with your shoulder. Extension: Lower your hand to be able to straighten your arm Select all that apply: Loss of walking independence causes what? -Leads to less injuries -Increases hospital stays -Increases the need for rehabilitation services or nursing home placement -Promotes quicker recovery - Correct answer Increases hospital stays Increases the need for rehabilitation services or nursing home placement __________________ describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting of a body part, or local nerve damage. - Correct answer Disuse atrophy Immobilized patients with a history of ___________ osteoporosis are at high risk for accelerated bone loss. - Correct answer primary When assisting a patient with standing following a prolonged period of bed rest, what physical response should the nurse be most prepared to assess? Steadiness of gait Dependent edema Respiratory rate Orthostatic hypotension - Correct answer Orthostatic hypotension Match the relationship 1.Calcium resorption 2.Endocrine system 3.Tissue catabolism 4.GI distrubances such as decreased appetite and slowing of peristalsis 5.Virchow's triad A. Weight loss, decreased muscle mass, and weakness B. Constipation or pseudodiarrhea. Dehydration, ceased absorption, and fluid and electrolytes C. Helps regulate through maintenance of sodium, potassium, water, and acid-base balance. D. Pathological fractures E. damage to the vessel wall, alterations in blood flow, and alterations in blood constituents - Correct answer 1.D 2.C. 3.A. 4.B 5.E 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 Ibs (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." "As long as we use proper body mechanics, no one will get hurt." "The patient only weighs 125 Ibs, 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 -help prevent odor -Protect the skin from effluent -Allow for the pouch to stay on more than expected -Help with charting input and output - Correct answer -Protect the skin from effluent What is the proper way to measure the length of NGT to be inserted? -from the inner canthus of the eye to the nose and then to the xiphoid process -From the tip of the nose to earlobe and then to the xiphoid process -From the xiphoid process to the earlobe to the tip of the nose -from the earlobe to the tip of the nose and then to the xiphoid process - Correct answer -From the tip of the nose to the earlobe and then to the xiphoid process You are checking the pH of gastric aspirate for a patient that is receiving enteral feeding. What should be the result of the pH? -1.3 -2.5 -8.0 -5.0 or higher - Correct answer -5.0 of higher In what position should a patient be when receiving an enema? -fowlers -reverse trendelenburg -Sims, laying on the left with right knee flexed -supine - Correct answer -Sims, laying on the left with right knee flexed The nurse sees the nursing assistive personnel perform the following for a patient receiving continuous enteral tube feedings. What intervention does the nurse need to address immediately? Fastens the tube to the gown with tape : elevates the head of the bed 45° Places the patient supine while giving a bath Fastens the tube to the gown with tape Performs oral are for the patient - Correct answer Places the patient supine while giving a bath What are some signs and symptoms that may put a patient at risk for malnutrition? Flatulenced Shortness of breath Enteral feedings Dysphagiac - Correct answer Dysphagiac A patient with fecal incontinence is at risk for what? Allergies Decrease water intake Constipation Impaired skin integrity - Correct answer Impaired Skin integrity Pouches should be emptied when they are one-third or half full because of what complication? The weight of the pouch may disrupt the seal and cause leaks No complication will happen Rupture of bag The need for another ostom - Correct answer The weight of the pouch may disrupt the seal and cause leaks 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? 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 8. What is the correct order in which elastic stockings should be applied? a. Identify patient using two identifiers. b. Smooth any creases or wrinkles. c. Slide the remainder of the stocking over the patient's heel and up the leg d. Turn the stocking inside out until heel is reached. e. Assess the condition of the patient's skin and circulation of the legs. f. Place toes into foot of the stocking. g. Use tape measure to measure patient's legs to determine proper stocking size. i. 1, 5, 7, 4, 6, 2, 3 ii. 1, 7, 5, 4, 6, 2, 3 iii. 1, 5, 7, 4, 6, 3, 2 iv. 1, 5, 4, 7, 6, 3, 2 - Correct answer iii 9. Which of the following are physiological outcomes of immobility? a. Increased metabolism b. Reduced cardiac workload c. Decreased lung expansion d. Decreased oxygen demand - Correct answer C 10. An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) a. B/P = 128/84 b. Respirations 26/min on room air c. HR 114 d. Crackles over lower lobes heard on auscultation e. Pain reported as 3 on scale of 0 to 10 after medication - Correct answer B,C,D 11. A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) a. "I usually go swimming with my family at the YMCA 3 times a week." b. "I need to ask my doctor if I should have a bone mineral density check this year." c. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." d. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." e. "My lactose intolerance should not be a concern when considering my calcium intake." - Correct answer A,B,C 12. A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) a. Bruising b. Pale yellow urine c. Bleeding gums d. Coffee ground-like vomitus e. Light brown stool - Correct answer A,C,D 13. The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) a. Initial patient measurement is made around the calves b. Inflation pressure averages 40 mm Hg c. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. d. Stockings are removed every 2 hours during application. e. Yellow light indicates SCD device is functioning. - Correct answer B,C 14. The effects of immobility on the cardiac system include which of the following? (Select all that apply.) a. Thrombus formation b. Increased cardiac workload c. Weak peripheral pulses d. Irregular heartbeat e. Orthostatic hypotension - Correct answer A,B,E 15. A nurse is instructing a patient who has decreased leg strength on the left side how to use a cane. Which action indicates proper cane use by the patient? a. The patient keeps the cane on the left side of the body. b. The patient slightly leans to one side while walking. c. The patient keeps two points of support on the floor at all times. d. After the patient places the cane forward, he or she then moves the right leg forward to the cane. - Correct answer C 16. A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use? a. Four-point b. Three-point 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 gait. (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 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. 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 b. Coughing up thin, watery sputum after nebulization c. Decreased ability to clear airway through couching d. Lung sounds clear only after coughing - Correct answer C 36. A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? a. "I'll make sure that I rest between activities so I don't get so short of breath." b. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." c. "If I have trouble breathing at night, I'll use two to three pillows to prop up." d. "If I get short of breath, I'll turn up my oxygen level to 6 L/min." - Correct answer D 37. The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action? a. Raise the head of the bed to 60 degrees or higher. b. Get his oxygen saturation with a pulse oximeter. c. Take his blood pressure and respiratory rate. d. Notify the health care provider of his shortness of breath. - Correct answer A 38. Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? a. Record the amount and continue to monitor drainage. b. Notify the physician. c. Strip the chest tube starting at the chest d. Increase the suction by 10 mm Hg - Correct answer A 39. The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: a. Palpable, elevated hardened area around a tuberculosis skin testing site. b. Sputum for culture and sensitivity identifies mycobacterium tuberculosis c. Presence of acid fast bacilli in sputum d. Arterial oxygen tension (PaO2) of 95 mmHg - Correct answer D 40. What is the correct sequence for suctioning a patient? a. 1. Open kit and basin. b. 2. Apply gloves. c. 3. Lubricate catheter. d. 4. Verify functioning of suction device and pressure e. 5. Connect suctioning tubing to suction catheter. f. 6. Increase supplemental oxygen. g. 7. Reapply oxygen. h. 8. Suction airway i. 6, 4, 3, 1, 2, 5, 8, 7 ii. 4, 6, 1, 2, 3, 8, 5, 7 iii. 4, 6, 1, 3, 2, 5, 8, 7 iv. 6, 4, 1, 3, 2, 5, 7, 8 - Correct answer iii 41. A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). a. Sharp pleuritic pain that worsens on inspiration b. Crackles over lung bases of affected lung c. Tracheal deviation toward the affected lung d. Worsening dyspnea e. Absent lung sounds to auscultation on affected side - Correct answer A,D,E 42. The nurse is caring for a patient who exhibits labored breathing, using accessory muscles, and is coughing up pink frothy sputum. The patient has bilateral lung bases and diminished breath sounds. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.) a. SpO2 levels b. Amount, color and consistency of sputum production c. Fluid status d. Change in respiratory rate and pattern e. Pain in lower leg - Correct answer A,B,D 43. Which of the following skills can be delegated to nursing assistive personnel (NAP)? (Select all that apply.) a. Nasotracheal suctioning b. Oropharyngeal suctioning of a stable patient c. Suctioning a new artificial airway d. Permanent tracheostomy tube suctioning e. Care of an endotracheal tube (ETT) - Correct answer B 44. The nurse evaluates which laboratory values to assess a patient's potential for wound healing? a. Fluid status b. Potassium c. Lipids d. Nitrogen balance - Correct answer D 45. The nurse is caring for a patient 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 their side c. Put on oxygen at 2-L nasal cannula d. Stop feeding her and place on NPO - Correct answer A 46. A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? a. Have the patient perform a Valsalva procedure 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 - Correct answer A 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 nasoenteric 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/dL. 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 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 c. Initiate bowel or habit training program to promote continence d. Help the patient to toilet once every hour - Correct answer C 64. During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with what problem? a. Food allergy b. Irritable bowel c. Increased peristalsis d. Lactose intolerance - Correct answer D 65. The nurse is caring for a patient with an ileostomy. Which intervention is most important? a. Cleansing the stoma with hot water b. Inserting a deodorant tablet in the stoma bag c. Selecting or cutting a pouch with an appropriate-size stoma opening d. Wearing sterile gloves while caring for the stoma - Correct answer C 66. The nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? a. Have you eaten more high-fiber foods lately? b. Are your bowel movements soft and formed? c. Have you experienced frequent, small liquid stools recently? d. Have you taken antibiotics recently? - Correct answer C 67. An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? a. Malnutrition b. Dehydration c. Skin breakdown d. Incontinence - Correct answer B 68. What is the correct order for an ostomy pouch change? 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin. a. 5, 8, 2, 7, 3, 6, 4, 1 b. 8, 5, 6, 2, 7, 3, 4, 1 c. 8, 5, 7, 6, 2, 3, 4, 1 d. 5, 8, 7, 2, 6, 3, 4, 1 - Correct answer D 69. Match the following steps for administering a prepackaged enema with the correct order in which they occur. a. 1. Insert enema tip gently in the rectum. b. 2. Help patient to bathroom when he or she feels urge to defecate. c. 3. Position patient on side. d. 4. Perform hand hygiene and apply clean gloves. e. 5. Squeeze contents of container into rectum. f. 6. Explain procedure to the patient. i. 6, 3, 4, 1, 5, 2 ii. 6, 4, 1, 3, 2, 5 iii. 4, 6, 3, 1, 2, 5 iv. 6, 4, 3, 1, 5, 2 - Correct answer iv 70. Which are key points that the nurse should include in patient education for a person with complaints of 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 - Correct answer A,E,F 71. Which skills must a patient with a new colostomy be taught 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 if the ostomy is healing appropriately - Correct answer A,B,C,E 72. Which of the following may cause Clostridium difficile infection? (Select all that apply.) a. Chronic laxative use b. Contact with C. difficile bacteria c. Overuse of antibiotics d. Frequent episodes of diarrhea caused by food intolerance e. Inflammation of the bowel - Correct answer B,C 73. Which of the following 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 - Correct answer A,B,F,H