FUNDAMENTAL OF NURSING 1 | This is the first set of nursing practice questions about the fundamentals of nursing. Nursing topics in this set include constipation, bowel elimination,
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Question 1 |
The most important nursing intervention to correct skin dryness is:
A | A. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection. |
B | B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear. |
C | C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas.
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D | D. Avoid bathing the patient until the condition is remedied, and notify the physician. |
Question 1 Explanation:
Correct Answer: C. (Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas).
Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing.
Question 2 |
When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:
A | A. Provides an opportunity for skin assessment.
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B | B. Avoids undue strain on the nurse.
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C | C. Increases venous blood return.
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D | D. Causes vasoconstriction and increases circulation. |
Question 2 Explanation:
Correct Answer: C. (Increases venous blood return).
Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care.
Question 3 |
Vivid dreaming occurs in which stage of sleep?
A | A. Stage I non-REM
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B | B. Rapid eye movement (REM) stage
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C | C. Stage II non-REM
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D | D. Delta stage |
Question 3 Explanation:
Correct Answer: B. (Rapid eye movement (REM) stage).
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after falling asleep, and each of the REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour.
Question 4 |
The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:
A | A. Flurazepam
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B | B. Temazepam
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C | C. Methotrimeprazine
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D | D. Tryptophan |
Question 4 Explanation:
Correct Answer: D. (Tryptophan).
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products contain the sleep-inducing amino acid tryptophan. Having warm milk at bedtime is a good way to work towards reaching the recommended number of servings of Milk and Alternatives each day, and can be a comforting way to unwind. Tryptophan is an amino acid that promotes sleep and is found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter).
Question 5 |
Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:
A | A. Have the patient take a 30- to 60-minute nap in the afternoon.
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B | B. Turn on the television in the patient’s room.
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C | C. Provide quiet music and interesting reading material.
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D | D. Massage the patient’s back with long strokes. |
Question 5 Explanation:
Correct Answer: A. (Have the patient take a 30- to 60-minute nap in the afternoon).
Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep.
Question 6 |
Restraints can be used for all of the following purposes except to:
A | A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters.
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B | B. Prevent a patient from falling out of bed or a chair.
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C | C. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety.
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D | D. Prevent a patient from becoming confused or disoriented. |
Question 6 Explanation:
Correct Answer: D. (Prevent a patient from becoming confused or disoriented).
By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than prevent it. Restraints in a medical setting are devices that limit a patient’s movement. Restraints can help keep a person from getting hurt or doing harm to others, including their caregivers. They are used as a last resort. The other choices are valid reasons for using restraints.
Question 7 |
Which of the following is the nurse’s legal responsibility when applying restraints?
A | A. Document the patient’s behavior.
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B | B. Document the type of restraint used.
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C | C. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others.
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D | D. All of the above. |
Question 7 Explanation:
Correct Answer: D. (All of the above).
When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints. Nurses are accountable for providing, facilitating, advocating and promoting the best possible patient care and to take action when patient safety and well-being are compromised, including when deciding to apply restraints.
Question 8 |
Kubler-Ross’s five successive stages of death and dying are:
A | A. Anger, bargaining, denial, depression, acceptance
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B | B. Denial, anger, depression, bargaining, acceptance
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C | C. Denial, anger, bargaining, depression acceptance
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D | D. Bargaining, denial, anger, depression, acceptance |
Question 8 Explanation:
Correct Answer: C. (Denial, Anger, Bargaining, Depression, Acceptance).
Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance.
Question 9 |
A terminally ill patient usually experiences all of the following feelings during the anger stage except:
A | A. Rage
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B | B. Envy
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C | C. Numbness
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D | D. Resentment |
Question 9 Explanation:
Correct Answer: C. (Numbness).
Numbness is typical of the depression stage, when the patient feels a great sense of loss. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient’s actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages.
Question 10 |
Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?
A | A. Taking psychology courses related to gerontology. |
B | B. Reading books and other literature on the subject of thanatology. |
C | C. Reflecting on the significance of death.
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D | D. Reviewing varying cultural beliefs and practices related to death. |
Question 10 Explanation:
Correct Answer: C. (Reflecting on the significance of death).
According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured. Thanatology is the science and study of death and dying from multiple perspectives—medical, physical, psychological, spiritual, ethical, and more.
Question 11 |
Which of the following symptoms is the best indicator of imminent death?
A | A. A weak, slow pulse
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B | B. Increased muscle tone
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C | C. Fixed, dilated pupils
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D | D. Slow, shallow respirations |
Question 11 Explanation:
Correct Answer: C. (Fixed, dilated pupils).
Fixed, dilated pupils are a sign of imminent death. Death is a part of natural life; however, society is notorious for being uncomfortable with death and dying as a topic on the whole. Many caregivers experience a level of burden from their duties during end-of-life care. This burden is multi-faceted and may include performing medical tasks, communicating with providers, decision-making and possibly anticipating the grief of impending loss.
Question 12 |
A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:
A | A. National League for Nursing (NLN)
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B | B. Centers for Disease Control (CDC)
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C | C. American Medical Association (AMA)
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D | D. American Nurses Association (ANA) |
Question 12 Explanation:
Correct Answer: B. Centers for Disease Control (CDC)
The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. CDC is responsible for controlling the introduction and spread of infectious diseases, and provides consultation and assistance to other nations and international agencies to assist in improving their disease prevention and control, environmental health, and health promotion activities.
Question 13 |
To institute appropriate isolation precautions, the nurse must first know the:
A | A. Organism’s mode of transmission
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B | B. Organism’s Gram-staining characteristics |
C | C. Organism’s susceptibility to antibiotics |
D | D. Patient’s susceptibility to the organism |
Question 13 Explanation:
Correct Answer: A. (Organism’s mode of transmission).
Before instituting isolation precaution, the nurse must first determine the organism’s mode of transmission. For example, an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and wearing a mask, a gown, and gloves when coming in direct contact with the patient.
Question 14 |
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
A | A. Have the patient place the specimen in a container and enclose the container in a plastic bag. |
B | B. Have the patient expectorate the sputum while the nurse holds the container. |
C | C. Have the patient expectorate the sputum into a sterile container.
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D | D. Offer the patient an antiseptic mouthwash just before he expectorate the sputum. |
Question 14 Explanation:
Correct Answer: C. (Have the patient expectorate the sputum into a sterile container).
Placing the specimen in a sterile container ensures that it will not become contaminated. A sputum specimen is obtained for culture to identify the microorganism responsible for lung infections; identify cancer cells shed by lung tumors; or aid in the diagnosis and management of occupational lung diseases. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection, the patient may use only tap water for nursing the mouth).
Question 15 |
An autoclave is used to sterilize hospital supplies because:
A | A. More articles can be sterilized at a time.
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B | B. Steam causes less damage to the materials.
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C | C. A lower temperature can be obtained.
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D | D. Pressurized steam penetrates the supplies better. |
Question 15 Explanation:
Correct Answer: D. (Pressurized steam penetrates the supplies better).
An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressurized steam, is used because it can destroy all forms of microorganisms, including spores. Autoclaves operate at high temperature and pressure in order to kill microorganisms and spores. They are used to decontaminate certain biological waste and sterilize media, instruments, and labware.
Question 16 |
The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:
A | A. Wash the gloves before removing them.
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B | B. Gently pull on the fingers of the gloves when removing them.
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C | C. Gently pull just below the cuff and invert the gloves when removing them.
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D | D. Remove the gloves and then turn them inside out. |
Question 16 Explanation:
Correct Answer: C. (Gently pull just below the cuff and invert the gloves when removing them).
Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should then be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged). The other choices can spread pathogens within the environment.
Question 17 |
After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:
A | A. Infection
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B | B. Infiltration
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C | C. Phlebitis
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D | D. Bleeding |
Question 17 Explanation:
Correct Answer: C. (Phlebitis).
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Superficial phlebitis affects veins on the skin surface. The condition is rarely serious and, with proper care, usually resolves rapidly. Sometimes people with superficial phlebitis also get deep vein thrombophlebitis, so a medical evaluation is necessary.
Question 18 |
To ensure homogenization when diluting powdered medication in a vial, the nurse should:
A | A. Shake the vial vigorously.
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B | B. Roll the vial gently between the palms.
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C | C. Invert the vial and let it stand for 1 minute.
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D | D. Do nothing after adding the solution to the vial. |
Question 18 Explanation:
Correct Answer: B. (Roll the vial gently between the palms).
Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a powdered medication.
Question 19 |
The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:
A | A. Assess the injection site.
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B | B. Select the appropriate injection site.
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C | C. Check the syringe to verify that the nurse has removed the prescribed insulin dose.
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D | D. Clean the injection site in a circular manner with an alcohol sponge. |
Question 19 Explanation:
Correct Answer: C. (Check the syringe to verify that the nurse has removed the prescribed insulin dose).
When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site with alcohol before injecting the insulin.
Question 20 |
The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
A | A. 25 gtt/minute
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B | B. 37 gtt/minute
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C | C. 50 gtt/minute
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D | D. 60 gtt/minute |
Question 20 Explanation:
Correct Answer: A. (25 gtt/minute).
When you have an order for an IV infusion, it is the nurse’s responsibility to make sure the fluid will infuse at the prescribed rate. IV fluids may be infused by gravity using a manual roller clamp or dial-a-flow, or infused using an infusion pump. Regardless of the method, it is important to know how to calculate the correct IV flow rate.
Question 21 |
A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?
A | A. 0.5 ml
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B | B. 0.75 ml
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C | C. 1 ml
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D | D. 2 ml |
Question 21 Explanation:
Correct Answer: A. (0.5 ml).
There are 3 primary methods for calculation of medication dosages; Dimensional Analysis, Ratio Proportion, and Formula or Desired Over Have Method. Desired Over Have or Formula Method uses a formula or equation to solve for an unknown quantity (x) much like ratio proportion.
Question 22 |
How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
A | A. Draw up the NPH insulin, then the regular insulin, in the same syringe.
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B | B. Draw up the regular insulin, then the NPH insulin, in the same syringe.
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C | C. Use two separate syringes.
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D | D. Check with the physician. |
Question 22 Explanation:
Correct Answer: B. (Draw up the regular insulin, then the NPH insulin, in the same syringe).
Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to ensure accurate measurements.
Question 23 |
A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
A | A. Call the physician
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B | B. Remedicate the patient
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C | C. Observe the emesis
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D | D. Explain to the patient that she can do nothing to help him. |
Question 23 Explanation:
Correct Answer: C. (Observe the emesis).
After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount. Nausea or vomiting is another commonly seen adverse effect that is expected to diminish the following days to weeks of continued codeine exposure. Antiemetic therapies, in oral and rectal formulations, are available for the treatment of nausea or vomiting.
Question 24 |
A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:
A | A. Trauma has occurred.
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B | B. His 24-hour output is adequate.
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C | C. He has a urinary tract infection.
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D | D. Residual urine remains in the bladder after voiding. |
Question 24 Explanation:
Correct Answer: B. (His 24-hour output is adequate).
A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine.
Question 25 |
A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
A | A. Writing down all assignments.
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B | B. Making changes after evaluating the situation and having discussions with the staff.
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C | C. Telling the staff nurses that she is making changes to benefit their performance.
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D | D. Evaluating the clinical performance of each staff nurse in a private conference. |
Question 25 Explanation:
Correct Answer: B. (Making changes after evaluating the situation and having discussions with the staff).
A new assistant nurse manager should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change.
Question 26 |
Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
A | A. Decreased plasma drug levels
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B | B. Sensory deficits
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C | C. Lack of family support
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D | D. History of Tourette syndrome |
Question 26 Explanation:
Correct Answer: B. (Sensory deficits).
Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Age-related decline of the five classical senses (vision, smell, hearing, touch, and taste) poses significant burdens on older adults. The co-occurrence of multiple sensory deficits in older adults is not well characterized and may reflect a common mechanism resulting in global sensory impairment.
Question 27 |
When examining a patient with abdominal pain the nurse in charge should assess:
A | A. Any quadrant first
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B | B. The symptomatic quadrant first
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C | C. The symptomatic quadrant last
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D | D. The symptomatic quadrant either second or third |
Question 27 Explanation:
Correct Answer: C. (The symptomatic quadrant last).
The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Question 28 |
The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A | A. Vital signs
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B | B. Laboratory test result
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C | C. Patient’s description of pain
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D | D. Electrocardiographic (ECG) waveforms |
Question 28 Explanation:
Correct Answer: C. (Patient’s description of pain).
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Subjective data provide clues to possible physiologic, psychological, and sociologic problems. They also provide the nurse with information that may reveal a client’s risk for a problem as well as areas of strengths for the client. The information is obtained through interviewing. Vital signs, laboratory test results, and ECG waveforms are examples of objective data.
Question 29 |
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
A | A. A palpable radial pulse
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B | B. A palpable ulnar pulse
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C | C. Cool, pale fingers
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D | D. Pink nail beds |
Question 29 Explanation:
Correct Answer: C. (Cool, pale fingers).
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
Question 30 |
Which of the following planes divides the body longitudinally into anterior and posterior regions?
A | A. Frontal plane
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B | B. Sagittal plane
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C | C. Midsagittal plane
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D | D. Transverse plane |
Question 30 Explanation:
Correct Answer: A. (Frontal plane).
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. The coronal plane or frontal plane (vertical) divides the body into dorsal and ventral (back and front, or posterior and anterior) portions. An anatomical plane is a hypothetical plane used to transect the body, in order to describe the location of structures or the direction of movements.
Question 31 |
A female patient with a terminal illness is in denial. Indicators of denial include:
A | A. Shock dismay
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B | B. Numbness
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C | C. Stoicism
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D | D. Preparatory grief |
Question 31 Explanation:
Correct Answer: A. (Shock dismay).
Shock and dismay are early signs of denial-the first stage of grief. Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. The other options are associated with depression—a later stage of grief.
Question 32 |
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
A | A. Position the head of the bed flat.
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B | B. Helps the patient dangle the legs.
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C | C. Stands behind the patient.
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D | D. Place the chair facing away from the bed. |
Question 32 Explanation:
Correct Answer: B. (Helps the patient dangle the legs).
After placing the patient in High Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
Question 33 |
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
A | A. Asking frequently if the patient understands the instruction.
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B | B. Asking an interpreter to replay the instructions to the patient.
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C | C. Writing out the instructions and having a family member read them to the patient.
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D | D. Demonstrating the procedure and having the patient return the demonstration. |
Question 33 Explanation:
Correct Answer: D. (Demonstrating the procedure and having the patient return the demonstration).
Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. One of the leading causes of medical errors in the United States is miscommunication between patients and providers. When patients with limited English proficiency (LEP) cannot adequately communicate their needs, they are less likely to comply with medical instructions and receive vital services.
Question 34 |
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
A | A. Discard the syringe to avoid a medication error.
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B | B. Obtain a label for the syringe from the pharmacy.
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C | C. Use the syringe because it looks like it contains the same medication the nurse was prepared to give.
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D | D. Call the day nurse to verify the contents of the syringe. |
Question 34 Explanation:
Correct Answer: A. (Discard the syringe to avoid a medication error).
As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
Question 35 |
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients have adverse drug effects?
A | A. Faster drug clearance
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B | B. Aging-related physiological changes
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C | C. Increased amount of neurons
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D | D. Enhanced blood flow to the GI tract |
Question 35 Explanation:
Correct Answer: B. (Aging-related physiological changes).
Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. ADEs are estimated to be indicated in 5% to 28% of acute geriatric medical admissions. Preventable ADEs are among one of the serious consequences of inappropriate medication use in older adults.
Question 36 |
A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A | A. Manager
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B | B. Educator
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C | C. Caregiver
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D | D. Patient advocate |
Question 36 Explanation:
Correct Answer: B. (Educator).
When teaching a patient about medications before discharge, the nurse is acting as an educator. They provide educational leadership to patients and care providers to enhance specialized patient care within established healthcare settings. Assists patients and caregivers with educational needs, problem resolution, and health management across the continuum of care.
Question 37 |
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
A | A. “Everything will be fine. Don’t worry.”
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B | B. “Read this manual and then ask me any questions you may have.”
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C | C. “Why don’t you listen to the radio?”
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D | D. “Let’s talk about what’s bothering you.” |
Question 37 Explanation:
Correct Answer: D. (“Let’s talk about what’s bothering you.”)
Anxiety may result from feelings of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feelings and block communication, they would not reduce anxiety.
Question 38 |
A scrub nurse in the operating room has which responsibility?
A | A. Positioning the patient
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B | B. Assisting with gowning and gloving
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C | C. Handling surgical instruments to the surgeon
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D | D. Applying surgical drapes |
Question 38 Explanation:
Correct Answer: C. (Handling surgical instruments to the surgeon).
The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
Question 39 |
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
A | A. Leave the medication at the patient’s bedside.
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B | B. Tell the patient to be sure to take the medication. And then leave it at the bedside.
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C | C. Return shortly to the patient’s room and remain there until the patient takes the medication.
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D | D. Wait for the patient to return to bed, and then leave the medication at the bedside. |
Question 39 Explanation:
Correct Answer: C. (Return shortly to the patient’s room and remain there until the patient takes the medication).
The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. With the growing reliance on medication therapy as the primary intervention for most illnesses, patients receiving medication interventions are exposed to potential harm as well as benefits. Benefits are effective management of the illness/disease, slowed progression of the disease, and improved patient outcomes with few if any errors. Harm from medications can arise from unintended consequences as well as medication error (wrong medication, wrong time, wrong dose, etc.).
Question 40 |
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?
A | A. ¼ ml
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B | B. ½ ml
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C | C. ¾ ml
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D | D. 1 ¼ ml |
Question 40 Explanation:
Correct Answer: C. (¾ ml).
The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X ****
10,000 X = 7,500 ****
X= 7,500/10,000 or ¾ ml
Question 41 |
The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
A | A. 39 degrees C
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B | B. 47 degrees C
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C | C. 38.9 degrees C
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D | D. 40.1 degrees C |
Question 41 Explanation:
To convert Fahrenheit degrees to centigrade, use this formula:
C degrees = (F degrees – 32) x 5/9 ****
C degrees = (102 – 32) 5/9 ****
+ 70 x 5/9 ****
38.9 degrees C
Question 42 |
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A | A. Red blood cell count
|
B | B. Sputum culture
|
C | C. Total hemoglobin
|
D | D. Arterial blood gas (ABG) analysis |
Question 42 Explanation:
Correct Answer: D. (Arterial blood gas (ABG) analysis).
All of these tests help evaluate a patient with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about a patient’s oxygenation status. An acceptable normal range of ABG values of ABG components are the following,[5][6] noting that the range of normal values may vary among laboratories, and in different age groups from neonates to geriatrics: pH (7.35-7.45) PaO2 (75-100 mmHg) PaCO2 (35-45 mmHg).
Question 43 |
The nurse uses a stethoscope to auscultate a male patient’s chest. Which statement about a stethoscope with a bell and diaphragm is true?
A | A. The bell detects high-pitched sounds best.
|
B | B. The diaphragm detects high-pitched sounds best.
|
C | C. The bell detects thrills best.
|
D | D. The diaphragm detects low-pitched sounds best. |
Question 43 Explanation:
Correct Answer: B. (The diaphragm detects high-pitched sounds best).
The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best. The bell is flat and round and is covered by a thin layer of plastic known as the diaphragm. The diaphragm vibrates as sound is produced within the body. These vibrations travel from the bell, up the hollow tube which splits into two, and into hollow earpieces to be heard as sound by the medical professional.
Question 44 |
A male patient is to be discharged with a prescription for an analgesic that is a controlled substance. During discharge teaching, the nurse should explain that the patient must fill this prescription how soon after the date on which it was written?
A | A. Within 1 month
|
B | B. Within 3 months
|
C | C. Within 6 months
|
D | D. Within 12 months |
Question 44 Explanation:
Correct Answer: C. (Within 6 months).
In most cases, an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written. A common reason people seek the care of medical professionals is pain relief. While many categories of pain medications are available, opioid analgesics are FDA-approved for moderate to severe pain. As such, they are a common choice for patients with acute, cancer-related, neurologic, and end-of-life pain. The prescribing of opioid analgesics for chronic pain is controversial and fraught with inconclusive standards.
Question 45 |
Which human element considered by the nurse in charge during assessment can affect drug administration?
A | A. The patient’s ability to recover
|
B | B. The patient’s occupational hazards
|
C | C. The patient’s socioeconomic status
|
D | D. The patient’s cognitive abilities |
Question 45 Explanation:
Correct Answer: D. (The patient’s cognitive abilities).
The nurse must consider the patient’s cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient’s ability to recover, occupational hazards, and socioeconomic status do not affect drug administration.
Question 46 |
An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?
A | A. Primary prevention
|
B | B. Secondary prevention
|
C | C. Tertiary prevention
|
D | D. Passive prevention |
Question 46 Explanation:
Correct Answer: A. (Primary prevention).
Primary prevention precedes disease and applies to healthy patients. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems from developing in the future.
Question 47 |
What does the nurse in charge do when making a surgical bed?
A | A. Leaves the bed in the high position when finished.
|
B | B. Place the pillow at the head of the bed.
|
C | C. Rolls the patient to the far side of the bed.
|
D | D. Tucks the top sheet and blanket under the bottom of the bed. |
Question 47 Explanation:
Correct Answer: A. (Leaves the bed in the high position when finished).
When making a surgical bed, the nurse leaves the bed in a high position when finished. After placing the top linens on the bed without pouching them, the nurse fan folds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed.
Question 48 |
The physician prescribes 250 mg of a drug. The drug vial reads 500 mg/ml. How much of the drug should the nurse give?
A | A. 2 ml
|
B | B. 1 ml
|
C | C. ½ ml
|
D | D. ¼ ml |
Question 48 Explanation:
Correct Answer: C. ½ ml
The nurse should give ½ ml of the drug. The dosage is calculated as follows:
250 mg/X=500 mg/1 ml ****
500x=250 ****
X=1/2 ml
Question 49 |
Nurse Satya is monitoring a patient for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use?
A | A. Prolonged half-life
|
B | B. Poor absorption
|
C | C. Potential for drug dependence
|
D | D. Potential for hepatotoxicity |
Question 49 Explanation:
Correct Answer: C. (Potential for drug dependence).
Patients can become dependent on barbiturates, especially with prolonged use. Due to the abuse potential of barbiturates, restricted access started with the passage of the Federal Comprehensive Drug Abuse and Control Act of 1970. Barbiturates classify as Schedule II-IV based on their abuse potential.
Question 50 |
Which nursing action is essential when providing continuous enteral feeding?
A | A. Elevating the head of the bed.
|
B | B. Positioning the patient on the left side.
|
C | C. Warming the formula before administering it.
|
D | D. Hanging a full day’s worth of formula at one time. |
Question 50 Explanation:
Correct Answer: A. (Elevating the head of the bed).
Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow in the patient’s intestines. Lying prone/supine during feeding increases the risk of aspiration and therefore where clinically possible the client should be placed in an upright position. If unable to sit up for a bolus feed or if receiving continuous feeding, the head of the bed should be elevated 30-45 degrees during feeding and for at least 30 minutes after the feed to reduce the risk of aspiration.
Question 51 |
When teaching a female patient how to take a sublingual tablet, the nurse should instruct the patient to place the table on the:
A | A. Top of the tongue
|
B | B. Roof of the mouth
|
C | C. Floor of the mouth
|
D | D. Inside of the cheek |
Question 51 Explanation:
Correct Answer: C. (Floor of the mouth).
The nurse should instruct the patient to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream from the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth.
Question 52 |
Which action by the nurse in charge is essential when cleaning the area around a Jackson-Pratt wound drain?
A | A. Cleaning from the center outward in a circular motion.
|
B | B. Removing the drain before cleaning the skin.
|
C | C. Cleaning briskly around the site with alcohol.
|
D | D. Wearing sterile gloves and a mask. |
Question 52 Explanation:
Correct Answer: A. (Cleaning from the center outward in a circular motion).
The nurse always should clean around a wound drain, moving from center outward in ever-larger circles, because the skin near the drain site is more contaminated than the site itself. A Jackson-Pratt (JP) drain is used to remove fluids that build up in an area of the body after surgery. The JP drain is a bulb-shaped device connected to a tube. One end of the tube is placed inside the client during surgery. The other end comes out through a small cut in the skin. The bulb is connected to this end. The client may have a stitch to hold the tube in place.
Question 53 |
The doctor orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops per milliliter. The nurse in charge should run the I.V. infusion at a rate of:
A | A. 15 drop per minute
|
B | B. 21 drop per minute
|
C | C. 32 drop per minute
|
D | D. 125 drops per minute |
Question 53 Explanation:
Correct Answer: C. (32 drop per minute).
Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes) to find the number of milliliters per minute:
125/60 min = X/1 minute ****
60X = 125X = 2.1 ml/minute ****
To find the number of drops/minute:
2.1 ml/X gtts = 1 ml/15 gtts ****
X = 32 gtts/minute, or 32 drops/minute ****
Question 54 |
A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock?
A | A. Restlessness
|
B | B. Pale, warm, dry skin
|
C | C. Heart rate of 110 beats/minute
|
D | D. Urine output of 30 ml/hour |
Question 54 Explanation:
Correct Answer: A. (Restlessness).
Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. Shock is characterized by decreased oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization leading to cellular and tissue hypoxia. It is a life-threatening condition of circulatory failure and most commonly manifested as hypotension (systolic blood pressure less than 90 mm Hg or MAP less than 65 mmHg).
Question 55 |
Which pulse should the nurse palpate during rapid assessment of an unconscious male adult?
A | A. Radial
|
B |
B. Brachial
|
C | C. Femoral
|
D | D. Carotid |
Question 55 Explanation:
Correct Answer: D. (Carotid).
During a rapid assessment, the nurse’s first priority is to check the patient’s vital functions by assessing his airway, breathing, and circulation. To check a patient’s circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient’s circulation.
Question 56 |
Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?
A | A. Constipation
|
B | B. Diarrhea
|
C | C. Incontinence
|
D | D. Hemorrhoids |
Question 56 Explanation:
Correct Answer: A. (Constipation).
Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Functional constipation is a prevalent condition in childhood, about 29.6% worldwide. In the United States, it represents 3% to 5% of pediatric visits and a considerable annual health care cost. Most children do not have an etiological factor, and one third continue to have problems beyond adolescence.
Question 57 |
Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?
A | A. "I need to drink one and a half to 2 quarts of liquid each day."
|
B | B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day."
|
C | C. "If my bowel pattern changes on its own, I should call you."
|
D | D. "Eating my meals at regular times is likely to result in regular bowel movements." |
Question 57 Explanation:
Correct Answer: B. (“I need to take a laxative such as milk of magnesium or if I don’t have a BM every day”).
Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults. In addition, a normal stool pattern for an older adult may not be daily elimination. The cause of constipation is multifactorial. The problem may arise in the colon or rectum or it may be due to an external cause. In most people, slow colonic motility that occurs after years of laxative abuse is the problem. In a few patients, the cause may be related to an outlet obstruction like rectal prolapse or a rectocele. External causes of constipation may include poor dietary habits, lack of fluid intake, overuse of certain medications, an endocrine problem like hypothyroidism or some type of an emotional issue.
Question 58 |
A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema?
A | A. Oil retention
|
B | B. Return flow
|
C | C. High large volume
|
D | D. Low, small volume |
Question 58 Explanation:
Correct Answer: D. (Low, small volume).
Small volume enemas along with other preparations are used to prepare the client for this procedure. The small volume enema is used to clean the lower portion of the colon or the sigmoid. This type of cleansing enema is often used for the patient who is constipated but does not need cleansing of the higher colon. The amount used is less than 500 ml and the bag is raised no higher than 12 inches.
Question 59 |
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
A | A. The stoma extends 1/2 inch above the abdomen.
|
B | B. The skin under the appliance looks red briefly after removing the appliance.
|
C | C. The stoma color is a deep red purple.
|
D | D. An ascending colostomy just delivers liquid feces. |
Question 59 Explanation:
Correct Answer: C. (The stoma color is a deep red purple).
An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. A stoma is the exteriorization of a loop of bowel from the anterior abdominal wall, done during a surgical procedure. It is done for diversion or decompression of the remaining bowel. It may be temporary or permanent, depending on the indication for which it was performed. Most stomas are incontinent, which means that there is no voluntary control over the passage of flatus and feces from the stoma.
Question 60 |
Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?
A | A. The client will wear a medical alert bracelet for antibiotic allergy.
|
B | B. The client will return to his or her previous fecal elimination pattern.
|
C | C. The client verbalizes the need to take an antidiarrheal medication PRN.
|
D | D. The client will increase intake of insoluble fiber such as grains, rice, and cereals. |
Question 60 Explanation:
Correct Answer: B. (The client will return to his or her previous fecal elimination pattern).
Once the cause of diarrhea has been identified and corrected, the client returns to his or her previous elimination pattern. Diarrhea is a common adverse effect of antibiotic treatments. Antibiotic-associated diarrhea occurs in about 5-30% of patients either early during antibiotic therapy or up to two months after the end of the treatment. The frequency of antibiotic-associated diarrhea depends on the definition of diarrhea, the inciting antimicrobial agents, and host factors.
Question 61 |
A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?
A | A. Prepare to irrigate the colostomy.
|
B | B. After assessing the stoma and surrounding skin, notify the surgeon.
|
C | C. Assess bowel sounds and administer antiemetic.
|
D | D. Administer a bulk forming laxative, and encourage increased fluids and exercise. |
Question 61 Explanation:
Correct Answer: B. (After assessing the stoma and surrounding skin, notify the surgeon).
The client has assessment findings consistent with complications of surgery. Providers and nurses should monitor stomas at regular intervals to look for the multiple complications of colostomies as an integrated team approach. Some complications are extremely troublesome to patients, and they come to the hospital with these presentations, but others may be more occult and have to be looked for.
Question 62 |
The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling “bloated” . The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?
A | A. Soapsuds
|
B | B. Retention
|
C | C. Return flow
|
D | D. Oil retention |
Question 62 Explanation:
Correct Answer: C. (Return flow).
This provides relief of postoperative flatus, stimulating bowel motility. Options one, two, and four manage constipation and do not provide flatus relief. A return-flow enema, or Harris flush, is used to remove intestinal gas and stimulate peristalsis. A large volume fluid is used but the fluid is instilled in 100-200 ml increments. Then, the fluid is drawn out by lowering the container below the level of the bowel. This brings the flatus out with the fluid.
Question 63 |
Which of the following is most likely to validate that a client is experiencing intestinal bleeding?
A | A. Large quantities of fat mixed with pale yellow liquid stool
|
B | B. Brown, formed stool
|
C | C. Semi soft tar colored stools
|
D | D. Narrow, pencil shaped stool |
Question 63 Explanation:
Correct Answer: C. (Semi soft tar colored stools).
Blood in the upper GI tract is black and tarry. Gastrointestinal (GI) bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit but isn’t always visible, though it may cause the stool to look black or tarry. The level of bleeding can range from mild to severe and can be life-threatening.
Question 64 |
Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply.
A | A. Bowel incontinence
|
B | B. Risk for deficient fluid volume
|
C | C. Disturbed body image
|
D | D. Social isolation
|
E | E. Risk for impaired skin integrity |
Question 64 Explanation:
Correct Answer: (A, C, D, and E).
Incontinence is the inability to control feces of normal consistency. Fecal incontinence (FI) is the involuntary passage of fecal matter through anus or inability to control the discharge of bowel contents. Its severity can range from an involuntary passage of flatus to complete evacuation of fecal matter. Depending on the severity of the disease, it has a significant impact on a patient’s quality of life
Question 65 |
A nurse determines that a fracture bedpan should be used for the patient who:
A | A. Has a spinal cord injury
|
B | B. Is on bedrest
|
C | C. Has dementia
|
D | D. Is obese |
Question 65 Explanation:
Correct Answer: A. (Has a spinal cord injury).
A fracture bedpan has a low back that promotes function of the patient’s lower back while on the bedpan. The fracture pan has one flat end for ease of use with specific patient populations: i.e. hip fractures, hip replacements, or lower extremity fractures. Using the toilet may be a source of discomfort and embarrassment among all genders. Semi-private rooms or shared wards and hospital overcrowding are a challenge regarding patient privacy.
Question 66 |
A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material?
A | A. Whole wheat bread
|
B | B. White rice
|
C | C. Pasta
|
D | D. Kale |
Question 66 Explanation:
Correct Answer: D. (Kale).
Kale is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale contains 6.6 g of dietary fiber. Fiber is a very important component of our diet and comes from plant-based food sources (fruits, vegetables, legumes and whole grains). Different food sources contain different types of fiber and resistant starches and the side effects depend on the individual’s microbiome (gut bacteria). Instead of avoiding fiber altogether, you may want to identify the certain types of food that cause the distress.
Question 67 |
Which statement by a patient with an ileostomy alerts the nurse to the need for further education?
A | A. "I don't expect to have much of a problem with fecal odor."
|
B | B. "I will have to take special precaution to protect my skin around the stoma."
|
C | C. "I'm going to have to irrigate my stoma so I have a bowel movement every morning."
|
D | D. "I should avoid gas forming foods like beans to limit funny noises from the stoma." |
Question 67 Explanation:
Correct Answer: C. (“I’m going to have to irrigate my stoma so I have a bowel movement every morning”)
This statement is inaccurate in relation to an ileostomy and indicates that the patient needs more teaching. An ileostomy produces liquid fecal drainage that is constant and cannot be regulated. An ileostomy is when the lumen of the ileum (small bowel) is brought through the abdominal wall via a surgical opening (created by an operation). This can either be temporary or permanent, an end or a loop. The purpose of an ileostomy is to evacuate stool from the body via the ileum rather than the usual route of the anus.
Question 68 |
A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema?
A | A. Lubricate the last 2 inches of the rectal tube.
|
B | B. Insert the rectal tube about 4 inches into the anus.
|
C | C. Raise the solution container about 12 inches above the anus.
|
D | D. Lower the solution container after instilling about 150 mL of solution. |
Question 68 Explanation:
Correct Answer: D. (Lower the solution container after instilling about 150 mL of solution).
Lowering the container of solution creates a siphon effect that pulls the instilled fluid back out through the rectal tube into the solution container. The return flow promotes the evacuation of gas from the intestines. This technique is used only with a return flow enema. This action is appropriate for all types of enemas.
Question 69 |
A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation?
A | A. Incontinence
|
B | B. Dysrhythmias
|
C | C. Fecal impaction
|
D | D. Rectal hemorrhoids |
Question 69 Explanation:
Correct Answer: B. (Dysrhythmias).
Straining on defecation requires the person to hold the breath while bearing down. This maneuver increases the intrathoracic and intracranial pressures, which can precipitate dysrhythmias, brain attack, and respiratory difficulties; all of these can be life threatening. Strain at stool causes blood pressure rise, which can trigger cardiovascular events such as congestive heart failure, arrhythmia, acute coronary disease, and aortic dissection.
Question 70 |
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
A | A. Eating more protein is optimal prior to testing.
|
B | B. One stool specimen is sufficient for testing.
|
C | C. A red color changes indicates a positive test.
|
D | D. The specimen cannot be contaminated with urine. |
Question 70 Explanation:
Correct Answer: D. (The specimen cannot be contaminated with urine).
For fecal occult blood testing at home, the stool specimens cannot be contaminated with water or urine. The fecal occult blood test (FOBT) is a diagnostic test to assess for occult blood in the stool. This test has commonly been used for colorectal cancer screening, especially in developed nations. When used correctly for screening, this testing modality has established associations with decreased morbidity and mortality. When performing at home, the stool should be collected in a dry, clean container.
Question 71 |
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend?
A | A. Macaroni and cheese
|
B | B. Fresh food and whole-wheat toast
|
C | C. Rice pudding and ripe bananas
|
D | D. Roast chicken and white rice |
Question 71 Explanation:
Correct Answer: B. (Fresh food and whole-wheat toast).
A high fiber diet promotes normal bowel elimination. The choice of fruit and toast is the highest-fiber option. Most Americans consume only half the levels of recommended fiber per day, which is almost 15 grams per day. All existing definitions recognize fiber as “carbohydrate or lignin which bypasses digestion in the small intestine and is partially or completely fermented in the large intestine or colon.”
Question 72 |
A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply.
A | A. Bradycardia
|
B | B. Hypotension
|
C | C. Fever
|
D | D. Poor skin turgor
|
E | E. Peripheral edema |
Question 72 Explanation:
Correct Answer: (B, C, and D).
Diarrhea is described as three or more loose or watery stools a day. Infection commonly causes acute diarrhea. Noninfectious etiologies are more common as the duration of diarrhea becomes chronic. Treatment and management are based on the duration and specific etiology. Rehydration therapy is an important aspect of the management of any patient with diarrhea. Prevention of infectious diarrhea includes proper handwashing to prevent the spread of infection.
Question 73 |
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply.
A | A. Warm the enema solution prior to installation.
|
B | B. Position the client on the left side with the right leg flexed forward.
|
C | C. Lubricate the rectal tube or nozzle.
|
D | D. Slowly insert the rectal tube about 2 inches.
|
E | E. Hang the enema container 24 inches above the clients anus. |
Question 73 Explanation:
Correct Answer: (A, B, and C).
Enemas are rectal injections of fluid intended to cleanse or stimulate the emptying of the bowel. Enemas can be administered by a medical professional or self-administered at home. Enemas may also be prescribed to flush out the colon before certain diagnostic tests or surgeries. The bowel needs to be empty before these procedures to reduce infection risk and prevent stool from getting in the way.
Question 74 |
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
A | A. Have a client hold his breath briefly.
|
B | B. Discontinue the fluid installation.
|
C | C. Remind the client that cramping is common at this time.
|
D | D. Lower the enema fluid container. |
Question 74 Explanation:
Correct Answer: D. (Lower the enema fluid container).
To relieve the client’s discomfort, the nurse should slow the rate of installation by reducing the height of the enema solution container. An enema may be helpful when there is a problem forming or passing stool. The colon, also called the large intestine or large bowel, is a long, hollow organ in the abdomen. It plays an important role in digestion by removing water from digested material and forming feces (stool). In some circumstances, due to diet, medical condition, or medication, among other possible causes, the bowel may form stool that is hard to pass easily resulting in constipation.
Question 75 |
A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s condition?
A | A. Hypoxia
|
B | B. Hypoxemia
|
C | C. Dyspnea
|
D | D. Cyanosis |
Question 75 Explanation:
Correct Answer: D. (Cyanosis).
A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes. Cyanosis refers to a bluish cast to the skin and mucous membranes. Peripheral cyanosis is when there is a bluish discoloration to the hands or feet. It’s usually caused by low oxygen levels in the red blood cells or problems getting oxygenated blood to the body.
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