Basic Nursing Interventions
Solved Exam Questions
Course Introduction
Basic Nursing Interventions is an essential course that introduces students to the fundamental skills and concepts required to provide safe and effective nursing care. The course emphasizes hands-on practice, covering topics such as patient hygiene, vital signs monitoring, medication administration, infection control, mobility assistance, wound care, and basic patient assessment. Students will learn the principles of critical thinking, communication, and documentation as they relate to the nursing process. Through both theoretical instruction and practical simulation, this course prepares future nurses to support patients health and well-being in a range of healthcare settings, adhering to ethical and professional standards.
Recommended Textbook
Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry
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44 Chapters
1316 Verified Questions
1316 Flashcards
Source URL: https://quizplus.com/study-set/2003
2
Chapter 1: Using Evidence in Nursing Practice
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20 Verified Questions
20 Flashcards
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Sample Questions
Q1) While caring for patients, the professional nurse must question
Answer: what does not make sense
Always think about your practice when caring for patients.Question what does not make sense to you, and question what you think needs clarification.
Q2) The researcher explains how to apply findings in a practice setting for the types of subjects studied in the _________________ section of a research article.
Answer: "Clinical Implications"
Clinical Implications
A research article includes a section that explains whether the findings from the study have "clinical implications." The researcher explains how to apply findings in a practice setting for the types of subjects studied.
Q3) When evidence-based practice is used, patient care will be:
A)standardized for all.
B)unhampered by patient culture.
C)variable according to the situation.
D)safe from the hazards of critical thinking.
Answer: C
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3
Chapter 2: Admitting, Transfer, and Discharge
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) Which of the following are considered "advance directives"? (Select all that apply.)
A)Living will
B)Power of attorney for health care
C)Notarized handwritten document
D)Nursing progress note
Answer: A, B, C
Q2) The patient has been admitted to the emergency department after being beaten and raped.She is agitated and is frightened that her attacker may find her in the hospital and try to kill her.What should the nurse tell her?
A)She is safe in the hospital, and she needs to provide her name.
B)She can be admitted to the hospital without anyone knowing it.
C)Her records will be used as evidence in the trial.
D)Since she has come to the hospital, she has to be examined by the doctor. Answer: B
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4
Chapter 3: Communication
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) The patient states, "I don't know what my family will think about this." The nurse wishes to use the communication technique of clarification.Which of the following statements would fit that need best?
A)"You don't know what your family will think?"
B)"I'm not sure that I understand what you mean."
C)"I think it would be helpful if we talk more about your family."
D)"I sense that you may be anxious about something."
Answer: B
Q2) The nurse is starting her first set of morning rounds.As she interacts with the patient, her questions revolve around his reactions to his disease process.She also asks if there is anything that she can do to make him more comfortable.This type of interaction is known as _______________.
Answer: therapeutic communication
Therapeutic communication is an application of the process of communication to promote the well-being of the patient.
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5
Chapter 4: Documentation and Informatics
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25 Flashcards
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Sample Questions
Q1) Which of the following is the best example of accurate documentation?
A)"Abdominal wound is 5 cm in length without redness, edema, or drainage."
B)"OD to be irrigated qd with NS."
C)"No complaint of abdominal pain this shift."
D)"Patient watching TV entire shift."
Q2) The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.With whom may the nurse communicate regarding this information?
A)The patient's parents
B)The patient's significant other only
C)No one in the hospital until the patient says so
D)The patient's physician, significant other, and laboratory personnel
Q3) The abbreviation for every day (___) is no longer used.
Q4) Nursing documentation: (Select all that apply.)
A)ensures continuity of care.
B)provides legal evidence.
C)evaluates patient outcomes.
D)increases the risk of litigation.
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Chapter 5: Vital Signs
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45 Verified Questions
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Sample Questions
Q1) The nurse chooses a sphygmomanometer that has a circular gauge and a needle that registers the millimeter calibrations.This type of device is known as a(n) _____ manometer.
A)mercury
B)electronic
C)aneroid
D)direct (invasive)
Q2) A person's core temperature is considered the most accurate since it is:
A)reflective of the surrounding environment.
B)the same for everyone.
C)controlled by the hypothalamus.
D)independent of external influences.
Q3) The nurse should report an assessment of _____ respirations per minutes for a(n) _____.
A)14; adult patient
B)16; 8-year-old patient
C)25; toddler
D)38; newborn
Q4) When heat loss mechanisms are unable to keep pace with heat production, ____________ is the result.
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Chapter 6: Health Assessment
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45 Verified Questions
45 Flashcards
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Sample Questions
Q1) Which of the following may a nursing assistant be responsible for determining?
A)Vital signs
B)Cranial nerve function
C)Neck vein distention
D)Auscultation of bowel sounds
Q2) A late sign of decreased oxygen levels may cause a change in skin color known as _________.
Q3) The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle.One test that is contraindicated in assessment of this patient is testing for _____________.
Q4) A nurse is documenting a patient's breath sounds.Rhonchi are heard as:
A)loud, low-pitched, coarse sounds.
B)high-pitched, musical squeaks.
C)dry, grating sounds on inspiration.
D)high-pitched, fine sounds at the end of inspiration.
Q5) The female nurse is preparing to assess and possibly change a scrotal dressing on a 34-year-old patient.Before changing the dressing, she should ______________.
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Chapter 7: Medical Asepsis
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26 Verified Questions
26 Flashcards
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Sample Questions
Q1) The primary strategies for prevention of infection transmission with regard to contact with blood, body fluids, nonintact skin, and mucous membranes are known as
Q2) The nurse has a "scratchy throat" and has been sniffling for 2 days.While at work, she wears a protective mask when coming into contact with her patients.She does this in an attempt to protect them from a __________________.
Q3) Which of the following measures is appropriate when a nurse is washing his or her hands?
A)Use very hot water.
B)Leave rings and watches in place.
C)Lather for at least 15 to 20 seconds.
D)Keep the fingers and hands up and the elbows down.
Q4) OSHA and CDC guidelines require health care workers who care for suspected or confirmed TB patients to wear special ________________.
Q5) The nurse knows that the basic concept of all patient care that is implemented to prevent the spread of infection from blood, body fluids, secretions, excretions, nonintact skin, and mucus membranes is __________________.
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Page 9
Chapter 8: Sterile Technique
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18 Verified Questions
18 Flashcards
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Sample Questions
Q1) When removing the mask after an aseptic procedure, what should the nurse do first?
A)Remove gloves.
B)Untie top strings of mask.
C)Untie bottom strings of mask.
D)Untie top strings and let mask hang.
Q2) Which is the appropriate sequence to use when applying sterile attire?
A)Apply sterile gloves.
B)Secure hair.
C)Don protective eyewear.
D)Apply hair cover.
E)Wash hands.
F)Apply mask.
Q3) When the following concepts are compared, which is most important in maintaining a safe environment by following aseptic principles?
A)Performing a surgical hand scrub
B)Applying a sterile gown
C)Recognizing the importance of following aseptic principles
D)Applying a mask and protective eyewear
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10
Chapter 9: Safe Patient Handling, Transfer, and Positioning
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) The nurse realizes that her patient needs to improve his or her mobility as quickly as possible.This is because the nurse realizes that mobilization: (Select all that apply.)
A)improves joint motion.
B)decreases circulation.
C)increases social activity.
D)enhances mental stimulation.
Q2) A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal independence is known as ________________.
Q3) An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to:
A)lower the height of the bed.
B)lower the head of the bed.
C)place the sling from shoulders to knees.
D)deep the check valve open when the patient is seated in the chair.
Q4) The patient is immobile and is being placed in the supine position.To reduce extension of the fingers and abduction of the thumb, the nurse places _________________ in the patient's hands.
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Chapter 10: Exercise and Ambulation
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31 Verified Questions
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Sample Questions
Q1) The patient has a leg injury and is being fitted for a cane.The patient should be taught to:
A)hold the cane on the uninvolved side.
B)hold the cane on the weaker side.
C)extend the cane 15 inches from the foot when used.
D)maintain approximately 60 degrees of elbow flexion.
Q2) The patient has been admitted for hypertension.His blood pressure is normally in the 160/90 range.He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication.The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous.The nurse lays the patient down and takes his vital signs.His pulse is 124.His blood pressure is 130/80.This blood pressure is indicative of what?
A)A normal blood pressure for this patient
B)Orthostatic hypotension
C)Orthostatic hypertension
D)Effective baroreceptor function
Q3) ____________ refers to an ability to move about freely.
Q4) A person's inability to move about freely is known as _______________.
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Chapter 11: Orthopedic Measures
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30 Flashcards
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Sample Questions
Q1) When teaching cast care, the nurse instructs the patient to:
A)blow dry the wet cast on the "hot" setting.
B)report changes in sensation or mobility to the area.
C)use only soft objects to slide down the cast for scratching.
D)cut away the edges of the cast if the skin becomes irritated.
Q2) Skeletal traction is implemented primarily for: (Select all that apply.)
A)simple fracture.
B)multiple trauma.
C)fractured ankle.
D)acetabular fracture.
E)cervical fracture.
Q3) For a patient with a fractured femur, a nurse is alert to the possibility of a fat embolus.What should the nurse specifically watch for?
A)Bradypnea
B)Restlessness
C)Bradycardia
D)Calf pain
Q4) When applying a plaster of Paris cast, it is important to keep the cast exposed for at least _____________ minutes.
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Chapter 12: Support Surfaces and Special Beds
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27 Verified Questions
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Sample Questions
Q1) Of the following problems that may occur with the use of an air-fluidized bed, which is of greatest concern to the nurse?
A)Nausea
B)Anxiety
C)Slight disorientation
D)Insensible fluid loss
Q2) ____________ are defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
Q3) It is recommended that the Rotokinetic bed stay in the rotation mode for at least _______ hours a day.
Q4) What is the most important factor in preventing and treating pressure ulcers?
A)Proper use of foam or air mattresses
B)Proper utilization of an air-fluidized bed
C)Frequent repositioning of the patient
D)Proper use of a low-air-loss bed
Q5) The patient will be going home but still requires an air-fluidized bed.Before discharge, it will be necessary for the company that is leasing the bed to inspect the home for accessibility and ________________.
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Chapter 13: Safety and Quality Improvement
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) __________ are the most common type of inpatient accident.
Q2) In a long-term care facility, an elderly patient drops his burning cigarette into a trash can and starts a fire.A Type _____ fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation.
A)A
B)B
C)C
D)D
Q3) The patient is an elderly gentleman who is admitted for a medical problem.While doing his admission assessment, the nurse learns that the patient gets up two to three times a night to use the restroom.The institution has only beds with four side rails.Which of the following is the appropriate rationale for leaving one of the lower side rails down?
A)Falls rarely happen in the inpatient setting.
B)Having all side rails raised increases the occurrence of falling.
C)Side rails have no bearing on whether or not a patient falls.
D)Patient falls rarely result in physical injury.
Q4) More than ____________ patients are injured in falls in inpatient settings annually in the United States.
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Page 15
Chapter 14: Disaster Preparedness
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32 Verified Questions
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Sample Questions
Q1) Why are children particularly vulnerable to environmental toxins? (Select all that apply.)
A)They have stronger immune systems.
B)They take in proportionally larger doses of toxins from food, water, and the air.
C)Their organ systems are less able to remove toxins than adult organs systems.
D)They have a greater number of years of life expectancy.
Q2) Dispersal of biological agents is a real and psychological terrorist threat.Which of the following organisms has the potential to cause the greatest harm?
A)Anthrax
B)Ricin
C)Salmonella
D)Hantavirus
Q3) Disaster nursing differs from general nursing because when caring for patients during a disaster:
A)the focus is on caring for the sickest people first.
B)using a color tag system reduces the amount of emotional stress on the nurse.
C)the focus is no longer on airway, breathing, and circulation.
D)the focus is on caring for those most likely to survive.
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Page 16
Chapter 15: Pain Assessment and Basic Comfort Measures
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38 Verified Questions
38 Flashcards
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Sample Questions
Q1) Drugs administered in the epidural space spread by: (Select all that apply.)
A)diffusion through the dura mater.
B)transport through blood vessels.
C)absorption by fat.
D)absorption through muscle.
Q2) The patient is admitted for chronic pain.He states that morphine sulfate (Morphine) has been used to relieve his pain, but recently he has been needing to use more of the medication to relieve pain.This patient's plan of care will have to incorporate interventions to deal with which of the following?
A)Addiction
B)Pseudoaddiction
C)Drug tolerance
D)Physical dependence
Q3) Massaging upward and outward from the vertebral column and back again is known as __________________.
Q4) __________________ is an interactive method of pain management that permits patient control over pain through self-administration of analgesics.
Q5) ________________ is a method of preventing pain while reducing overall opioid use.
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Chapter 16: Palliative Care
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Sample Questions
Q1) Hospice care can be provided in which of the following settings? (Select all that apply.)
A)Home
B)Free-standing hospice facilities
C)Extended care facilities
D)Acute care facilities
E)None of above
Q2) An appropriate technique for the nurse to implement when caring for a patient's body after death is to:
A)remove the patient's ID band and put a new gown on the patient.
B)cover the patient with a sheet and transfer him or her to the morgue.
C)inquire about particular cultural or spiritual practices.
D)remove tubes and lines if the patient is to be autopsied.
Q3) The patient was a practicing Hindu when he died.Knowing this, the nurse realizes that:
A)the body should be covered with a cotton sheet.
B)anointing of the sick is performed even after death.
C)family members often prefer to wash the body after death.
D)the body should be buried within 24 hours.
Q4) _____________ helps people live as well as possible through the dying process.
Page 18
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Chapter 17: Personal Hygiene and Bed Making
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Sample Questions
Q1) What should the nurse do before starting a patient's bed bath?
A)Lower the bed.
B)Offer the bedpan or urinal.
C)Partially undress the patient.
D)Place the head of the bed in high-Fowler's position.
Q2) The nurse is about to provide oral hygiene to an unconscious patient.To do so, she places the patient in which position?
A)Fowler's
B)Semi-Fowler's
C)Sims'
D)Supine
Q3) The optimal position for a female patient for the provision of perineal care is: A)prone.
B)side-lying.
C)high-Fowler's.
D)dorsal recumbent.
Q4) ________________ is defined as excessive growth of body and facial hair.
Q5) ______________ are mucous membranes with underlying supportive tissue that encircle the neck of erupted teeth to hold them in place.
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Chapter 18: Pressure Ulcer Care
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19 Flashcards
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Sample Questions
Q1) In a patient with a stage II pressure ulcer, the nurse describes the wound as:
A)superficial blistering.
B)nonblanchable redness.
C)loss of skin without bone exposure.
D)loss of skin with exposed muscle.
Q2) A nurse classifies a pressure ulcer according to the type of tissue in the wound bed.What does it indicate if the wound bed has granulation in it?
A)Wound needs debridement
B)The presence of significant infection
C)Colonization by bacteria
D)Movement toward healing
Q3) The patient with a nasogastric (NG) tube in place may experience skin breakdown: A)in the nose.
B)on the tongue.
C)behind the ears.
D)around the lips.
Q4) The removal of devitalized tissue in a wound is known as ______________.
Q5) When skin layers adhere to the linens and deeper tissue layer move downward, ________ damage occurs.
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Chapter 19: Care of the Eye and Ear
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Sample Questions
Q1) In caring for a patient with contact lenses, the nurse should be aware that:
A)rigid gas-permeable (RGP) lenses are no longer used.
B)soft contact lenses are smaller than the cornea.
C)all lenses must be removed periodically.
D)extended wear lenses can be used for only 6 nights.
Q2) When removing and cleansing a patient's eye prosthesis, the nurse:
A)places the patient in a prone position.
B)retracts the upper eyelid with her thumb and forefinger.
C)cleans the prosthesis using an alcohol solution.
D)cleans the prosthesis using mild soap and water.
Q3) How should the nurse position the ear when performing ear irrigation for a 2-year-old patient?
A)Instill the irrigating solution quickly and forcefully.
B)Pull the pinna up and back.
C)Direct the fluid toward the anterior aspect of the ear canal.
D)Pull the pinna down and back.
Q4) A _____________ is a small, battery-powered, electronic device that amplifies sound.
Q5) The substance found in the ear canal that has an antibacterial effect and maintains an acid pH is called ______________.
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Chapter 20: Safe Medication Preparation
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Sample Questions
Q1) To prevent medication errors, which action should be taken by the nurse?
A)Clarify illegible orders with the prescriber.
B)Document the medication before administration.
C)Read medication labels 2 times when preparing.
D)Prepare all of the client's medications for the shift at the same time.
Q2) The nurse receives an order to give a drug parenterally.The nurse will administer this medication by which route?
A)Oral
B)Topical
C)Sublingual
D)Intramuscular
Q3) Medication errors include which of the following? (Select all that apply.)
A)Administration of the wrong medication
B)Administration via the wrong route
C)Inaccurate prescribing
D)Failing to administer a medication
E)None of above
Q4) The dose ordered for a patient is 75 mg IM.The medication is available in a 50-mg/mL solution.The nurse prepares ________________ mL.
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Chapter 21: Oral and Topical Medications
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39 Verified Questions
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Sample Questions
Q1) The patient is prescribed an ophthalmic medication via an intraocular disc.Which action by the nurse is appropriate when administering the medication?
A)Place the disc in the conjunctival sac.
B)Apply sterile gloves before placing the disc.
C)Pull on the patient's upper eyelid and ask the patient to look up.
D)Instruct the patient that the disc will be changed daily.
Q2) The nurse is preparing to administer a pediatric dose of liquid medication to an infant.Which action by the nurse is appropriate?
A)Empty the unit-dose container into a plastic cup.
B)Gently shake the multi-dose bottle before pouring the medication.
C)Draw the medication into a syringe with a needle.
D)Use an oral syringe to measure liquid dosages greater than 25 mL.
Q3) The nurse is to administer several medications to a patient via a nasogastric (NG) tube.What should the nurse do first?
A)Add the medications to the tube feeding being given.
B)Crush all tablets and capsules before administration.
C)Administer all of the medications mixed together.
D)Check for placement of the NG tube.
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23
Chapter 22: Parenteral Medications
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Sample Questions
Q1) An experienced nurse recognizes that the dorsogluteal injection site is no longer used for intramuscular injections because of the risk of damaging the _______________.
Q2) The nurse is preparing to administer a medication using a volume-controlled administration set or Volutrol.Which action should the nurse do first?
A)Open the clamp between the Volutrol and the main IV bag.
B)Open the air vent on the Volutrol.
C)Inject the medication into the Volutrol.
D)Clean the injection port on top of the Volutrol.
Q3) The nurse is preparing to administer an immunization to a toddler.Which action by the nurse is appropriate?
A)Grasp the body of the muscle during injection.
B)Place one hand above the knee and one below the knee to find the site.
C)Have the patient's knee flexed with the foot internally rotated.
D)Ask the mother to hold the toddler on his side.
Q4) The patient is complaining of tenderness at his intravenous (IV) insertion site.The nurse examines the site and notices that the site is swollen, warm, and reddened.The nurse stops the intravenous infusion, realizing that the patient has
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Page 24
Chapter 23: Oxygen Therapy
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Sample Questions
Q1) A patient will be using a nasal cannula continuously to deliver oxygen at home, and the nurse is instructing the patient and family about important safety guidelines.Which of the following should be included in the teaching plan? (Select all that apply.)
A)Smoking is allowed if it is not done in the same room in which the oxygen device is placed.
B)If you feel short of breath, increase your oxygen by 2 to 3 L per minute.
C)Avoid using an electric razor.
D)Keep the oxygen tank at least 5 feet away from the stove.
Q2) The nurse is teaching a patient how to use a flow-oriented incentive spirometer (IS) the night before abdominal surgery.Which statement by the patient indicates an understanding of the procedure?
A)"I need to get the balls to the top as quickly as possible."
B)"Quick rapid breaths are the most effective when the incentive spirometer is used."
C)"I need to keep the balls elevated as long as possible."
D)"The balls must be elevated to be effective."
Q3) In noninvasive ventilation, ________________ keeps the terminal airways (alveoli) partially inflated, reducing the risk for atelectasis.
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Chapter 24: Performing Chest Physiotherapy
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Sample Questions
Q1) The nurse is planning to perform postural drainage on a patient who is receiving continuous tube feedings.What should the nurse do before performing the treatment? (Select all that apply.)
A)Stop the tube feedings for 1 to 2 hours before and after postural drainage.
B)Check for residual feeding in the patient's stomach and hold treatment if greater than 100 mL.
C)Give the prescribed inhaled bronchodilator 20 minutes before the procedure.
D)Auscultate all lung fields, assess vital signs, and draw arterial blood gas levels (ABG).
Q2) A patient who is very frail and thin with osteoporosis has just undergone abdominal surgery.The nurse anticipates that which technique will be used to control respiratory secretions in this patient?
A)Forceful coughing
B)Percussion
C)Vibration
D)Shaking
Q3) The _______________ provides positive expiratory pressure (PEP) with oral airway oscillations.
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26
Chapter 25: Airway Management
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Sample Questions
Q1) After oropharyngeal suctioning of a patient, the nurse notes bloody secretions in the suction catheter and tubing.What should the nurse do next?
A)Increase the suction pressure.
B)Provide additional oxygen.
C)Reduce the frequency of oral hygiene.
D)Check the suction catheter for nicks.
Q2) The nurse is providing care to a patient with a tracheostomy tube that has an inner cannula.Which intervention by the nurse follows proper procedure for tracheostomy tube care?
A)Carefully removes the inner cannula and places it in a basin of 1:10 bleach solution
B)Scrubs the inner cannula on the inside and outside with a 1:10 bleach solution
C)After scrubbing the inner cannula, rinses it with normal saline
D)Uses a wet 4 ´ 4 gauze and cleans the inside of the outer cannula
Q3) A _______________ is inserted directly into the trachea through a small incision made in the patient's neck.
Q4) A patient has extremely copious and thick oral secretions.The nurse provides oropharyngeal suctioning using a _________________ suction device.
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Chapter 26: Closed Chest Drainage Systems
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Sample Questions
Q1) A pneumothorax can be caused by which of the following? (Select all that apply.)
A)Trauma
B)Rupture of a blister
C)Emphysema
D)Dyspnea
Q2) The nurse knows that _______________ is the proper term to describe that the patient's water seal is fluctuating up and down with each breath.
A)bubbling
B)tidaling
C)fluttering
D)alternating
Q3) Which of the following is an expected outcome of chest tube insertion?
A)Mild chest pain is maintained.
B)Breath sounds are auscultated in all lobes.
C)Drainage from the pleural cavity increases over time.
D)Lung expansion is increased beyond the unaffected side.
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Chapter 27: Emergency Measures for Life Support
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Sample Questions
Q1) The nurse observes a person collapse and stop breathing.The nurse would establish an airway by:
A)inserting an endotracheal tube.
B)inserting a finger to pull the tongue forward.
C)using the head tilt-chin lift maneuver.
D)using a modified jaw-thrust maneuver.
Q2) The most common cause of airway obstruction in an unresponsive patient is the
Q3) The nurse is performing CPR on an adult patient who has an endotracheal tube in place.At what rate does the nurse, who is alone, administer breaths?
A)8 per minute
B)12 per minute
C)20 per minute
D)24 per minute
Q4) A semicircular, minimally flexible, curved piece of hard plastic that is inserted into the mouth so it extends from just outside the lips to the pharynx is known as an
Q5) Many cardiac arrests are caused by irregular heart rhythms known as
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Chapter 28: Intravenous and Vascular Access Therapy
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Q1) An intravenous catheter that is inserted through a large arm vein and is advanced until the tip enters the central venous system is known as a __________________.
Q2) The nurse is caring for a patient diagnosed with pneumonia who receives IV antibiotics every 8 hours.How often should the nurse change the primary intermittent IV sets?
A)No more often than every 72 hours
B)At least every 72 hours
C)With each IV bag change
D)Every 24 hours
Q3) Established standards for routine replacement of peripheral IV catheters and intravenous administration sets have recommended a maximum of _____ hours to reduce IV fluid contamination and prevent catheter site complications.
A)24
B)48
C)72
D)96
Q4) _________________________ pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that possibly will result in pulmonary edema.
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Chapter 29: Blood Transfusions
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Sample Questions
Q1) The specific blood product used for replacement of clotting factors and fibrinogen is:
A)whole blood.
B)packed RBCs.
C)cryoprecipitate.
D)albumin, 25% pooled.
Q2) The nurse is administering blood.What should the nurse do to detect a blood reaction as quickly as possible?
A)Remain with the patient during the first 15 minutes.
B)Transfuse the blood at 10 mL/min.
C)Monitor vital signs q 1 hour.
D)Transfuse blood at 50 gtt/min.
Q3) The patient is receiving a unit of packed RBCs.Fifteen minutes into the procedure, he complains of severe kidney pain, and his temperature increases by 3° F.The nurse stops the transfusion immediately, suspecting that which of the following reactions is occurring?
A)Delayed hemolytic transfusion reaction
B)Nonhemolytic febrile reaction
C)Acute hemolytic transfusion reaction
D)Severe allergic reaction
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Page 31
Chapter 30: Oral Nutrition
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Sample Questions
Q1) The nurse is caring for a patient who requires assistance with eating.The patient repeatedly apologizes to the nurse, saying, "I'm so sorry.I'm like a baby.I'm such a burden since I can't even feed myself." What is the most appropriate strategy for the nurse to use?
A)Feed all of the solid foods first, and then offer liquids.
B)Feed the patient quickly so as not to make the patient feel like it is taking a great deal of time out of the nurse's day.
C)Minimize conversation so that the patient can eat faster.
D)Appear unhurried, sit at the bedside, and encourage the patient to feed himself/herself as much as possible.
Q2) A patient is admitted to the hospital for evaluation for sleep apnea.The nurse calculates his body mass index (BMI) at 42 kg/m².What does this indicate about the patient's weight?
A)The patient is overweight.
B)The patient falls into the class 1 range of obesity.
C)The patient falls into the class 2 range of obesity.
D)The patient falls into the class 3 range of extreme obesity.
Q3) _______________ is useful for monitoring short-term changes in visceral protein.
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Page 32
Chapter 31: Enteral Nutrition
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Sample Questions
Q1) The nurse is checking the residual volume on a patient who is getting intermittent tube feedings via his NG tube.Which of the following may indicate that the patient has started to bleed again?
A)The nurse obtains brown aspirate.
B)The nurse notices that the abdomen is distended.
C)The nurse obtains red aspirate.
D)The nurse notices severe respiratory distress.
Q2) An appropriate technique for nasogastric (NG) tube insertion is for the nurse to:
A)position the patient supine.
B)apply oil-based lubricant to the plastic tube.
C)advance the tube while the patient swallows.
D)measure the tube length from the nose to the sternum.
Q3) The home health nurse evaluates the provision of intermittent tube feedings by the patient's family member.The nurse notes that additional teaching is required when she notices that the family member:
A)keeps the formula refrigerated between feedings.
B)keeps the feeding tube capped between feedings.
C)begins the feeding before checking tube placement.
D)irrigates the tube with 30 to 60 mL of water before and after feedings.
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Page 33
Chapter 32: Parenteral Nutrition
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Sample Questions
Q1) The nurse is caring for a patient who is receiving PN.As part of therapy, the patient undergoes routine bedside glucose monitoring that reveals which expected outcome?
A)Lower than normal blood glucose to determine adequate tolerance for PN
B)Slightly higher than normal blood glucose to meet increased cellular needs
C)Slightly higher than normal blood glucose to prevent infection or systemic sepsis
D)Normal blood glucose to prevent associated complications
Q2) For patients receiving PN, ___________ provide supplemental kilocalories and prevent essential fatty acid deficiencies.
Q3) The nurse is managing the care of a patient receiving PN.Which assessment finding indicates potential septicemia?
A)Shakiness and dizziness
B)Chest pain/hypotension
C)Increased thirst
D)Increased temperature
Q4) If PN must be discontinued suddenly, hang __________ in water at the same infusion rate to prevent hypoglycemia.
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Chapter 33: Urinary Elimination
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Sample Questions
Q1) The nurse is assessing a patient whose 24-hour output is 2400 mL.Which finding reflects the nurse's understanding of urine output?
A)Increased output
B)Decreased output
C)Normal output
D)Balanced output
Q2) The nurse is preparing the patient for a bladder scan to determine PVR.Which of the following is part of the preparation?
A)Limit food intake for 2 hours before the scan.
B)Begin scan 10 minutes after the patient has voided.
C)Limit liquid intake for 30 minutes before the scan.
D)Administer an analgesic 30 minutes before the scan.
Q3) When providing care for a patient with a suprapubic catheter who has acquired a UTI, which intervention is most important for the nurse to implement?
A)Using clean technique
B)Securing the tube to the inner thigh
C)Cleansing the insertion site in a direction toward the drain
D)Promoting intake of 2200 mL of fluid per day
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Chapter 34: Bowel Elimination and Gastric Intubation
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Sample Questions
Q1) The patient has increased his fluid and dietary fiber intake and has started a supervised exercise program.However, he is still having problems with constipation.Which of the following would be an effective intervention? (Select all that apply.)
A)Metamucil
B)Milk of magnesia
C)Dulcolax
D)Mineral oil
E)Colace
Q2) The nurse is preparing to administer an enema to an adult patient who has normal sphincter control.For administration of the enema, the patient is placed in which position?
A)Right side-lying
B)Dorsal recumbent
C)Sims'
D)Prone
Q3) An ___________ is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.
Q4) The inability to pass a hard collection of stool is known as ______________.
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Chapter 35: Ostomy Care
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Sample Questions
Q1) The nurse is caring for a patient who has an ostomy.The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool.The nurse recognizes that this is indicative of which location?
A)Descending colon
B)Ileal portion of the small intestine
C)Sigmoid colon
D)Transverse or ascending colon
Q2) In caring for a patient who has a pouching for a noncontinent urinary diversion, which nursing intervention is essential?
A)Empty the pouch when it is one-third to one-half full.
B)Remove the ureteral stents after 2 days.
C)Pouch the stoma with the patient sitting up.
D)Dispose of used pouches in the toilet.
Q3) In caring for a patient who had a fecal surgical diversion, which nursing intervention is essential?
A)Place a pouch over the newly created stoma.
B)Place a dressing over the stoma.
C)Wait several days before placing a pouch.
D)Prepare several pouches in advance.
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Page 37
Chapter 36: Preoperative and Postoperative Care
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Sample Questions
Q1) When teaching the patient about positive expiratory pressure therapy (PEP) and "huff" coughing, the nurse incorporates which of the following in the plan of care?
A)Instruct the patient to remain flat in bed.
B)Place a nose clip on the patient's nose.
C)Instruct the patient to breathe through his nose.
D)Instruct the patient to exhale with long slow breaths.
Q2) The goal of prophylactic antibiotic therapy is to protect the patient from infection with as little risk as possible.To achieve this goal, the nurse recognizes that antibiotics should be administered when they will be most beneficial.When would that be?
A)Twenty-four hours before surgery
B)For 2 weeks after surgery
C)For no longer than 24 hours after surgery
D)When signs of infection first appear
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Chapter 37: Intraoperative Care
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Sample Questions
Q1) Which of the following are principles of sterile procedure? (Select all that apply.)
A)Gowns are sterile from the chest and shoulder to table level.
B)Sterile persons must keep hands in view and above the waist and below the neck.
C)Sterile persons must fold arms across chest with hands tucked into the axillary region.
D)Unscrubbed persons must stay at least 6 inches away from the sterile field.
E)Sterile persons may position themselves with their back to the sterile field.
Q2) When one prepares to enter the operating room, which technique demonstrates the safest outcome?
A)Keeping the hands below the elbows
B)Applying surgical gloves before the scrub
C)Scrubbing for at least 3 to 5 minutes with an antimicrobial
D)Drying the hands and arms, starting at the elbow and moving toward the fingers
Q3) The _______________ phase begins when the patient enters the operating room suite and ends with admission to the postanesthesia care unit (PACU).
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Chapter 38: Wound Care and Irrigations
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Sample Questions
Q1) What should the nurse do to reestablish the vacuum of the Hemovac system after emptying?
A)Place a safety pin on the part of the drain outside the body.
B)Replace the cap immediately after emptying.
C)Pin the drainage tubing to the patient's gown.
D)Place the Hemovac on a flat surface.
Q2) ___________ are threads of wire or other materials used to sew body tissues together.
Q3) The nurse is caring for a patient with a postsurgical wound dehiscence who is being treated with a wet-to-dry dressing.Which of the following can be appropriately delegated to the nurse assistant?
A)Performing a sterile dressing change
B)Observing for any drainage on the dressing
C)Performing wound assessment during the dressing change
D)Notifying the physician of drainage present on the dressing
Q4) What should the nurse do when removing intermittent sutures?
A)Snip both sides of the suture before removing.
B)Snip the suture as close to the knot as possible.
C)Snip the suture as close to the skin as possible.
D)Pull up the knot to apply as much tension as possible.
Page 40
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Chapter 39: Dressings, Bandages, and Binders
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Sample Questions
Q1) The nurse is caring for a patient who has a negative-pressure dressing.The nurse realizes that typically the dressing should be changed:
A)every shift.
B)daily.
C)every 8 hours.
D)every 48 hours.
Q2) What should the nurse anticipate might happen to a patient if bleeding cannot be controlled?
A)Skin dryness
B)Bradycardia
C)Hypovolemic shock
D)Hypertension
Q3) The nurse is changing a film dressing over a wound that is showing a large amount of drainage.How should the nurse proceed?
A)Apply a film dressing after culturing the wound.
B)Apply a film dressing after cleansing the area.
C)Choose another type of dressing for this wound.
D)Keep the wound open to air.
Q4) _______________ dressings are used for wounds that require debridement.
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Chapter 40: Therapeutic Use of Heat and Cold
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Sample Questions
Q1) The patient is receiving cold therapy and complains to the nurse that the area being treated is numb.How should the nurse respond?
A)Continue application of therapy.
B)Stop cold therapy.
C)Apply more ice to the ice pack.
D)Check for moisture on the ice pack, indicating leakage.
Q2) Which of the following conditions are best treated with cold therapy? (Select all that apply.)
A)Localized inflammatory responses
B)Hemorrhage
C)Muscle spasm
D)Pain
E)None of above
Q3) A new staff nurse is assigned to the unit.The charge nurse evaluated that the new staff member knows proper use of the aquathermia pad when the:
A)temperature was set between 95° F and 98° F.
B)water in the reservoir was allowed to run out.
C)pad was covered with a towel or a pillowcase.
D)patient was positioned to lie directly over the pad.
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Page 42
Chapter 41: Home Care Safety
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Sample Questions
Q1) The nurse is assessing a patient for mobility problems that could lead to falls.She has the patient perform a Timed Up and Go (TUG) test.The nurse uses this test to gauge:
A)the patient's ability to perform advanced ambulation maneuvers.
B)whether the patient can walk 30 feet without fatiguing.
C)whether the patient can tolerate the activity for longer than 30 seconds.
D)how quickly the patient can perform the test.
Q2) Patients who require home care often experience physical alterations that require changes in their home environment.In the case of older adults, what is the best way to make these changes?
A)Make changes quickly to prevent problems.
B)Make changes to limit the patient's need to move around.
C)Make changes to complement the patient's strengths.
D)Make changes regardless of the patient's previous sense of personal space.
Q3) Of what should the nurse remind the patient when discussing safety measures for the home environment?
A)Set the hot water heater to only 160° F.
B)Turn on the cold water faucet first.
C)Use small throw rugs on slippery wood floors.
D)Put high-wattage bulbs into all lamps.
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Page 43
Chapter 42: Home Care Teaching
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Sample Questions
Q1) What does the nurse teach the patient and caregiver to do when setting up and changing administration sets for continuous tube feedings to preserve medical asepsis?
A)Add formula to formula already hung to prevent waste.
B)Store unused formula at room temperature to prevent spasm.
C)Hang only enough formula that will be infused in a 4- to 6-hour period.
D)Change the administration set every 48 hours.
Q2) In teaching the patient how to take his own blood pressure, which of the following is true?
A)Blood pressure cuffs that are too small will give a falsely low reading.
B)Blood pressure cuffs that are too large will give a falsely high reading.
C)Electronic blood pressure cuffs are just as accurate as other methods.
D)The cuff should be placed directly over the skin and not over clothing.
Q3) A patient is discharged and is sent home with enteral feedings.What instructions should the nurse give to the caregiver?
A)Flush the tube out after administering medications.
B)Keep the tube loose to allow for patient movement.
C)Use sterile technique when preparing and administering feedings.
D)Hang enough formula each time to cover 8 to 12 hours of feeding.
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Chapter 43: Specimen Collection
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Sample Questions
Q1) When discussing the collection of a clean-voided urine specimen, it is important for the nurse to instruct the patient to:
A)use a clean specimen cup.
B)collect 100 to 150 mL of urine for testing.
C)void some urine first and then collect the sample.
D)wash the perineal area with soap and water immediately before voiding.
Q2) The nurse is preparing to perform a venipuncture on a patient.Which of the following is an appropriate action for the nurse to take?
A)Apply the tourniquet until the distal pulse is no longer felt.
B)Remove the tourniquet after 1 minute.
C)Instruct the patient to vigorously open and close the fist.
D)Do not use veins that rebound.
Q3) A patient is concerned because her first guaiac test is positive.What information should the nurse share with the patient?
A)The patient probably has colorectal cancer.
B)The test needs to be repeated after she eats some red meat.
C)The test needs to be repeated at least 3 times.
D)The patient needs a low-residue diet to reduce intestinal abrasions.
Q4) _______________ organisms grow in superficial wounds exposed to the air.
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Chapter 44: Diagnostic Procedures
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Sample Questions
Q1) The physician needs to visually examine a patient's esophagus, stomach, and duodenum.The nurse anticipates that the physician will order:
A)endoscopic retrograde cholangiopancreatography ( ERCP ).
B)esophagoscopy.
C)esophagogastroduodenoscopy ( EGD ).
D)proctoscopy.
Q2) Under which circumstances should a nurse contact the physician to postpone an angiography?
A)If a patient has been NPO for only 1 hour
B)If a patient's femoral site has been shaved and cleansed with an antiseptic
C)If the patient received Benadryl as a pre-procedure medication
D)When test results reveal a BUN level of 15 mg/100 mL and a creatinine level of 0.8 mg/mL
Q3) Which is the appropriate patient position for a lumbar puncture?
A)Prone
B)Supine
C)Sims'
D)Lateral recumbent
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