Nursing Assessment and Procedures
Exam Solutions
Course Introduction
Nursing Assessment and Procedures provides students with foundational knowledge and practical skills essential for effective patient care. The course covers comprehensive health assessment techniques, including physical examination, health history taking, and use of assessment tools to recognize normal and abnormal findings. Emphasis is placed on the development of critical thinking and clinical judgment required for accurate data collection, interpretation, and documentation. Students also learn and practice core nursing procedures such as vital signs measurement, wound care, medication administration, and infection control, ensuring safety and competency in various healthcare settings.
Recommended Textbook
Clinical Nursing Skills and Techniques 9th Edition by Perry FAAN
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44 Chapters
1283 Verified Questions
1283 Flashcards
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Page 2
Chapter 1: Using Evidence in Practice
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Sample Questions
Q1) _________________ is a guide for making accurate,timely,and appropriate clinical decisions.
Answer: Evidence-based practice
Evidence-based practice is a guide for making accurate,timely,and appropriate clinical decisions.
Q2) A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice.In _____________,all entries include information on systematic reviews.Individual randomized controlled trials (RCTs)are the gold standard for research.
Answer: The Cochrane Database
A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice.In The Cochrane Database,all entries include information on systematic reviews.Individual randomized controlled trials (RCTs)are the gold standard for research.
Q3) __________________ are the gold standard for research.
Answer: Randomized controlled trials
Individual randomized controlled trials (RCTs)are the gold standard for research (Titler and others,2001).An RCT establishes cause and effect and is excellent for testing therapies.
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Page 3
Chapter 2: Admitting, Transfer, and Discharge
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25 Flashcards
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Sample Questions
Q1) While preparing for the patient's discharge,the nurse uses a discharge planning checklist and notes that the patient is concerned about going home because she has to depend on her family for care.The nurse realizes that successful recovery at home is often based on:
A)the patient's willingness to go home.
B)the family's perceived ability to care for the patient.
C)the patient's ability to live alone.
D)allowing the patient to make her own arrangements.
Answer: B
Q2) The patient is admitted to the ICU after having been in a motor vehicle accident.He was intubated in the emergency department and needs to receive two units of packed red blood cells.He is conscious but is indicating that he is in pain by guarding his abdomen.To admit this patient,the nurse first will focus on:
A)examining the patient and treating the pain.
B)orienting the family to the ICU visitation policy.
C)making sure that the consent forms are signed.
D)informing the patient of his HIPAA rights.
Answer: A
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Chapter 3: Communication and Collaboration
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Sample Questions
Q1) The patient is an elderly male who had hip surgery 3 days ago.He states that his hip hurts,but he does not like how the medicine makes him feel.He believes that he can tolerate the pain better than he can tolerate the medication.What would be the best response from the nurse?
A)Explain the need for the pain medication using a slower rate of speech.
B)Explain the need for the pain medication using a simpler vocabulary.
C)Explain the need for the pain medication,but ask the patient if he would like the doctor called and the medication changed.
D)Explain in a loud manner the need for the pain medication.
Answer: C
Q2) The nurse is assessing a patient who says that she is feeling fine.The patient,however,is wringing her hands and is teary eyed.The nurse should respond to the patient in which of the following ways?
A)"You seem anxious today.Is there anything on your mind?"
B)"I'm glad you're feeling better.I'll be back later to help you with your bath."
C)"I can see you're upset.Let me get you some tissue."
D)"It looks to me like you're in pain.I'll get you some medication."
Answer: A
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Chapter 4: Documentation and Informatics
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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) A patient's private health information is legally protected by the ________________.
Q3) To limit liability,nursing documentation must clearly indicate that the nurse provided individualized,goal-directed nursing care to a patient based on the _____________________.
Q4) Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000.At 1000,a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?
A)Document the 1000 vital signs in the graphic record only.
B)Not report the incident because it was a transient episode.
C)Document the vital signs in the graphic and progress record.
D)Document the vital signs as 12 o'clock signs.
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Chapter 5: Vital Signs
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Sample Questions
Q1) The nurse is caring for a 2-year-old child who is admitted with croup and crying.To take the child's vital signs,the nurse should:
A)place the pediatric blood pressure cuff on the left arm.
B)place the blood pressure cuff on the right thigh.
C)skip the blood pressure measurement.
D)place the blood pressure cuff on the left thigh.
Q2) _________ is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.
Q3) When inserting a rectal thermometer,the nurse encounters resistance.The nurse should:
A)apply mild pressure to advance.
B)ask the patient to take deep breaths.
C)remove the thermometer immediately.
D)remove the thermometer and reinsert it gently.
Q4) The percent to which hemoglobin is filled with oxygen is known as
Q5) ___________ is the sound of the tricuspid and mitral valves closing at the end of ventricular filling.
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Chapter 6: Health Assessment
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Sample Questions
Q1) The nurse is preparing to examine a comatose patient on a ventilator.Before beginning the procedures,she: (Select all that apply. )
A)speaks to the patient to minimize anxiety.
B)drapes the body parts not being examined.
C)encourages the patient to ask questions.
D)uses medical terms to let the patient know that she is professional.
Q2) How does a nurse appropriately measure intake and output?
A)Recording 50% of ice chip consumption
B)Checking urinary output every 24 hours
C)Emptying the chest tube drainage every 2 hours
D)Subtracting liquid medications from the total intake
Q3) Petechiae are noted on the patient as a result of the nurse finding:
A)bluish-black patches.
B)tenting.
C)pinpoint-sized red dots.
D)large areas of raised,irritated skin.
Q4) ____________ is a yellow-orange skin color seen with increased deposit of bilirubin in tissues.
Q5) A late sign of decreased oxygen levels may cause a change in skin color known as
8
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Chapter 7: Specimen Collection
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Sample Questions
Q1) The least traumatic method of obtaining a blood specimen is known as
Q2) What must the nurse do to collect a midstream urine sample from an infant?
A)Apply a sterile plastic collection bag to the perineum.
B)Wring out diapers and collect the urine in a specimen container.
C)Have the infant sit facing the back of the toilet.
D)Catheterize the infant and collect the urine using sterile procedure.
Q3) What instructions does the nurse provide to the patient to obtain a double-voided urine specimen?
A)Save two separate specimens from the first voiding in the morning.
B)Add two specimens together from the morning voiding and the evening voiding.
C)Discard the first sample,then wait a half hour and void again.
D)Void first and then self-catheterize to obtain the specimens.
Q4) A nurse suspects that the patient may have tuberculosis (TB).She sends a sputum sample to the lab for testing.When the following tests are compared,which will best support the diagnosis of possible tuberculosis?
A)Acid-fast bacilli (AFB)
B)General cytology
C)Chemical analysis
D)Culture and sensitivity
Page 9
Q5) _______________ organisms grow in superficial wounds exposed to the air.
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Chapter 8: Diagnostic Procedures
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Sample Questions
Q1) When explaining about a lumbar puncture,the nurse informs the patient that during the procedure,he or she will be asked to:
A)remain very still.
B)cough during the fluid aspiration.
C)change position.
D)breathe deeply during the needle insertion.
Q2) A patient who is a candidate for an upper gastrointestinal endoscopy has:
A)been NPO for 8 hours.
B)evident respiratory distress.
C)active gastrointestinal bleeding.
D)an esophageal diverticulum.
Q3) What action should the nurse take after an angiography?
A)Limit the patient's fluid intake.
B)Have the patient ambulate as soon as possible.
C)Apply a pressure dressing to the vascular site.
D)Maintain the patient in a sitting position while he or she is in bed.
Q4) A specialized form of angiography in which a catheter is inserted into the left or right side of the heart via a major peripheral vessel to study pressures within the heart,cardiac volumes,valvular function,and patency of coronary arteries is known as
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Chapter 9: Medical Asepsis
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26 Verified Questions
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Sample Questions
Q1) Infection control practices that reduce and eliminate sources and transmission of infection are known as _______________.
Q2) The nurse is applying for a position at a local hospital.As part of the employment criteria,she will be required to be assessed for TB exposure.She should be prepared for the ___________ blood test to be scheduled.
Q3) If hands are not visibly soiled,the nurse may use an alcohol-based hand rub in which of the following situations? (Select all that apply. )
A)Before having direct contact with patients
B)After contact with a patient's intact skin
C)After contact with body fluids or excretions
D)After removing gloves
Q4) The patient is admitted to the pediatric unit with severe pertussis.The nurse explains to the parents and the child that the patient will be treated with the use of:
A)airborne precautions.
B)standard precautions only.
C)droplet precautions.
D)contact isolation.
Q5) ________________ is the absence of pathogenic (disease-producing)microorganisms.
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Chapter 10: Sterile Technique
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Sample Questions
Q1) A sterile field consists of which of the following? (Select all that apply. )
A)Sterile tray
B)Work surface draped with a sterile towel
C)Table covered by a large sterile drape
D)Patient's bedside table
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) Which patient may the nurse suspect will be at risk for a latex allergy?
A)Patient with food allergies
B)Patient with diabetes
C)Patient with arthritis
D)Patient with hypertension
Q4) The minimum standard for infection control as established by the Centers for Disease Control and Prevention (CDC)is _______________.
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Chapter 11: Safe Patient Handling, Transfer, and Positioning
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position?
A)Fatigue
B)Muscle injury
C)Sensory disorientation
D)Orthostatic hypotension
Q2) Which of the following risk factors contribute to complications of immobility? (Select all that apply. )
A)Paralysis
B)Traction
C)Arterial insufficiency
D)Incontinence
E)Constipation
Q3) Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all that apply. )
A)Thrombus
B)Pressure ulcer
C)Kyphosis
D)Contractures
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Page 13
Chapter 12: Exercise Mobility
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27 Flashcards
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Sample Questions
Q1) An appropriate way for the nurse to measure a patient for crutches is to:
A)have a flexion of 45 degrees at both of the patient's elbows.
B)have a space of two to three fingers between the top of the crutch and the axilla.
C)place the crutch tips 1 foot to each side of the patient's feet,and observe the positioning of the crutches.
D)place the crutch tips 1 foot to the front of the patient's feet,and observe the positioning of the crutches.
Q2) When the four gaits listed below are compared,which is the most stable of the crutch gaits?
A)Four-point gait
B)Three-point gait
C)Two-point gait
D)Swing-to gait
Q3) ____________ refers to an ability to move about freely.
Q4) A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.
Q5) A person's inability to move about freely is known as _______________.
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Page 14
Chapter 13: Support Surfaces and Special Beds
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Sample Questions
Q1) _________________ beds are for patients who are immobile or otherwise are confined to the bed;they support a patient's weight on air-filled cushions.
Q2) After comparing the following support surfaces,the nurse realizes that an extremely obese patient should benefit from the use of a(n):
A)bariatric bed.
B)foam mattress.
C)water mattress.
D)air-fluidized bed.
Q3) The nurse is caring for a patient who is in an air-fluidized bed.She places the patient in semi-Fowler's position using foam wedges,even though she realizes that:
A)patients gain the greatest benefit from the prone position in an air-fluidized bed. B)for resuscitation,she may have to increase the air pressure of the bed to do CPR. C)she may have to increase the air pressure of the bed to turn the patient. D)the foam wedges may decrease the effects of the bed.
Q4) Use of the low-air-loss bed is contraindicated in patients with ___________________.
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Page 15
Chapter 14: Patient Safety
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Sample Questions
Q1) Effective fall prevention programs include which of the following? (Select all that apply. )
A)Risk assessment
B)Medication reviews
C)Use of assistive devices
D)Exercise and strength training
Q2) A thumb-less device used to restrain patients' hands to prevent them from dislodging invasive equipment,removing dressings,or scratching is known as a
Q3) _________________ are sudden,abnormal,and excessive electrical discharges from the brain that change motor or autonomic function,consciousness,or sensation.
Q4) The use of restraints has been associated with which of the following complications? (Select all that apply. )
A)Pressure ulcers
B)Pneumonia
C)Constipation
D)Death
Q5) Continuous seizure activity that lasts longer than 10 minutes is known as
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Chapter 15: Disaster Preparedness
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Sample Questions
Q1) A patient has been exposed to a toxic chemical.The nurse's first priority is _______________.
Q2) The strategic plan of the Centers for Disease Control and Prevention (CDC)in the event of a disaster first focuses on __________________.
Q3) If a patient is receiving radiation using gamma rays,the nurse would be watching for which of the following?
A)Severe pain during administration
B)Development of an allergy to shellfish
C)Severe burns or internal injury
D)Confusion and lethargy
Q4) An _________________ provides a standard approach to managing emergencies in which multiple agencies are involved.
Q5) For safety reasons,rescue workers should be upwind and uphill from a toxic chemical disaster scene to avoid exposure.The exception is when ____________ has been released,because it is lighter than air.
Q6) __________ is the sorting of individuals by the seriousness of their condition and the likelihood of their survival.
Q7) It is recommended that every household prepares a ____________.
Page 17
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Chapter 16: Pain Management
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Sample Questions
Q1) While reviewing a patient's medication history,the nurse determines that intraspinal analgesia is contraindicated as a result of:
A)previous spinal anesthesia.
B)recent administration of anticoagulants.
C)a history of cardiac problems.
D)a diagnosis of advanced cancer.
Q2) The _______________ is a potential space between the vertebral bones and the dura mater,the outermost meninges covering the brain and spinal cord.
Q3) The application of touch and movement to muscles,tendons,and ligaments without manipulation of the joints is called _________________.
Q4) The nurse caring for a patient who has a patient-controlled analgesia (PCA)knows that it:
A)allows the family to participate in pain management for the patient.
B)prevents mistakes in medication administration.
C)can be used by all hospitalized patients.
D)provides a more constant level of medication.
Q5) Massaging upward and outward from the vertebral column and back again is known as __________________.
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Chapter 17: Palliative Care
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Sample Questions
Q1) _______________ grief (symptoms lasting longer than 6 months)occurs when a person experiences significant distress related to the loss.
Q2) An _______________ is the surgical dissection of a body after death.
Q3) ___________________ specify medical interventions that the patient does not want in certain situations,such as mechanical ventilation,and are used to communicate the care a patient wants,for example,pain relief to the fullest extent possible.
Q4) The patient was brought into the emergency department with a cardiac arrest after suffering multiple gunshot wounds.The patient did not survive even after multiple attempts at resuscitation.The nurse is preparing the body for transport to the morgue by completing hospital procedures for __________________.
Q5) Before allowing the family of a deceased patient to view the body,the nurse should:
A)insert the patient's dentures.
B)lower the head of the bed.
C)fold the arms and hands over the chest.
D)leave all of the old dressings and tape in place.
Q6) _____________ helps people live as well as possible through the dying process.
Q7) The irreversible absence of all brain function is termed ______________.
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Chapter 18: Personal Hygiene and Bed Making
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Sample Questions
Q1) _____________ is balding patches in the periphery of the hairline.
Q2) What should hygienic care of the patient with dry skin include?
A)Use of moisturizers
B)Use of ultraviolet light
C)Application of antiseptic lotion
D)Lowering of bath water temperature
Q3) When taking a shower in the home setting,the patient at risk for falls may benefit from: (Select all that apply. )
A)installation of grab bars.
B)adhesive strips applied to the tub floor.
C)addition of a shower chair or stool.
D)a hydraulic lift.
Q4) The nurse is preparing to provide a complete bed bath to a patient who has a running IV.She places a bath blanket over the patient and:
A)removes the gown from the arm with the IV first.
B)removes the gown from the arm without the IV first.
C)removes the gown after the bath to keep the patient warm.
D)readjusts the IV rate before removing the gown.
Q5) ________________ is defined as excessive growth of body and facial hair.
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Chapter 19: Care of the Eye and Ear
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Sample Questions
Q1) When providing eye care for the comatose patient,the nurse should:
A)place the patient in a prone position for easier access.
B)use a different corner of the washcloth for each eye.
C)wipe each eye from outer to inner canthus.
D)use a sterile medicine cup to instill lubricant.
Q2) The nurse is preparing to clean the patient's hearing aid.The nurse realizes that she must:
A)make sure the hearing aid volume is turned on before removing the hearing aid.
B)hold the hearing aid over the sink when cleansing.
C)insert a paper clip into the receiver port to cleanse cerumen buildup.
D)make sure the pressure equalization channel is clear.
Q3) The substance found in the ear canal that has an antibacterial effect and maintains an acid pH is called ______________.
Q4) When instructing a patient on correct technique for inserting a hearing aid into the ear,the nurse will include which of the following instructions?
A)Pull the outer ear up and out.
B)Hold the aid with the long portion upright.
C)Fit the aid snugly in the midline of the canal.
D)Turn the aid to the desired sound level before insertion.
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Chapter 20: Safe Medication Preparation
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Sample Questions
Q1) The intended or desired physiological response to a medication is known as its
Q2) A patient with a history of renal failure and liver disease has been receiving morphine sulfate every 4 hours for the past 2 weeks.The nurse finds the patient lethargic with a respiratory rate of 6 breaths per minute.The health care provider orders naloxone.The nurse anticipates which effects when naloxone is given? (Select all that apply. )
A)Increase in alertness
B)Decrease in urine output
C)Complaints of pain
D)Increase in respiratory rate
Q3) The nurse reviews a medication administration record for an anticoagulant that is ordered at 0900 daily.The medication record indicates that the drug was given at the following times over the past 4 days.Which times follow the "right time" of medication administration? (Select all that apply. )
A)0800
B)0830
C)0930
D)1000
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Page 22
Chapter 21: Administration of Nonparenteral Medications
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Sample Questions
Q1) The nurse is preparing to administer an eye ointment to the patient.Which action by the nurse is appropriate?
A)Clean away drainage or crusts by wiping from the outer to the inner canthus.
B)Instruct the patient to keep the eye open for 2 minutes after instillation.
C)Apply a thin ribbon evenly along the inner edge of the lower eyelid.
D)Instruct the patient to avoid wiping the eye after instillation.
Q2) The nurse is teaching a patient how to use a topical medication.Which statement indicates an understanding of the procedure?
A)"If the patch starts to come off,I can secure it with tape."
B)"If the patch falls off,I will put a new one on in the same place."
C)"If my skin is irritated,I will cleanse it using water only."
D)"I can dispose of used materials in the household trash as usual."
Q3) The patient has a bronchodilator and an inhaled steroid scheduled for the same time.What teaching should the nurse provide to the patient about administering these medications?
A)Inhale the bronchodilator,wait 20 to 30 seconds,then inhale the steroid.
B)Inhale the bronchodilator,wait 2 to 5 minutes,then inhale the steroid.
C)Inhale the steroid,wait 20 to 30 seconds,then inhale the bronchodilator.
D)Inhale the steroid,wait 2 to 5 minutes,then inhale the bronchodilator.
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Page 23
Chapter 22: Administration of Parenteral Medications
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Sample Questions
Q1) The most frequent route of exposure to bloodborne disease for health care workers is needlestick injury.The nurse recognizes that implementation of _________________ can prevent needlestick injury.
Q2) The nurse is preparing to administer an intramuscular injection via the Z-track method.Which action should be taken by the nurse?
A)Pinch the skin between the thumb and the first finger.
B)Insert the needle at a 90-degree angle.
C)Immediately remove the needle after injecting the medication.
D)Release the skin before removing the needle from the site.
Q3) A patient with a continuous IV infusion has an order for ciprofloxacin to be given IV piggyback.Which action by the nurse is appropriate for administering the medication?
A)Hang the bag with ciprofloxacin higher than the continuous infusion bag.
B)Stop the continuous infusion while running the ciprofloxacin.
C)Connect the piggyback tubing into the Y-port on the tubing of the continuous infusion that is closest to the patient.
D)Occlude the tubing of the continuous infusion just above the injection port while injecting the medication.
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Chapter 23: Oxygen Therapy
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Sample Questions
Q1) A condition in which oxygen is insufficient to meet the metabolic demands of the tissues and cells is known as __________________.
Q2) A patient is admitted to the emergency department following a motor vehicle accident.The patient is unconscious and has a broken jaw,a broken nose,and facial lacerations.The patient's breath sounds are diminished,and the health care provider suspects atelectasis.Frequent suctioning is required to clear the airway.Oxygen saturation levels range from 70% to 75%.The nurse recognizes that this patient most likely will have which type of ventilatory device ordered?
A)Continuous positive airway pressure (CPAP)
B)Bi-level positive airway pressure (BiPAP)
C)Nasal cannula
D)Mechanical ventilation
Q3) A patient diagnosed with chronic obstructive pulmonary disease (COPD)is on oxygen therapy at 3 L per nasal cannula.Which assessment finding should alert the nurse to a potential problem with this patient?
A)Respiratory rate of 26
B)Low carbon dioxide levels
C)Arterial oxygen saturation level of 99%
D)Lower oxygen saturation levels at night than during the day
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Page 25
Chapter 24: Performing Chest Physiotherapy
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Sample Questions
Q1) The system that lines the internal lumen of the tracheobronchial tree and consists of a thin layer of mucus that constantly is propelled toward the larynx by cilia is called the
Q2) The nurse auscultates the patients' lung fields and notes congestion in several patients.The nurse anticipates that postural drainage may be used for the patient with which condition?
A)Congestive heart failure (CHF)with pulmonary edema
B)History of cigarette smoking with recent hemoptysis
C)Chronic bronchitis with frequent coughing
D)Pulmonary embolism after a long international flight
Q3) The health care provider orders percussion on a patient to help clear airway secretions.Which action by the nurse is appropriate?
A)Performing percussion over the ribs,while avoiding the clavicles and sternum
B)Administering pain medication before performing the percussion because the vibrations will be painful
C)Performing percussion during exhalation only with the flat part of the palm
D)Creating a rocking motion by slightly leaning on the patient's chest
Q4) The _______________ provides positive expiratory pressure (PEP)with oral airway oscillations.
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Chapter 25: Airway Management
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Sample Questions
Q1) A patient has extremely copious and thick oral secretions.The nurse provides oropharyngeal suctioning using a _________________ suction device.
Q2) The nurse is assessing the risk for aspiration of gastric contents into the lungs resulting in airway obstruction.The nurse identifies patients with which conditions as having increased risk? (Select all that apply. )
A)Presence of a gastrostomy feeding tube
B)History of smoking 2 packs per day for 30 years
C)Head injury with a decreased level of consciousness
D)Stroke with dysphagia
Q3) The nurse is performing nasotracheal suctioning for a patient.Which action by the nurse is appropriate?
A)Applying intermittent suctioning while slowly withdrawing the suction catheter
B)Carefully pushing the suction catheter in and out while applying suction
C)Applying suction for 15 seconds or less
D)Asking the patient to deep-breathe for 15 seconds before passing the catheter a second time
Q4) A _______________ is inserted directly into the trachea through a small incision made in the patient's neck.
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Page 27
Chapter 26: Cardiac Care
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35 Flashcards
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Sample Questions
Q1) In order to determine the patient and family caregiver's level of understanding of the rationale for obtaining the 12-lead ECG,the nurse most effectively utilizes which of the following statements?
A)Can you tell me why you need this test?
B)Did you experience pain during the test?
C)Can you tell me when the test results will be shared with you?
D)Can you give me your name and date of birth?
Q2) After obtaining a 12-lead ECG,the nurse records the date and time the ECG was obtained,the reason for obtaining the ECG,and who the ECG was given to for interpretation in the patient's chart.After this documentation,what is the appropriate action of the nurse?
A)Immediately report any unexpected outcomes.
B)Reposition the patient to a position of comfort.
C)Report to the nursing assistive personnel that the 12-lead ECG is completed.
D)Invite the family caregivers to visit at the bedside.
Q3) _______________ develops when a person is exposed to an excessive number of alarms.
Q4) Some patients may have allergies,or more commonly,sensitivities to the adhesive used to affix the leads.In these cases,_____________ are available from various manufacturers.
Page 28
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Chapter 27: Closed Chest Drainage Systems
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30 Flashcards
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Sample Questions
Q1) 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
Q2) The nurse is caring for a patient with a chest tube connected to wall suction.To keep the tube patent,the nurse should implement which of the following? (Select all that apply. )
A)Routinely "milk" the drainage tubing.
B)Avoid dependent loops of the drainage tubing.
C)Lift and clear the tube every 15 minutes.
D)Coil the drainage tubing to prevent dependent loops.
Q3) What is the expected amount of drainage for an adult patient with a mediastinal chest tube?
A)Less than 100 mL/hr during the immediate postoperative period
B)Less than 10 mL/hr during the immediate postoperative period
C)1000 mL/hr during the first 24-hour period
D)200 mL/hr during the first 24-hour period
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Page 29
Chapter 28: Emergency Measure for Life Support
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29 Flashcards
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Sample Questions
Q1) The nurse is working in the emergency department when an 8-year-old patient is brought in with respiratory distress.The nurse is preparing to insert an oral airway.Which of the following is the appropriate size for this patient?
A)Size 1
B)Size 2
C)Size 3
D)Size 7
Q2) Which of the following is the appropriate technique for a nurse to implement when inserting an oral airway?
A)Insert the airway with the curved end up,then rotate it 180 degrees at the back of the throat.
B)Insert the airway with the curved end down along the curve of the tongue.
C)Use a tongue blade to insert and push the airway into position.
D)Insert the airway sideways,then rotate it with the curved end up.
Q3) The nurse would call the code team for which of the following patients?
A)A patient with blood pressure of 60/28 mm Hg
B)A patient experiencing severe dyspnea secondary to asthma
C)A patient in atrial fibrillation
D)An unconscious patient in ventricular tachycardia
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Page 30
Chapter 29: Intravenous and Vascular Access Therapy
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44 Flashcards
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Sample Questions
Q1) _________________________ are surgically inserted through a tunnel into subcutaneous tissue,usually between the clavicle and the nipple,into the internal jugular or subclavian vein,with the catheter tip resting in the distal end of the superior vena cava.The subcutaneous tunnel allows the catheter to remain in place for months to years.
Q2) What should be the next action by the nurse once an over-the-needle catheter (ONC)has been inserted through the skin and into the vein?
A)Loosen the stylet for removal.
B)Check for blood return in the flashback chamber.
C)Stabilize the catheter and release the tourniquet.
D)Advance the catheter until the hub rests at the insertion site.
Q3) Fluids that have the same osmolality as body fluids are used most often to replace extracellular volume and are known as _______________ fluids.
Q4) While assessing the patient's intravenous (IV)catheter site,the nurse notes that the site is reddened and warm.The patient states that it is "sore." The nurse recognizes these as signs of ____________.
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Chapter 30: Blood Therapy
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Sample Questions
Q1) The patient is receiving blood when he suddenly complains of low back pain and develops diaphoresis and chills.The nurse should: (Select all that apply. )
A)stop the transfusion.
B)start normal saline connected to the Y tubing.
C)notify the physician.
D)start normal saline using new intravenous (IV)tubing.
Q2) The nurse is administering 1 unit of packed red blood cells as ordered by the primary care provider.While the nurse is measuring vital signs 15 minutes after starting the transfusion,the patient complains of chills and back pain.What is the nurse's first action?
A)Stop the blood transfusion and keep the vein patent by administering saline to infuse from the other side of the Y tubing.
B)Slow the blood transfusion and notify the charge nurse.
C)Disconnect the blood tubing from the catheter and replace it with an infusion of normal saline.
D)Stop the blood transfusion and notify the primary care provider.
Q3) A transfusion in which the donor is the patient is known as an ______________ transfusion or autotransfusion.
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Chapter 31: Oral Nutrition
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28 Verified Questions
28 Flashcards
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Sample Questions
Q1) The nurse is caring for a patient 2 days after surgery.The ordered diet is a mechanical soft diet.Which of the following foods may the patient choose to eat?
A)Salad
B)Baked potato without skin
C)Cooked cereal
D)Soft peeled apples
Q2) The nurse is caring for a patient who is believed to be suffering from malnutrition.The nurse calculates that the patient's body mass index (BMI)is 16.4 kg/m².What does this indicate about the patient's weight?
A)The patient is underweight.
B)The patient's weight is normal.
C)The patient is overweight.
D)The patient is obese (class 1).
Q3) What must the nurse do before assisting the patient with feeding?
A)Assess the patient's gag reflex.
B)Make sure that the consistency of the food is thin.
C)Remove the patient's dentures to prevent gagging.
D)Prepare the patient to be fed by a staff member.
Q4) _______________ is useful for monitoring short-term changes in visceral protein.
Page 33
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Chapter 32: Enteral Nutrition
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Sample Questions
Q1) Before insertion of a nasogastric (NG)tube,of which finding should the physician be notified?
A)Patent nares
B)Absent bowel sounds
C)Evident gag reflex
D)Impaired swallowing
Q2) Which technique is appropriate for providing intermittent tube feeding once placement of the tube has been checked?
A)Cooling the formula
B)Lowering the head of the bed
C)Allowing the bag to empty gradually over 30 to 45 minutes
D)Adding food coloring to detect aspiration
Q3) The nurse is preparing to administer an enteral feeding for the patient.The patient has been on enteral feedings for 2 days.The nurse knows that the most appropriate technique for implementing enteral feeding is:
A)weighing the patient weekly.
B)measuring the gastric residual every hour.
C)changing the formula every 12 hours in an open system.
D)leaving the formula in place in an open system for up to 24 hours.
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Page 34
Chapter 33: Parenteral Nutrition
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Sample Questions
Q1) A patient receiving parenteral nutrition (PN)has gained 4 pounds over a 24-hour period.Given this weight gain,which interpretation by the nurse is most accurate?
A)Increased nutrition from the patient's parenteral infusions
B)Decreased linoleic acid intake
C)Increased fluid loss
D)Fluid retention
Q2) A 72-year-old patient is admitted to the hospital with a medical diagnosis of intestinal failure.Which intervention should the nurse include in the plan of care to deliver nutritional needs?
A)Enteral nutrition (EN)
B)Parenteral nutrition (PN)
C)A combination of enteral and parenteral nutrition
D)Oral nutrition
Q3) Which assessment should a nurse expect to see for a patient receiving parenteral nutrition (PN)?
A)Weight gain of 1 to 2 pounds per week
B)Serum calcium level of 10 mEq/L
C)Serum potassium level of 2.8 mEq/L
D)Serum glucose level of more than 200 mg/100 mL
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Page 35
Chapter 34: Urinary Elimination
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Sample Questions
Q1) When evaluating the health care team member's ability to apply a condom catheter,it is most important for the nurse to provide further instruction for which intervention?
A)Clipping of hair at the base of the penis
B)Applying skin preparation to the penis before catheter placement
C)Using regular adhesive tape to hold the catheter in place
D)Leaving 1 to 2 inches of space between the tip of the penis and the end of the catheter
Q2) When the balloon on an indwelling urinary catheter is inflated and the patient expresses discomfort,it is essential for the nurse to take which action?
A)Remove the catheter.
B)Continue to blow up the balloon because discomfort is expected.
C)Aspirate the fluid from the balloon and advance the catheter.
D)Pull back on the catheter slightly to determine tension.
Q3) The risk for catheter-associated urinary tract infection can be reduced by using ___________ when inserting the catheter.
Q4) An ______________ has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use.
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Chapter 35: Bowel Elimination and Gastric Intubation
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Sample Questions
Q1) When developing a plan of care for a patient requiring a nasogastric (NG)tube,the nurse recognizes that it is essential to implement which technique in measuring the length of the tube?
A)Measure from the nose to the ear to the patient's navel.
B)Measure from the nose to the middle of the sternum.
C)Measure and mark a point 30 inches from the end.
D)Mark the 50-cm point on the tube,measure in the traditional way,and insert halfway between the two spots.
Q2) _____________ is defined by a number of signs including infrequent bowel movements,difficulty evacuating,hard stools,and inability to defecate.
Q3) The patient is being prepped for surgery and has an order for "enemas until clear." The nurse realizes that she will be giving a maximum of how many enemas?
A)One
B)Two
C)Three
D)Four
Q4) The inability to pass a hard collection of stool is known as ______________.
Q5) __________________ is strongest during the hour after the first meal of the day.
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Chapter 36: Ostomy Care
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Sample Questions
Q1) The nurse has removed the patient's old urostomy pouch and is attempting to measure the stoma opening for placement of a new pouch.Which action should the nurse take next?
A)Place the patient in a prone position.
B)Cleanse the peristomal skin with warm soap and water.
C)Remove any stents that are in place.
D)Place rolled gauze at the stoma opening.
Q2) The nurse is caring for a patient with an ostomy.The nurse notes that the ostomy is putting out watery effluent.The nurse recognizes that this is indicative of which location?
A)Descending colon
B)Sigmoid colon
C)Ileal portion of the small-intestine
D)Transverse colon
Q3) When providing care for a patient with a colostomy or an ileostomy,the nurse recognizes that which is an expected assessment finding?
A)A moist,reddish-pink stoma
B)A dry,purplish stoma
C)Erythema on the skin around the stoma
D)No drainage noted from the stoma when washed
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Page 38
Chapter 37: Preoperative and Postoperative Care
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Sample Questions
Q1) When planning care for a post anesthesia care unit (PACU)or recovery room patient,how often should the nurse plan to assess the patient?
A)Every 5 minutes
B)Every 15 minutes
C)Every 30 minutes
D)Hourly
Q2) The nurse is helping the patient prepare for surgery.The patient has removed her jewelry and glasses.Which action should the nurse take to keep the jewelry safe?
A)Put these items in the patient's bedside stand.
B)Inventory the items and give them to the family.
C)Place the items in a plastic bag and send them to the OR with the patient.
D)Keep these items with her until the patient returns.
Q3) 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.
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Chapter 38: Intraoperative Care
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Sample Questions
Q1) While supervising the surgical team,the charge nurse notices that a team member's nails are long and chipped.Which action should the nurse take next?
A)Allow the team member to complete the task.
B)Remove the team member to have the nails cut.
C)Turn the team member in to the RNFA.
D)Ask the team member why the nails are long and chipped.
Q2) 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.
Q3) The ________________ is a "sterile" team member who provides the surgeon with instruments and supplies,disposes of soiled sponges,and accounts for sponges,sharps,and instruments in the surgical field.
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Chapter 39: Pressure Injury Prevention and Care
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Sample Questions
Q1) The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site,and the site feels cooler than the areas immediately around the site.The nurse recognizes that this patient has developed:
A)a stage I pressure ulcer.
B)a stage II pressure ulcer.
C)an unstageable pressure ulcer.
D)deep tissue injury.
Q2) The nurse is caring for four patients during a shift.Which of the following patients is at greatest risk for developing a pressure ulcer?
A)The patient who is bedridden,but who turns himself randomly
B)The patient whose Braden Scale score is 8
C)The patient who can ambulate to the bathroom independently
D)The patient whose Braden Scale score is 18
Q3) A _______________ is a 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.
Q4) When skin layers adhere to the linens and deeper tissue layer move downward,________ damage occurs.
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Chapter 40: Wound Care and Irrigations
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29 Flashcards
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Sample Questions
Q1) How does the skin defend the body? (Select all that apply. )
A)Skin serves as a sensory organ for pain.
B)Skin serves as a sensory organ for touch.
C)Skin serves as a sensory organ for temperature.
D)Skin has an acid pH.
Q2) The _____________ is composed of newly formed collagen,and the nurse can usually feel it along a healing wound.It is usually present directly under the suture line between days 5 and 9.
Q3) Which of the following approaches is correct technique when wound irrigation is performed?
A)Placing the patient in supine position
B)Placing the syringe directly into the wound
C)Using sterile technique for a chronic wound
D)Selecting a soft catheter for deep wounds with small openings
Q4) Healing by primary intention is expected to occur with which of the following situations?
A)The wound is left open and is allowed to heal.
B)A surgical wound is left open for 3 to 5 days.
C)Connective tissue development is evident.
D)The edges of a clean incision remain close together.
Page 42
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Chapter 41: Dressings, Bandages, and Binders
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Sample Questions
Q1) 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.
Q2) The patient is brought from a construction site to the emergency department with a pipe puncturing his abdomen.The pipe is still in place.The patient is triaged and is scheduled for the operating room.What should the nurse do while waiting for the surgeon?
A)Pull the pipe out in the direction of entry.
B)Push the pipe through to the other side,then out.
C)Leave the pipe in place.
D)Apply direct pressure to the insertion site of the pipe.
Q3) ___________ healing takes place when tissue is cleanly cut and the margins are reapproximated.
Q4) _____________ dressings cover or hold primary dressings in place.
Q5) A __________ dressing comes in direct contact with the wound bed.
Q6) _______________ dressings are used for wounds that require debridement.
Page 43
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Chapter 42: Therapeutic Use of Heat and Cold
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Sample Questions
Q1) The nurse is using cryotherapy for a patient with a sprained ankle.The nurse explains the benefits to her patient.Which of the following statements made about the benefits of cryotherapy is correct?
A)It causes vasodilatation.
B)It provides local anesthesia.
C)It increases nerve conduction velocity.
D)It increases blood flow.
Q2) 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.
Q3) The ________________ blanket raises,lowers,or maintains body temperature through conductive heat or cold transfer between the blanket and the patient.
Q4) ___________ exerts a profound physiological effect on the body,reducing inflammation caused by injury to the musculoskeletal system.
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Chapter 43: Home Care Safety
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Sample Questions
Q1) Dementia is characterized by a gradual,progressive,irreversible _______ dysfunction.
Q2) Which assistive device would most benefit a patient with a neuromuscular weakness?
A)Large-print labels
B)A syringe with a magnifier
C)Screw-top medication containers
D)Color-coded tops for medications
Q3) The nurse is assessing a patient for mobility problems that could lead to falls.The nurse has the patient perform a timed up and go (TUG)test and 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.
Q4) ___________ is a generalized impairment of intellectual functioning,with the most common form being Alzheimer's disease.
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Chapter 44: Home Care Teaching
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Sample Questions
Q1) Of the following types of thermometers available,which is not recommended for home use?
A)Digital
B)Tympanic
C)Mercury
D)Disposable single-use
Q2) In preparing to teach a patient how to self-administer mediation,the nurse realizes that 80% of patients who are instructed to self-medicate for preventative care fail to do so.Reasons for this include which of the following rationales? (Select all that apply. )
A)Fear of adverse events
B)Inconvenient medication regimens
C)Costly prescriptions
D)Forgetfulness
Q3) While teaching how to check for gastric residual volume (GRV),the nurse instructs the caregiver to delay the tube feeding if he or she obtains more than _________ mL of gastric aspirate.
Q4) Temperatures in the older adult are different from those in the younger adult.The mean oral temperature for older adults often ranges from ____________.
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