ExN105A

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Author:
ndarlenebeck
ID:
297127
Filename:
ExN105A
Updated:
2015-02-28 21:00:57
Tags:
Excelsior
Folders:
Excelsior
Description:
Excelsior Form A
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  1. What is the theoretical basis for performing passive range-of motion exercises?
    A) to maintain joint flexibility
    B) to increase muscle mass and strength
    C) to prevent pressure ulcers
    D) to restore mobility to a contractured joint
    A) to maintain joint flexibility
    (this multiple choice question has been scrambled)
  2. The nurse is assessing an older adult's tolerance for activity while performing activities of daily living (ADL's). Which is the most important nursing assessment?
    A) monitoring the patient's pulse
    B) determining the patient's range of motion
    C) recording the length of time required for each activity
    D) keeping a log of completed activities
    A) monitoring the patient's pulse
    (this multiple choice question has been scrambled)
  3. Which physiological change predisposes a patient who is immobile to thrombus formation?
    A) increased cardiac workload
    B) increased stasis of the blood
    C) decreased calcium in the blood
    D) decreased circulating blood volume
    B) increased stasis of the blood
    (this multiple choice question has been scrambled)
  4. Which assistive device will prevent external rotation of the hip when the patient is lying in the supine position?
    A) abductor pillow
    B) ankle roll
    C) knee splint
    D) trochanter roll
    D) trochanter roll
    (this multiple choice question has been scrambled)
  5. In helping a patient to move from the bed to a wheelchair, the nurse should take which action first?
    A) Lock the wheels on the chair and the bed.
    B) Place the patient's bed in the low position.
    C) Ask another nurse for assistance.
    D) Assess the patient's ability to assist with the transfer.
    D) Assess the patient's ability to assist with the transfer.
    (this multiple choice question has been scrambled)
  6. When caring for a patient who is bedridden, the nurse should implement which intervention to avoid the effects of shearing?
    A) Keep the patient's siderails up.
    B) Teach the patient to exhale during position changes.
    C) Use pillows to support the patient's joints in alignment.
    D) Use a lift sheet to move the patient up in the bed.
    D) Use a lift sheet to move the patient up in the bed.
    (this multiple choice question has been scrambled)
  7. Which observation would indicate that the nurse's application of heel protectors was effective?
    A) Erythema on the heel is present.
    B) Footdrop is absent.
    C) The dorsalis pedis pulse is of good quality.
    D) The skin of the feet is intact.
    D) The skin of the feet is intact.
    (this multiple choice question has been scrambled)
  8. A patient who is immobile and has a history of respiratory infections shows signs of lung congestion. Which nursing diagnosis would be most appropriate?
    A) fluid volume excess related to mucus accumulation in the lungs
    B) risk for aspiration related to weakness
    C) activity intolerance related to dyspnea
    D) ineffective airway clearance related to bed rest
    D) ineffective airway clearance related to bed rest
    (this multiple choice question has been scrambled)
  9. The nurse instructs an older adult patient with postural hypotension how to ambulate safely. Which observation best indicates that the instruction has been effective?
    A) The patient sits on the side of the bed for two minutes before getting up.
    B) The patient's blood pressure remains between 110/70 and 120/80
    C) The patient verbalizes an understanding of the effects of postural hypotension.
    D) The patient ambulates with the assistance of two people.
    A) The patient sits on the side of the bed for two minutes before getting up.
    (this multiple choice question has been scrambled)
  10. The nurse's assessment of a patient who is confined to bed indicates a positive Homans' sign. This is a possible indicator of which condition?
    A) planter flexion
    B) thrombophlebitis
    C) renal calculi
    D) decreased lung expansion
    B) thrombophlebitis
    (this multiple choice question has been scrambled)
  11. The nurse collects the following date from a 65 year old patient who lives alone; height 5'10"; weight 132 lb; eats two meals a day consisting of cereal and milk for breakfast and a tuna sandwich and coffee for dinner; reports having a bowel movement every three days. Which nursing diagnosis is most applicable?
    A) social isolation
    B) constipation
    C) altered nutrition; less than body requirements
    D) altered health maintenance
    C) altered nutrition; less than body requirements
    (this multiple choice question has been scrambled)
  12. Which instructional technique should maximize independence for a patient who needs to limit sodium in the diet?
    A) Provide the patient with a list of foods that must be avoided.
    B) Calculate the actual volume of salt in the patient's usual diet.
    C) Give the patient a set of written, preplanned low sodium menus.
    D) Explain to the patient how to read and interpret food labels.
    D) Explain to the patient how to read and interpret food labels.
    (this multiple choice question has been scrambled)
  13. The digestion and absorption of nutrients occurs primarily in which organ?
    A) esophagus
    B) stomach
    C) small intestine
    D) large intestine
    C) small intestine
    (this multiple choice question has been scrambled)
  14. Which nutrient does total parenteral nutrition (TPN) provide that routine intravenous therapy solutions do not?
    A) vitamins
    B) proteins
    C) carbohydrates
    D) minerals
    B) proteins
    (this multiple choice question has been scrambled)
  15. When initiating total parental nutrition (TPN) therapy, it is critical for the nurse to monitor for which complication?
    A) polycythemia
    B) hyperglycemia
    C) hypoglycemia
    D) anemia
    B) hyperglycemia
    (this multiple choice question has been scrambled)
  16. In planning a nutritionally sound vegetarian diet, the nurse needs to pay special attention to the inclusion of which nutrients?
    A) vitamins A and C
    B) simple carbohydrates
    C) fats
    D) complementary proteins
    D) complementary proteins
    (this multiple choice question has been scrambled)
  17. The nurse determines that teaching a patient who follows a strict vegetarian diet to include sufficient protein intake has been successful when the patient chooses which foods?
    A) scrambled eggs and toast
    B) broccoli and cauliflower
    C) black-eye peas and rice
    D) cereal and milk
    C) black-eye peas and rice
    (this multiple choice question has been scrambled)
  18. Which measurement does the nurse use to estimate the insertion depth when inserting a nasogastric tube for tube feedings?
    A) the distance from the tip of the nose to the sternal manubrial angle
    B) the distance from the tip of the earlobe to the top of the sternum
    C) the distance for the nose to the earlobe to the end of the sternum
    D) the distance from the mouth to the end of the xiphoid process
    C) the distance for the nose to the earlobe to the end of the sternum
    (this multiple choice question has been scrambled)
  19. Why should a ferrous sulfate (Feosol) capsule to taken with orange juice?
    A) to disguise the medication's bitter taste
    B) to aid in the medication's absorption
    C) to dissolve the medication more quickly
    D) to reduce gastrointestinal irritation
    B) to aid in the medication's absorption
    (this multiple choice question has been scrambled)
  20. Which patient has an increased need for vitamin C?
    A) A patient has a urine pH of 4.0 and low urine specific gravity.
    B) A patient is postoperative and smokes two packs of cigarettes per day.
    C) A patient is pregnant and has a history of preterm labor.
    D) A patient has diabetes mellitus and is on a weight reduction diet.
    B) A patient is postoperative and smokes two packs of cigarettes per day.
    (this multiple choice question has been scrambled)
  21. Which caregiver action for a client with a gastrostomy tube indicates effective home management?
    A) Proper positioning of the tube after each feeding is maintained.
    B) An empty feeding bag remains attached to the tubing.
    C) The tube is replaced on a weekly basis.
    D) The tube is flushed only after medication is given.
    A) Proper positioning of the tube after each feeding is maintained.
    (this multiple choice question has been scrambled)
  22. Which vitamin is most often lost during food preparation?
    A) A
    B) K
    C) D
    D) C
    D) C
    (this multiple choice question has been scrambled)
  23. Where is the principal site of water absorption in the intestinal tract?
    A) rectum
    B) jejunum
    C) colon
    D) duodenum
    C) colon
    (this multiple choice question has been scrambled)
  24. According to the Food Guide Pyramid, how many servings from the milk, yogurt, and cheese group are recommended each day?
    A) five
    B) three
    C) one
    D) seven
    B) three
    (this multiple choice question has been scrambled)
  25. Which factor would most likely account for a toddler's sudden decrease in appetite?
    A) the onset of food allergies
    B) the end of a growth spurt
    C) the eruption of permanent teeth
    D) the development of food dislikes
    B) the end of a growth spurt
    (this multiple choice question has been scrambled)
  26. The nurse should instruct patients who are at home and receiving total parenteral nutrition (TPN) to be alert for which sign of metabolic complication?
    A) tachycardia and hypotension
    B) high temperature and inflammation at insertion site
    C) excessive thirst and urination
    D) sharp chest pain and decreased breath sounds
    C) excessive thirst and urination
    (this multiple choice question has been scrambled)
  27. A meal consists of 115 grams of carbohydrate, 35 grams of protein, and 20 grams of fat. Approximately what percentage of kcalories comes from fat?
    A) 12%
    B) 20%
    C) 23%
    D) 30%
    C) 23%
    (this multiple choice question has been scrambled)
  28. A deficiency of which nutrient is responsible for pernicious anemia?
    A) folic acid
    B) riboflavin
    C) cobalamin
    D) iron
    C) cobalamin
    (this multiple choice question has been scrambled)
  29. An adult has an average daily intake of 1,600 kcalories and an average daily energy expenditure of 2,100 kcalories.  Assuming no changes in energy intake or expenditure, how many pounds is this person likely to lose in one month?
    A) 2
    B) 4
    C) 1
    D) 8
    B) 4
    (this multiple choice question has been scrambled)
  30. According to kosher dietary laws, which food is prohibited in a meal containing meat?
    A) eggs
    B) milk
    C) unleavened bread
    D) yellow vegetables
    B) milk
    (this multiple choice question has been scrambled)
  31. A patient with polycythemia is most at risk for developing which problem?
    A) hypoxia
    B) infection
    C) thrombus
    D) hemorrhage
    C) thrombus
    (this multiple choice question has been scrambled)
  32. How does the inhalation of carbon monoxide affect oxygenation?
    A) It causes peripheral vasoconstriction
    B) It inhibits cellular respiration.
    C) It interferes with the release of surfactant in the alveolar linings.
    D) It exerts a toxic effect on the airways.
    B) It inhibits cellular respiration.
    (this multiple choice question has been scrambled)
  33. Which finding is characteristic in a patient with left-sided heart failure?
    A) one pillow orthopnea
    B) fatigue
    C) O2 saturation of 94%
    D) dyspnea upon exertion
    D) dyspnea upon exertion
    (this multiple choice question has been scrambled)
  34. Which intervention should the nurse implement for a patient receiving oxygen through a nasal cannula?
    A) Inspect the mouth for redness each day.
    B) Check the patency of the cannula every 2 hours.
    C) Assess the nares for skin breakdown every 8 hours.
    d) Check to make sure the liter flow is set at 10 or above every 3 hours.
    C) Assess the nares for skin breakdown every 8 hours.
    (this multiple choice question has been scrambled)
  35. The nurse is assessing the patient's pulse and notes a pulse rate of 128 beats/min. Which term describes this clinical finding?
    A) bradypnea
    B) bradycardia
    C) tachypnea
    D) tachycardia
    D) tachycardia
    (this multiple choice question has been scrambled)
  36. Which type of mask is recommended for precise regulation of oxygen delivery?
    A) partial rebreather
    B) Venturi
    C) simple mask
    D) non-rebreather
    B) Venturi
    (this multiple choice question has been scrambled)
  37. Which person will have the highest respiratory rate?
    A) the person who is sunbathing at the beach
    B) the person who is waiting in the cold for a bus
    C) the person who is sitting in a poorly ventilated area
    D) the person who is resting on the top of a mountain
    D) the person who is resting on the top of a mountain
    (this multiple choice question has been scrambled)
  38. Which finding is a client's lower extremities should lead the nurse to suspect venous insufficiency?
    A) leathery skin texture
    B) pallor
    C) swollen joints
    D) tenderness to touch
    A) leathery skin texture
    (this multiple choice question has been scrambled)
  39. Which assessment finding is an objective sign of chronic oxygen deprivation?
    A) clubbing of the fingers
    B) fatigue
    C) chest pain
    D) dyspnea
    A) clubbing of the fingers
    (this multiple choice question has been scrambled)
  40. When performing a suctioning procedure, the nurse should include which action?
    A) Insert the catheter no more that 8 inches.
    B) Apply suction for no longer than 20 seconds.
    C) Rotate the catheter while applying suction.
    D) Apply gentle suction during the insertion of the catheter.
    C) Rotate the catheter while applying suction.
    (this multiple choice question has been scrambled)
  41. What is the primary purpose of assessing a patient's oxygenation status using pulmonary function tests?
    A) to identify breath sounds
    B) to detect presence of hypoxemia
    C) to measure lung volume
    D) to determine pulse rate
    C) to measure lung volume
    (this multiple choice question has been scrambled)
  42. Which best explains why a patient with a chronic respiratory illness experiences exacerbations of the illness at high altitudes?
    A) There are atmospheric differences in the heavy cold air at higher altitudes.
    B) There are atmospheric differences in the heavy cold air at higher altitudes.
    C) Pollutants rise, making them more concentrated at higher altitudes.
    D) There is a decrease in partial pressure of oxygen at higher altitudes.
    A) There are atmospheric differences is the heavy cold air at higher altitudes.
    (this multiple choice question has been scrambled)
  43. Which method of oxygen delivery provides the patient with an oxygen concentration of greater than 80 percent?
    A) non-rebreather mask
    B) nasal cannula
    C) face mask
    D) Venturi mask
    A) non-rebreather mask
    (this multiple choice question has been scrambled)
  44. Which pattern is characteristic of an infant?
    A) retention of air in the lungs and bradycardia
    B) 80 breaths/min and irregular pulse
    C) abdominal breathing and sinus arrhythmia
    D) 25 breaths/min and rapid pulse
    C) abdominal breathing and sinus arrhythmia
    (this multiple choice question has been scrambled)
  45. At which time of day will a patient benefit most from postural drainage?
    A) after morning care
    B) before breakfast
    C) before oral hygiene
    D) after lunch
    B) before breakfast
    (this multiple choice question has been scrambled)
  46. Which finding should the nurse expect to observe in a patient with Biot's respiration?
    A) increasing inspiratory time with short grunting
    B) respiratory rate less and 12/min
    C) tachypnea and deep respirations
    D) apnea and shallow respirations
    D) apnea and shallow respirations
    (this multiple choice question has been scrambled)
  47. Which type of respiration accompanies congestive heart failure?
    A) Kussmaul's
    B) Biot's
    C) Cheyne-Stokes
    D) apneustic
    C) Cheyne-Stokes
    (this multiple choice question has been scrambled)
  48. Which instruction should the nurse give to a patient concerning the use of a volume-oriented incentive spirometer?
    A) Blow slowly into the spirometer until the bellows are fully raised.
    B) Inhale rapidly to raise the bellows and repeat this three times.
    C) Inhale slowly to maximum volume and hold for three seconds.
    D) Take a deep breath and blow into the spirometer as fast as possible.
    C) Inhale slowly to maximum volume and hold for three seconds.
    (this multiple choice question has been scrambled)
  49. Which statement is true related to pulmonary volumes and capacities?
    A) Lung expansion is dependent upon normal breathing and vital capacity.
    B) Total lung capacity is equal to tidal volume plus residual volume.
    C) Tidal volumes are larger in young female adults than in young male adults.
    D) Residual volume is normally about 50% of the total lung capacity.
    A) Lung expansion is dependent upon normal breathing and vital capacity.
    (this multiple choice question has been scrambled)
  50. An apical-radial pulse is taken to determine which pulse characteristic?
    A) pressure
    B) rhythm
    C) volume
    D) deficit
    D) deficit
    (this multiple choice question has been scrambled)

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