EXN105B

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Anonymous
ID:
299089
Filename:
EXN105B
Updated:
2015-03-24 17:23:02
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Excelsior
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Excelsior
Description:
Excelsior N105 Form B
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  1. Which intervention is appropriate for a patient with an indwelling (Foley) catheter?
    A) Empty the drainage bag once every 24 hours.
    B) Place the drainage bag at the level of the bladder.
    C) Maintain a closed drainage system.
    D) Use Betadine antiseptic for routine catheter care.
    C) Maintain a closed drainage system.
    (this multiple choice question has been scrambled)
  2. The nurse provides discharge teaching for a patient who is going home with a new colostomy.  The patient asks the nurse how to clean the ostomy.  Which instruction is appropriate?
    A) Scrub with gauze and hydrogen peroxide.
    B) Scrub with a washcloth and deodorant soap.
    C) Clean with sterile gauze and betadine.
    D) Clean with a washcloth and warm tap water.
    D) Clean with a washcloth and warm tap water.
    (this multiple choice question has been scrambled)
  3. Which fluid should the nurse use to administer an enema to an infant?
    A) mineral oil
    B) castile soap
    C) tap water
    D) normal saline
    D) normal saline
    (this multiple choice question has been scrambled)
  4. The nurse should expect to test the urine of a patient with uncontrolled diabetes mellitus for which product?
    A) occult blood
    B) specific gravity
    C) urinary pH
    D) ketone bodies
    D) ketone bodies
    (this multiple choice question has been scrambled)
  5. The RN is observing a new graduate nurse applying an external catheter to a male patient.  Which action indicates that the graduate nurse is performing the procedure incorrectly?
    A) thoroughly washes and dries the genital area.
    B) positions the patient in a bed-setting position.
    C) applies the external catheter directly over the tip of the penis.
    D) attaches the urinary drainage bag to the leg.
    C) applies the external catheter directly over the tip of the penis.
    (this multiple choice question has been scrambled)
  6. A patient with impaired kidney function should avoid which type of cathartic?
    A) emollient
    B) stimulant
    C) bulk forming
    D) saline
    D) saline
    (this multiple choice question has been scrambled)
  7. An appropriate nursing intervention for a patient experiencing flatulence is to have the patient restrict which activity?
    A) consuming hot tea
    B) sucking hard candies
    C) eating spicy foods
    D) drinking through straws
    D) drinking through straws
    (this multiple choice question has been scrambled)
  8. Which statement from a patient's history represents an increased risk for constipation?
    A) "I have a bowel movement every two or three days."
    B) "I walk one mile three times a week."
    C) "I drink two glasses of water a day."
    D) "I eat fruits but don't like vegetables."
    C) "I drink two glasses of water a day."
    (this multiple choice question has been scrambled)
  9. When performing a digital removal of fecal impaction, the nurse should periodically assess the patient for which response?
    A) change in pulse rate
    B) blood in the feces
    C) complaints of rectal discomfort
    D) complaints of flatulence
    A) change in pulse rate
    (this multiple choice question has been scrambled)
  10. A nurse identifies the nursing diagnosis "altered patterns of urinary elimination: frequency related to UTI" as being appropriate for the client who was diagnosed with a UTI. Which client outcome would demonstrate that this problem has been resolved?
    A) absence of edema
    B) absence of pain
    C) normal temperature
    D) normal voiding pattern
    D) normal voiding pattern
    (this multiple choice question has been scrambled)
  11. A patient complains of nausea, has a distended abdomen, is passing liquid stool, but has had no formed bowel movement in three days.  The nurse should assess the patient for which problem?
    A) fecal incontinence
    B) diarrhea
    C) constipation
    D) fecal impaction
    D) fecal impaction
    (this multiple choice question has been scrambled)
  12. What altered elimination pattern is most likely affecting a patient who experiences a  small loss of urine upon coughing, sneezing, or laughing?
    A) reflex incontinence
    B) functional incontinence
    C) stress incontinence
    D) urge incontinence
    C) stress incontinence
    (this multiple choice question has been scrambled)
  13. A patient complains of feeling bloated.  The nursing assessment reveals that the patient last had a small, formed stool four days ago.  The patient reports normally having a soft, formed bowel movement each morning. Based on this data, which nursing diagnosis is most appropriate?
    A) self-care deficit, toileting
    B) constipation
    C) pain
    D) perceived constipation
    B) constipation
    (this multiple choice question has been scrambled)
  14. Which food should the nurse include when selection a menu for a school age child who is at risk for constipation?
    A) rice
    B) popcorn
    C) bananas
    D) cheese
    B) popcorn
    (this multiple choice question has been scrambled)
  15. Which diagnostic study is used to determine the  presence of occult blood in a patient's stool?
    A) checking the melena
    B) colonoscopy
    C) guaiac
    D) bilirubin test
    C) guaiac
    (this multiple choice question has been scrambled)
  16. Which question by the nurse should most effectively elicit information about the quality of a patient's sleep?
    A) "Do you feel rested today?"
    B) "Do you dream a lot?"
    C)" Do you take a nap often?"
    D) "Do you have trouble getting to sleep?"
    A) "Do you feel rested today?"
    (this multiple choice question has been scrambled)
  17. Which is characteristic of rapid eye movement (REM) sleep?
    A) slow, regular respirations
    B) dilated peripheral blood vessels
    C) depressed muscle tone
    D) decreased brain metabolism
    C) depressed muscle tone
    (this multiple choice question has been scrambled)
  18. Which is a clinical manifestation of sleep deprivation?
    A) intense concentration
    B) precise speech
    C) animated facial expression
    D) excitability
    D) excitability
    (this multiple choice question has been scrambled)
  19. When implementing a discharge plan for a patient with insomnia, the nurse should discourage the patient from which practice?
    A) eating a light bedtime snack of cheese, crackers, and milk
    B) taking a warm bath before going to bed.
    C) exercising one or two hours before going to bed.
    D) drinking several glasses of wine before going to bed.
    D) drinking several glasses of wine before going to bed.
    (this multiple choice question has been scrambled)
  20. The nurse employs measures at bedtime to induce sleep in a patient who is experiencing a sleep pattern disturbance.  Under what circumstances should the nurse modify the plan of care?
    A) The patient awakens in the morning complaining of fatigue.
    B) The patient awakens in the morning complaining of fatigue.
    C) The patient awakens feeling rested, but requires a nap in the day.
    D) The patient experiences pain on awakening in the morning.
    A) The patient awakens in the morning complaining of fatigue.
    (this multiple choice question has been scrambled)
  21. Which observation indicates that a patient is responding positively to oxygen therapy?
    A) hyperpnea
    B) eupnea
    C) orthopnea
    D) dyspnea
    B) eupnea
    (this multiple choice question has been scrambled)
  22. Which instruction should the nurse include when teaching a patient pursed-lip breathing?
    A) Inhale through the nose and exhale through pursed lips.
    B) Inhale through the nose, keeping the lips pursed.
    C) Inhale and exhale through pursed lips.
    D) Inhale through the mouth and exhale through pursed lips.
    A) Inhale through the nose and exhale through pursed lips.
    (this multiple choice question has been scrambled)
  23. What changes related to the respiratory system should the nurse anticipate in the older adult?
    A) decreased mucociliary clearance
    B) decreased size of alveoli
    C) increased chest wall compliance
    D) increased elastic recoil
    A) decreased mucociliary clearance
    (this multiple choice question has been scrambled)
  24. Which statement by the LPN/LVN indicates the need for in-service education about oxygen delivery?
    A) "The non-rebreather mask is contraindicated in patients with chronic airway obstruction."
    B) "A simple face mask should be used to deliver oxygen to 2 to 3 L/min.
    C) "Oxygen delivered by nasal cannula at 5 to 6 L/min should be humidified."
    D) "The non-rebreather mask bag should be kept inflated at all times when in use."
    B) "A simple face mask should be used to deliver oxygen to 2 to 3 L/min.
    (this multiple choice question has been scrambled)
  25. The nurse is performing postural drainage on a patient who is confused and has difficulty hearing.  The patient does not cough when instructed to cough.  Which action should the nurse implement next?
    A) Administer an expectorant from a prn order.
    B) Perform nasal tracheal suctioning.
    C) Offer the patient a large glass of water.
    D) Provide oxygen on 2 L/min via nasal cannula.
    B) Perform nasal tracheal suctioning.
    (this multiple choice question has been scrambled)
  26. Which early sign should the nurse expect to assess in a client experiencing hypoxia?
    A) enlarged liver
    B) constricted pupils
    C) cyanosis
    D) confusion
    D) confusion
    (this multiple choice question has been scrambled)
  27. Which person will have the lowest respiratory rate?
    A) the person who is resting on top of a mountain.
    B) the person who is sunbathing at the beach.
    C) the person who is waiting in the cold for a bus.
    D) the person who is sitting in a poorly ventilated area.
    C) the person who is waiting in the cold for a bus.
    (this multiple choice question has been scrambled)
  28. Which laboratory finding should the nurse expect for a patient who develops polycythemia secondary to chronic hypoxia?
    A) increased hematocrit
    B) decreased platelets
    C) increased white blood cells
    D) decreased blood urea nitrogen
    A) increased hematocrit
    (this multiple choice question has been scrambled)
  29. Which type of respiration accompanies metabolic acidosis?
    A) Biot's
    B) Cheyne-Stokes
    C) apneustic
    D) Kussmaul's
    D) Kussmaul's
    (this multiple choice question has been scrambled)

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