EXN105B

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Author:
ndarlenebeck
ID:
299093
Filename:
EXN105B
Updated:
2015-03-24 19:59:17
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Excelsior
Folders:
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-sitting 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 the patient's history represents an increased risk for constipation?
    A) "I have a bowel movement every two or three days."
    B) "I walk on 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 pattern 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 nurse 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 selecting 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 after having slept eight hours.
    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 patient with chronic airway obstruction."
    B) "A simple face mask should be used to deliver oxygen at 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 at 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 at 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 the 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 is 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)
  30. From which area should a specimen for a throat culture be obtained?
    A) upper palate
    B) gingiva
    C) pharynx
    D) buccal mucosa
    C) pharynx
    (this multiple choice question has been scrambled)
  31. Hypercapnia describes the elevation of which substance?
    A) carbon dioxide
    B) serum calcium
    C) sodium bicarbonate
    D) oxygen
    A) carbon dioxide
    (this multiple choice question has been scrambled)
  32. Which instruction should the community health nurse give to the patient who is prescribed oxygen therapy?
    A) electronic equipment
    B) a room humidifier
    C) fingernail polish
    D) cotton blankets
    C) fingernail polish
    (this multiple choice question has been scrambled)
  33. What is the primary purpose of assessing a patient's oxygenation status using a pulse oximeter?
    A) to determine pulse rate
    B) to measure lung volume
    C) to identify breath sounds
    D) to detect presence of hypoxemia
    D) to detect presence of hypoxemia
    (this multiple choice question has been scrambled)
  34. Which best describes tidal volume?
    A) the volume of air (mL) inhaled and exhaled per breath
    B) the volume of air (mL) exhaled after a maximum inhalation
    C) the volume of air (mL) in the lungs following a maximal inhalation
    D) the volume of air (mL) left in the lungs after maximal exhalation
    A) the volume of air (mL) inhaled and exhaled per breath
    (this multiple choice question has been scrambled)
  35. Prior to suctioning the nasopharyngeal cavity of a patient who is unconscious, the nurse should place the patient in which position?
    A) semi-Fowler's
    B) high-Fowler's
    C) lateral
    D) supine
    C) lateral
    (this multiple choice question has been scrambled)
  36. What is the physiological response to living at a high altitude?
    A) decreased blood pressure
    B) increased hematocrit levels
    C) increased oxygen saturation
    D) decreased respiratory excursion
    B) increased hematocrit levels
    (this multiple choice question has been scrambled)
  37. The nurse is assessing the patient's pulse and notes a pulse rate of 50 beats/min. Which term describes this clinical finding?
    A) tachycardia
    B) bradypnea
    C) tachypnea
    D) bradycardia
    D) bradycardia
    (this multiple choice question has been scrambled)
  38. Which type of mask delivers the highest possible oxygen concentration?
    A) partial rebreather
    B) Venturi
    C) non-rebreather
    D) simple face
    C) non-rebreather
    (this multiple choice question has been scrambled)
  39. A client admitted with chronic obstructive pulmonary disease (COPD) is in respiratory failure. Which arterial blood gas results should the nurse expect for this client?
    A) pH 7.45, pCO2 37, HCO3 22
    B) pH 7.33, pCO2 55, HCO3 29
    C) pH 7.48, pCO2 31, HCO3 20
    D) pH 7.40, pCO2 41, HCO3 24
    B) pH 7.33, pCO2 55, HCO3 29
    (this multiple choice question has been scrambled)
  40. Which finding should the nurse expect to observe in a patient with Kussmaul's respiration?
    A) respiratory rate less than 12/min
    B) apnea and shallow respirations
    C) increasing inspiratory time with short grunting
    D) tachypnea and deep respirations
    D) tachypnea and deep respirations
    (this multiple choice question has been scrambled)
  41. Which clinical manifestation is indicative of thrombophlebitis in the lower leg of a light skinned patient?
    A) pain on dorsiflexion of the foot
    B) loss of function in the foot
    C) bluish discoloration of the leg
    D) blanching of the leg
    A) pain on dorsiflexion of the foot
    (this multiple choice question has been scrambled)
  42. Which safety instruction should the nurse include in the teaching plan for a patient who is learning to use a cane?
    A) Be sure the body weight is on both legs at all times.
    B) Move the cane and the stronger leg together.
    C) Hold the cane away from the body.
    D) Wear rubber-soled shoes or slippers.
    D) Wear rubber-soled shoes or slippers
    (this multiple choice question has been scrambled)
  43. Which instruction will help minimize the effect of orthostatic hypotension in a patient when helping the patient get out of bed?
    A) Sit up in bed before getting out of bed.
    B) Get out of bed after eating.
    C) Take a deep breath before transfer.
    D) Create a wider base of support.
    A) Sit up in bed before getting out of bed.
    (this multiple choice question has been scrambled)
  44. Which intervention is a priority when assisting a hospitalized ten year old in traction to deal with the monotony of immobilization?
    A) Assist the patient to change positions frequently.
    B) Urge the parents to feed and bathe their child.
    C) Encourage the patient to wear personal clothing from home.
    D) Request that the parents urge their child's friends to call or visit.
    D) Request that the parents urge their child's friends to call or visit.
    (this multiple choice question has been scrambled)
  45. Which physiological change that is associated with aging makes older adults particularly susceptible to fractures?
    A) bone demineralization
    B) vitamin D deficiency
    C) loss of cartilage
    D) loss of muscle tone
    A) bone demineralization
    (this multiple choice question has been scrambled)
  46. Which motor skill would a six month old infant usually be striving to accomplish?
    A) achieving head control
    B) picking up tiny objects
    C) sitting steadily without support
    D) pulling self to a standing position
    C) sitting steadily without support
    (this multiple choice question has been scrambled)
  47. What is the rationale for encouraging a patient who is immobile to perform leg exercises?
    A) to prevent orthostatic hypotension
    B) to promote full long expansion
    C) to prevent thrombus formation
    D) to increase the cardiac workload
    C) to prevent thrombus formation
    (this multiple choice question has been scrambled)
  48. A patient who is immobile has a nursing diagnosis of risk for impaired skin integrity related to sensory deficit. To prevent injury to the patient, the nurse should include which action in the plan of care?
    A) Keep the patient's siderails padded at all times.
    B) Position the patient in a dorsal recumbent position.
    C) Place heel protectors on the patient's feet.
    D) Place trochanter rolls lateral to the femur.
    C) Place heel protectors on the patient's feet.
    (this multiple choice question has been scrambled)
  49. The nurse places a patient in right Sim's position. Which observation would indicate proper body alignment?
    A) a trochanter roll is placed at the right thigh.
    B) Pillows are placed under the head, left arm, and left leg.
    C) The patient's neck is flexed at a 90 degree angle.
    D) The patient's knees are flexed equally.
    B) Pillows are placed under the head, left arm, and left leg.
    (this multiple choice question has been scrambled)
  50. Which intervention will best prevent contractures in a patient who is confined to bed?
    A) Have the patient perform range of motion exercises.
    B) Keep the patient's joints in a brace.
    C) Keep the patient's joints warm.
    D) Turn the patient every two hours.
    A) Have the patient perform range of motion exercises.
    (this multiple choice question has been scrambled)

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