exam 1

Question 1

Florence Nightingale

Answer 1

focused on improving sanitation, temperature, light and well being of the pt; organized the first school of nursing

Question 2

Mary Adelaide Nutting

Answer 2

first professor at Columbia teachers college

Question 3

Benners Stages of Nursing Proficiency

Answer 3

1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

Question 4

Communication

Answer 4

process of interaction b/w people which symbols are used to create, exchange & interpret messages about ideas, emotions and mind states

Question 5

Intrapersonal

Answer 5

with yourself

Question 6

Interpersonal

Answer 6

communication b/w you and someone else

Question 7

Small group

Answer 7

2 or more people

Question 8

Paralinguistic Communication

Answer 8

non-verbal

Question 9

Meta-communication

Answer 9

context of the message

Question 10

Nurse-Patient Relationship

Answer 10

caring relationship, make sure there is boundaries, facilitate positive change and growth

Question 11

Pre-interaction Phase

Answer 11

occurs before meeting the pt

- pre assessment, getting report

Question 12

Orientation phase

Answer 12

nurse and pt. meeting, getting to know eachother

Question 13

AIDET

Answer 13

A: acknowledge
I: introduce
D: duration
E: explanation
T: Thank you

Question 14

Working Phase

Answer 14

nurse and pt. work together to solve problems and accomplish goals
ex: gather further data, asking pt preferences, evaluate needs and reassess

Question 15

Termination Phase

Answer 15

occurs at the end of the relationship (stay)

ex: summarize goals and objectives
- also at end of shift

Question 16

Therapeutic Communication Techniques

Answer 16

using silence, active listening, clarifying techniques, don’t give false hope

Question 17

Non- Therapeutic Communication Techniques

Answer 17

false reassurance, telling them not to worry, not listening, bad attitude

Question 18

Assessment

Answer 18

• health hx
• subjective & objective info
• diagnostic labs
• family dynamic
• environment

Question 19

Diagnosis

Answer 19

• potential problems

- actual problems

Question 20

Goals

Answer 20

smart, specific, measurable, attainable, realistic, timely

Question 21

Actions/Interventions

Answer 21

plan of care, education, rationale

assess pt’s rx to treatments, ask their input

Question 22

Evaluation

Answer 22

was the goal met, what was helpful, what to do better next time

Question 23

Culture

Answer 23

pattern of shared attitudes or beliefs, self-definitions, norms

Question 24

Enculturation

Answer 24

process by which a person learns norms, values, and behaviors of another culture
ex: HS student from the U.S spends a summer abroad with a family in Sweden

Question 25

Acculturation

Answer 25

process of acquiring new attitudes, roles, customs or behaviors
ex: immigrant from China develops a preference for western food and music

Question 26

Assimilation

Answer 26

process by which a person gives up his or her original identity and develops a new culture culture becoming absorbed into the dominant group
ex: Native American loses his native identity after living in Chicago for 10 years

Question 27

Biculturalism

Answer 27

dual pattern of identification

ex: woman of christian faith marries a muslim, adopts some Muslim practices, and maintains some christian practices

Question 28

Cultural Awareness

Answer 28

self-examination of ones biases towards other cultures

Question 29

Cultural Knowledge

Answer 29

learning or becoming educated about beliefs and values of other cultures
- health related (treatments)

Question 30

Cultural Skill

Answer 30

Collect Pt. Hx
- ensure language competence, make sure assistances is avliable
Assess Health Literacy
- find out what they know about health/what they want to discuss
Culturally Based Physical Assessment
- ask preference

Question 31

RESPECT MODEL

Answer 31

• what do they call the problem? (ex: not calling it cancer, call it the lump)
• what do you think caused the problem?
• why do you think it started?
• What do you think the sickness does?
• How severe is the sickness?
• What kind of tx’s should the pt. recieve
• What are the chief problems of the sickness?
• What does the pt. fear the most?

Question 32

Emic

Answer 32

insider world view

Question 33

Etic

Answer 33

outsider world view

Question 34

Intersectionality

Answer 34

a model that described the forces, factors and structures that shape and influence life

1. privilege
2. oppression

Question 35

Family Assessment

Answer 35

family-centers approach establishes a working relationship w the pt. and family

• determine pt.’s attitude towards family
• cultural aspects
• discharge planning

Question 36

Macronutrients

Answer 36

kilocalorie containing sources of carbs, proteins, fats

Question 37

Micronutrients

Answer 37

vitamins and minerals

Question 38

Phytochemical’s

Answer 38

plant compounds that promote health through antioxidants, anti-inflammatory and immune boosting properties
ex: tomatoes

Question 39

Malnutriton

Answer 39

suboptimal state w/ either insufficient or excessive quantity or quality of macro and micronutrients

Question 40

Sarcopenia

Answer 40

condition of loss of muscle mass and strength

Question 41

Anasarca

Answer 41

generalized edema characterized by fluid overload; due to hypoabuminemia

Question 42

Risk Factors Related to Nutrition

Answer 42

-age, race & ethnicity, genetics, socioeconomic status

Question 43

Basal Metabolic Rate

Answer 43

energy needs at rest to maintain life-sustaining activities for a specific amount of time

Question 44

Resting Energy Expenditure

Answer 44

amount of energy need to consume over 24 hours for the body to maintain internal working activities while at rest

Question 45

Carbohydrates

Answer 45

complex and simple saccharides; main source of energy

Question 46

Proteins

Answer 46

amino acids; necessary for nitrogen balance

Question 47

Fats

Answer 47

calorie-dense

Question 48

Pinocytosis

Answer 48

during absorption, doesn’t pass through cell, has to become bound to another cell to get through

Question 49

Metabolism

Answer 49

all biochemical rxns w/in the cells of the body

Question 50

Anabolism

Answer 50

building of more complex biochemical substances by synthesis of nutrients (glycogenesis)

Question 51

Catabolism

Answer 51

breakdown of biochemical substances into smaller substances; occurs during physiological states of negative nitrogen balance (glycogenolysis)

Question 52

Dietary Reference Intakes (DRI’s)

Answer 52

acceptable range of quantities of vitamins & minerals for each gender & age group

Question 53

Assessment (nutrition)

Answer 53

• assess pt. nutrition hx

- food preferences etc

Question 54

Anthropometry

Answer 54

height & weight (BMI)

Question 55

Glucose Measurements

Answer 55

HgA1c blood test; reflects metabolism of carbs; over time

Question 56

Serum Albumin

Answer 56

-measures protein in blood

Low: protein-calorie malnutrition, inflammation, blood loss, altered fluid status

Question 57

Pre-Albumin

Answer 57

reflects recent protein intake

Low: more closely related to nutritional status than albumin

Question 58

C-reactive

Answer 58

• identifies inflammation w/ low serum albumin

Question 59

Unsaturated Fats

Answer 59

Monounsaturated: canola, peanut oil, avocados
Polyunsaturated: corn, soybean oils

Question 60

Saturated Fats

Answer 60

fatty beef, butter, cured meats

Question 61

Trans Fats

Answer 61

• worst for you

ex: French fries, processed foots

Question 62

Clear Liquid Diet

Answer 62

must be see through

ex: jello, broths

Question 63

Full Liquid Diet

Answer 63

clears, milk products, creams, soups, custards

Question 64

Pureed Diet

Answer 64

soft foots, pureed foods

Question 65

Mechanical Soft Diet

Answer 65

pureed, soft diced foots

Question 66

Soft/Low Residual Diet

Answer 66

low fiber foods

Question 67

High Fiber

Answer 67

fruits, steamed veggies, bran, oatmeal

Question 68

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication?

1. check need for adaptive equipment
2. exaggerate lip movements to help the pt. lip-read
3. give the pt. time to response to questions
4. keep communication short and to the point
5. communicate only through written information

Answer 68

1,3,4

Question 69

Nursings must communicate effectively with the health care team for which of the following reasons?

1. to improve the nurses status with health care team members
2. to reduce the risk of errors to the pt
3. to provide optimum levels of patient care
4. to improve patient outcomes
5. to prevent issues that needed to be reported to outside agencies

Answer 69

2,3,4

Question 70

Motivational interviewing (MI) is a technique that applies understanding a patients values and goals in helping the patient make behavioral changes. When using MI, what outcomes does the nurse expect?

1. gaining an understand of the pt’s motivations
2. directing the pt. to avoid poor health choices
3. recognizing the pt.’s strengths and supporting his or her efforts
4. providing assessment data that can be shared with families to promote change
5. identifying differences in pt;s health goals and current behaviors

Answer 70

1,3,5

Question 71

The nurse therapeutically responds to an adult pt. who is anxious by:

1. match the rate of speed to be the same of that as the pt.
2. provide good eye contact
3. demonstrate a calm presence
4. spending time attentively with the pt
5. assuring the pt that all will be well

Answer 71

2,3,4

Question 72

A nurse prepares to contact a patient’s physician about a change in the patient’s condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication.

1. “She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 PM yesterday. She states she has a poor appetite; her weight has remained stable over the past 2 days.”
2. “The patient reported feeling very nauseated after her dose of levofloxacin an hour ago.”
3. “Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?”
4. “The patient started to complain of nausea yesterday evening and has vomited several times during the night.”

Answer 72

4,1,2,3

Question 73

The patient states, “I don’t have confidence in my doctor. She looks so young.” The nurse therapeutically responds: (Select all that apply.)

1. Tell me more about your concern.
2. You have nothing to worry about. Your doctor is perfectly competent.
3. You are worried about your care?
4. You can go online and see how others have rated your doctor. I do that.
5. You should ask your doctor to tell you her background.

Answer 73

1,3

Question 74

The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.)

1. Validate health care needs through verbal discussion with the patient.
2. Compare actual and expected patient care outcomes with the patient.
3. Provide support through therapeutic communication techniques.
4. Complete a nursing history using verbal communication techniques.

Answer 74

4,1,3,2

Question 75

A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurse’s statements in order according to these phases.

1. The nurse states, “Let’s work on learning injection techniques.”
2. The nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency.
3. The nurse summarizes progress made during the nursing relationship.
4. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship.

Answer 75

2,4,1,3

Question 76

Which strategies should a nurse use to facilitate a safe transition of care during a patient’s transfer from the hospital to a skilled nursing facility? (Select all that apply.)

1. Collaboration between staff members from sending and receiving departments
2. Requiring that the patient visit the facility before a transfer is arranged
3. Using a standardized transfer policy and transfer tool
4. Arranging all patient transfers during the same time each day
5. Relying on family members to share information with the new facility

Answer 76

1,3

Question 77

The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse’s silence? (Select all that apply.)

1. Allows the nurse time to focus and avoid saying the wrong thing
2. Prompts the patient to talk when he or she is ready
3. Allows the patient time to think and gain insight
4. Allows time for the patient to drift off to sleep
5. Determines whether the patient would prefer to talk with another staff member

Answer 77

2,3

Question 78

Which of the following is an example of a patient with a health disparity? (Select all that apply.)

1. A patient who has a homosexual sexual preference
2. A patient unable to access primary care services
3. A patient living with a chronic disease
4. A family who relies on public transportation
5. A patient who has had a history of smoking for 10 years

Answer 78

2,3,5

Question 79

A 35-year-old woman has Medicaid coverage for herself and two young children. She missed an appointment at the local health clinic to get an annual mammogram because she has no transportation. She gets the annual screening because her mother had breast cancer. Which of the following are social determinants of this woman’s health? (Select all that apply.)

1. Medicaid insurance
2. Annual screening
3. Mother’s history of breast cancer
4. Lack of transportation
5. Woman’s age

Answer 79

1,4,5

Question 80

. Health care organizations must provide which of the following based on federal civil rights laws? (Select all that apply.)

1. Provide language assistance services at all points of contact free of charge.
2. Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services.
3. Use patients’ family members to interpret difficult topics.
4. Ensure that interpreters are competent in medical terminology.
5. Provide language assistance to all patients who speak limited English or are deaf.

Answer 80

1,2,4,5

Question 81

A nurse working in a large occupational health clinic knows that many of the workers at her company are marginalized and at risk for poor health outcomes. Which of the following individuals are most likely to be marginalized?

1. Wives of the employees
2. The head supervisors of the company
3. Workers who have a high school education
4. Workers employed for less than a year at the company

Answer 81

3

Question 82

A mother is concerned about her child’s flulike symptoms. You learn from the health assessment that the mother practices use of “hot” and “cold” foods to treat ailments. Which of the following foods do you expect the mother to use to treat her child?

1. Chicken
2. Yogurt
3. Fresh fruits
4. Eggs

Answer 82

4

Question 83

Which explanation provided by the nurse is the most accurate meaning for “providing culturally congruent care”?

1. It fits the patient’s valued life patterns and set of meanings.
2. It is the same set of values as those of the health care team member providing daily care.
3. It holds one’s own way of life as superior to those of others.
4. It redirects the patient to a more socially expected set of values.

Answer 83

1

Question 84

Which statement made by a new graduate nurse about the teach-back technique requires intervention and further instruction by the nurse’s preceptor?

1. “After teaching a patient how to use an inhaler, I need to use the teach-back technique to test my patient’s technique.”
2. “The teach-back technique is an ongoing process of asking patients for feedback.”
3. “Using teach-back will help me identify explanations and communication strategies that my patients will most commonly understand.”
4. “Using pictures, drawings, and models can enhance the effectiveness of the teach-back technique.”

Answer 84

1

Question 85

Which statement made by a new graduate nurse about the teach-back technique requires intervention and further instruction by the nurse’s preceptor?

1. “After teaching a patient how to use an inhaler, I need to use the teach-back technique to test my patient’s technique.”
2. “The teach-back technique is an ongoing process of asking patients for feedback.”
3. “Using teach-back will help me identify explanations and communication strategies that my patients will most commonly understand.”
4. “Using pictures, drawings, and models can enhance the effectiveness of the teach-back technique.”

Answer 85

1

Question 86

A family includes a mother, a stepfather, two teenage biological daughters of the mother, and a biological daughter of the father. The father’s daughter just moved home following the loss of her job in another city. The family is converting a study into a bedroom and is in the process of distributing household chores. Nursing assessment reveals all members of the family think that their family can adjust to lifestyle changes. This is an example of family:

1. Diversity.
2. Durability.
3. Resiliency.
4. Configuration.

Answer 86

3

Question 87

A mother and her two children are homeless and enter a free health care clinic. Which statements most likely describe the effects of homelessness on this family? (Select all that apply.)

1. The children have stability in their education.
2. The family members may have symptoms of malnutrition, such as anemia.
3. The family is at a low risk for experiencing violence.
4. The children are at higher risk for developing ear infections.
5. All family members may have mental health issues.

Answer 87

2,4,5

Question 88

A nurse is caring for a 66-year-old patient who lives alone and is receiving chemotherapy and radiation for a new cancer diagnosis. He is unable to care for himself because of severe pain and fatigue. He moves into his 68-year-old brother’s home so his brother can help care for him. Which assessment findings indicate that this family caregiving situation will be successful? (Select all that apply.)

1. Both the patient and his brother attend church together regularly.
2. The brothers are living together and enjoy eating the same foods.
3. Other siblings live in the same city and are willing to help.
4. The patient and his brother have a close network of friends.
5. The patient has obsessive-compulsive disorder and has difficulty throwing away possessions.

Answer 88

1,3,4

Question 89

A family is facing job loss of the father, who is the major wage earner, and relocation to a new city where there is a new job. The children will have to switch schools, and his wife will have to resign from the job she enjoys. Which of the following contribute to this family’s hardiness? (Select all that apply.)

1. Family meetings
2. Established family roles
3. New neighborhood
4. Willingness to change in time of stress
5. Passive orientation to life

Answer 89

1,2,4

Question 90

A patient who is newly diagnosed with breast cancer states, “Although I am really scared about what is going to happen to me, I know my family will learn from this experience, and we will be stronger in the end.” What term does the nurse use in the patient’s 133medical record to describe the characteristic displayed in this statement?

1. Resiliency
2. End-of-life care
3. Family functioning
4. Family’s culture

Answer 90

1

Question 91

A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. The nurse focuses on symptom management for the grandmother and on helping the family with developing coping skills. This approach is an example of which of the following?

1. Family as context
2. Family as patient
3. Family as a system
4. Family as structure

Answer 91

2

Question 92

A 7-year-old child was recently diagnosed with asthma. A nurse is providing education to the child and her parents about the treatment and management of asthma and changes they need to make in their home environment to promote her health. Which statement made by the parents requires follow-up by the nurse?

1. “We have made an appointment to talk with the school nurse about the change in our child’s health.”
2. “We forgot to give our daughter her medications before bedtime, so we made a list of her medications to help us remember.”
3. “We have worked out a schedule to check on her before and after school.”
4. “We have not been spending time with our parents because we are so busy taking care of our daughter.”

Answer 92

4

Question 93

A family consisting of a grandparent, two adults, and three school-age children just immigrated to the United States. They come to a community wellness center to establish health care. Which of the following questions does the nurse ask to assess the family’s function? (Select all that apply.)

1. “What does your family do to keep members healthy?”
2. “How does your family usually make decisions?”
3. “What health services are available in your neighborhood?”
4. “Which rituals or celebrations are important for your family?”
5. “Is there a lot of crime in your neighborhood?”
6. “How many parks are there in your community?”

Answer 93

1,2,4

Question 94

A married couple has three children. The youngest child just graduated from college and is moving to a different city to take a job. The other two children left the home several years ago. Both of their parents are older and are beginning to need help to maintain their home. What assessment questions will help the nurse determine the family’s functioning? (Select all that apply).

1. Which transitions or changes in your family are you currently experiencing?
2. Are your children having any problems that are affecting your family right now?
3. Describe a recent family conflict and how your family resolved it.
4. What coping strategies do you typically use as a family?
5. Who is involved in helping care for your parents?

Answer 94

2,3,5

Question 95

During a visit to a family clinic, a nurse teaches a mother about immunizations, the use of car seats, and home safety for an infant and toddler. Which type of nursing interventions are these?

1. Restorative
2. Health promotion
3. Acute care
4. Growth and development

Answer 95

2

Question 96

The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE?

1. Allowing the patient to discuss the experience
2. Referring the patient to pastoral care
3. Having the patient talk to another patient who had an NDE
4. Offering to pray for the patient

Answer 96

1

Question 97

Which statement made by a patient who is recovering after recently experiencing third-degree burns shows connectedness?

1. “My pain medicine helps me feel better.”
2. “I know I will get better if I just keep trying.”

738
3. “I see God’s grace and become relaxed when I watch the sun set at night.”

4. “I feel so much closer to God after I read my Bible and pray.”

Answer 97

4

Question 98

A nurse is caring for a patient who is Muslim and has diabetes. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient?

1. Small container of vanilla ice cream
2. A dozen red grapes
3. Bacon and eggs
4. Garden salad with ranch dressing

Answer 98

3

Question 99

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are assessment findings that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.)

1. “I need to call my sister for support.”
2. “I have nothing to live for now.”
3. “Why would my God do this to me?”
4. “I need to pray for a miracle.”
5. “I want to be more involved in my church.”

Answer 99

2,3

Question 100

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. The nurse has been caring for her for only 2 hours but has a good relationship with her. What is the most appropriate intervention for support of her spiritual well-being at this time?

1. Make a referral to a professional spiritual care adviser.
2. Sit down and talk with the patient; have her discuss her feelings and listen attentively.
3. Move the patient’s Bible from her bedside cabinet drawer to the top of the over-bed table.
4. Ask the patient whether she would like to learn more about the implications of having this type of tumor.

Answer 100

2

Question 101

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.)

1. Encourage family members to participate in the exercise.
2. Have patient identify a quiet room in the home that has minimal interruptions.
3. Suggest the use of a quiet fan running in the room.
4. Explain that it is best to meditate about 5 minutes 4 times a day.
5. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

Answer 101

2,3,5

Question 102

A nursing student is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.)

1. Older adults do not routinely use complementary medicine to cope with illness.
2. Older adults dislike discussing the afterlife and what might have happened to people who have passed on.
3. Older adults achieve spiritual resilience through frequent expressions of gratitude.
4. Have the patient determine whether her husband left a legacy behind.
5. Offer the patient her choice of rituals or participation in exercise.

Answer 102

3,4,5

Question 103

A nurse used spiritual rituals as an intervention in a patient’s care. Which of the following questions is most appropriate to evaluate its efficacy?

1. Do you feel the need to forgive your wife over your loss?
2. What can I do to help you feel more at peace?
3. Did either prayer or meditation prove helpful to you?
4. Should we plan on having your family try to visit you more often in the hospital?

Answer 103

3

Question 104

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.)

1. Pay attention to the patient’s spiritual identity throughout the course of her illness.
2. Select interventions that you know scientifically support spiritual well-being.
3. Listen to the patient’s story each visit to the clinic, and offer a compassionate presence.
4. When the patient questions the reason for her long-time suffering, try to provide answers.

Answer 104

1,3

Question 105

The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.)

1. Heart disease
2. Sepsis
3. Hemorrhage
4. Skin breakdown
5. Diarrhea

Answer 105

2,3,4

Question 106

The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.)

1. Serum total protein
2. Potassium
3. Lipids
4. Albumin

5 Serum BUN

Answer 106

1,5

Question 107

The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention?

1. Suction her mouth and throat.
2. Turn her on her side.
3. Put on oxygen at 2 L nasal cannula.
4. Stop feeding her.

Answer 107

4

Question 108

A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse’s priority action?

1. Have the patient turn on the left side and perform a Valsalva maneuver.
2. Clamp the intravenous (IV) tubing to prevent more air from entering the line.
3. Have the patient take a deep breath and hold it.
4. Notify the health care provider immediately.

Answer 108

1

Question 109

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition?

1. When 25% of the patient’s nutritional needs are met by the tube feedings
2. When bowel sounds return
3. When the central line has been in for 10 days
4. When 75% of the patient’s nutritional needs are met by the tube feedings

Answer 109

4

Question 110

A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention?

1. Assess bowel sounds.
2. Raise the head of the bed to at least 45 degrees.
3. Continue the feedings; this is normal gastric residual for this feeding.
4. Hold the feeding until you talk to the primary care provider.

Answer 110

3

Question 111

Which action can a nurse delegate to assistive personnel (AP)?

1. Performing glucose monitoring every 6 hours on a patient
2. Teaching the client about the need for enteral feeding
3. Administering enteral feeding bolus after tube placement has been verified
4. Evaluating the client’s tolerance of the enteral feeding

Answer 111

1

Question 112

Which statement made by the parents of a 2-month-old infant requires further education by the nurse?

1. “I’ll continue to use formula for the baby until he is at least a year old.”
2. “I’ll make sure that I purchase iron-fortified formula.”
3. “I’ll start feeding the baby cereal at 4 months.”
4. “I’m going to alternate formula with whole milk, starting next month.”

Answer 112

4

Question 113

A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse?

1. Fastening tube to the gown with new tape
2. Placing client supine while giving a bath
3. Monitoring the client’s weight as ordered
4. Ambulating patient with enteral feedings still infusing

Answer 113

2

Question 114

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.)

1. Change the dressing using sterile technique.
2. Change TPN containers every 48 hours.
3. Change the TPN tubing every 24 hours.
4. Monitor glucose levels to watch and assess for glucose intolerance.
5. Elevate head of the bed 45 degrees to prevent aspiration.

Answer 114

1,3