Test 4

Question 1

To evaluate your Activity tolerance nursing plan for Mrs Gonzales, at the end of 12 weeks an indication of its effectiveness would be that Mrs. Gonzales:

1. Has lot 15 Pounds
2. Has full range of motion to all joints without experiencing pain.
3. Jogs 5 city blocks twice a week
4. Participates in an exercise program at the YWCA 3 days a week.

Answer 1

4. Participates in an exercise program at the YWCA 3 days a week.

Question 2

4. Dehiscence”

Answer 2

4. Dehiscence

Question 3

While caring for a 27-yr-old man on a mechanical ventilator, the ventilator alarms sound. On entering the patient’s room, the nurse notes that he is very agitated and his skin is ashen and diaphoretic. His pulse oximeter shows an oxygen saturation of 78%. The nurse is unable to identify any obvious problems with the ventilator. The first step the nurse should take is to:

1 Assess his breath sounds

2 Call the respiratory therapist to troubleshoot the probem

3. manually ventilate him with an Ambu-bag

4 Contact the physician

Answer 3

3. manually ventilate him with an Ambu-bag

Question 4

The duration of sleep is regulated by the:

1. Electrical impulses transmitted from the cerebral cortex to the cerebellum
2. Person’s innate biorhythms
3. Amount of sleep a person usually requires.

4 Reticular activating system

Answer 4

4 Reticular activating system

Question 5

The head of the bed of a patient who is receiving enteral feedings is elevated to 30 degrees. Which complication associated with enteral feedings does this intervention help prevent?

1. Aspiration
2. Diarrhea
3. Infection
4. Electrolyte imbalane

Answer 5

1. Aspiration

Question 6

Which of the following goals is appropriate for a client without underlying cardiopulmonary disease who is being monitored with continuous pulse oximetry?

1. Patient will refrain from movement while monitored in order to ensure accurate readings.

2 oxygen saturation will remain at 80%-90% during hospitalization

3 Patient will report pain as less than 3 on a scale of 1-10 during monitoring

4 Oxygen saturation will remain at 95%-100% while monitored.

Answer 6

4 Oxygen saturation will remain at 95%-100% while monitored.

Question 7

Respiratory function involves which four body systems?

1 Respiratory, neurological, endocrine, and cardiovascular

2 Respiratory, cardiovascular, neurological, and integumentary

3 Respiratory, cardiovascular, neurological, and musculoskeletal

4 respiratory, musculosckeletal, cardiovascular, and endocrine

Answer 7

3 Respiratory, cardiovascular, neurological, and musculoskeletal

Question 8

The most appropriate nursing diagnosis for Mr Jerome, who developed a fistula, at this time would be:

1. Risk for infection related to dehiscence of wound

2 Body Image Disturbance related to nonhealing surgical wound

3 Risk for impaired skin integrity related to wound drainage

4 Pain related to surgical incision.

Answer 8

3 Risk for impaired skin integrity related to wound drainage

Question 9

Mrs Ray is a 50-yr-old woman who had a surgical repair of a fracture of her right tibia 2 days ago. She has been using crutches for ambulation and must remain non-weight bearing on her right leg, but must learn to use the steps leading into her house. The nurse should instruct Mrs Ray to:

1 Lay the crutches down and hop on the left leg when going up or down the stairs

2 Use the crutches, maintaining toe-touch weight-bearing on the right leg when going up or down the stairs

3 Have someone carry her up and down the stairs

4 Lead with the left leg when going up steps, and lean with the right leg when going down steps.

Answer 9

4 Lead with the left leg when going up steps, and lean with the right leg when going down steps.

Question 10

The nurse is caring for a 14-yr-old boy with a history of asthma. He is currently being treated for acute bronchitis. A thorough nursing assessment of his pulmonary status will include (select all that apply)

1. Skin color and temperature

2 Auscultation of breath sounds

3 Testing of cough reflex

4 Chest x-ray

Answer 10

1. Skin color and temperature

2 Auscultation of breath sounds

Question 11

To obtain the most accurate culture information of a chronic wound, the nurse would recommend:

1 Tissue biopsy

2 swab culture

3 sterile culture

4 Needle aspiration culture

Answer 11

1 Tissue biopsy

Question 12

Mr Jerome had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects Mr Jerome has:

1 An infected wound

2 Wound dehiscence

3 A hematoma

4 A fistula

Answer 12

4 A fistula

Question 13

A 10-yr-old boy fell on the playground. He is complaining of pain in his right forearm. The nurse notes that the boy’s arm is swelling and tender to touch. There is an area of protrusion on the lateral aspect of his arm, which upon palpation is very firm. The nurse suspects a fracture; however, her suspicion cannot be confirmed until

1. A venous and arterial Doppler are obtained
2. The boy demonstrates that he cannot use his arm

3 The swelling is decreased by applying ice

4 An X-ray is obtained

Answer 13

4 An X-ray is obtained

Question 14

What signs and symptoms might the nurse expect to see in a patient experiencing hypxia?

1 Altered level of consciousness

2 Peripheral pitting edema

3 Cyanosis of skin and mucous membranes

4 Weak or absent peripheral pulses

Answer 14

1 Altered level of consciousness

3 Cyanosis of skin and mucous membranes

4 Weak or absent peripheral pulses

Question 15

4 Impaired skin integrity related to fecal drainage”

Answer 15

2 Disturbed body image related to colostomy

Question 16

The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3cm X 2cm X 1cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o’clock to 3 o’clock under the wound edges. The nurse would document this as:

1 State IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00

2. State III pressure ulcer with undermining of 3 cm from 12:00 to 3:00
3. Stage IV pressure ulcer with sinus tract from 12:00 to 3:00
4. Stage III pressure ulcer with sinus tract from 12:00 to 3:00

Answer 16

2. State III pressure ulcer with undermining of 3 cm from 12:00 to 3:00

Question 17

Depression, hyperthyroidism, hypothyroidism, pain, and sleep apnea are examples:

1 Disorders that are provoked by sleep

2 Parasomnias

3 Conditions that cause secondary sleep disorders

4 Disorders associated with narcolepsy

Answer 17

3 Conditions that cause secondary sleep disorders

Question 18

4 Impaired Physical Mobility related to limited range of motion, secondary to obesity”

Answer 18

3. Activity intolerance related to morbid obesity and dyspnea secondary to sedentary lifestyle.

Question 19

Which of the following nursing interventions would be appropriate for Mrs Gonzales who has a diagnosis of activity intolerance? Encourge Mrs Gonzales to (select all that apply)

1 Participate in a scheduled exercise program

2 Participate in activities outside of the home

3 Increase her fluid intake

4 Increase the length of time between rest periods

Answer 19

1 Participate in a scheduled exercise program

2 Participate in activities outside of the home

4 Increase the length of time between rest periods

Question 20

Langerhans cells are:

1 Protein-containing cells that give the skin strength and elasticity

2 Cells that provide protection from ultra light

3 Mobile and able to phagocytize foreign material

4 Located in the dermal layer of the skin

Answer 20

3 Mobile and able to phagocytize foreign material

Question 21

Mr Cannes developed a wound 16 days ago. When performing a wound assessment, the nurse notes the formation of granulation tissue in the wound bed and recognizes that Mr Cannes is in this stage of wound healing

1. Proliferative phase
2. Maturation phase
3. Aggregation phase
4. Inflammatory phase

Answer 21

1. Proliferative phase

Question 22

Mr Vann has a 3.0 cm X 2.0 eschar on the right heel. The best treatment choice for this wound is:

1 Elevate the right heel off the bed

2 Request a surgical consult for debridement of the area

3 Apply a hydrocolloid to promote autolytic debridement of the wound

4 Request an order for an enzymatic debridement medication

Answer 22

1 Elevate the right heel off the bed

Question 23

The nurse is planning goals for activity intolerant Mrs Gonzales. Which of the following NOC outcome(s) relate(s) directly to the above nursing diagnosis; that is, which outcome(s), if achieved, would demonstrate resolution of her problem? Select all that apply.

1. Endurance
2. Activity Tolerance
3. Active Joint Movement
4. Mobility Level

Answer 23

1. Endurance
2. Activity Tolerance

Question 24

The nurse will know interventions were successful when Mrs Lore:

1. Demonstrates the proper method of cleansing her skin
2. Demonstrates proficiency when providing treatment to excoriated skin
3. States she will start caring for the colostomy after she gets home
4. Proficiently performs colostomy care prior to discharge

Answer 24

4. Proficiently performs colostomy care prior to discharge

Question 25

The nurse is caring for a 78-yr-old woman who was admitted 3 days ago following a cerebrovascular accident. She has had trouble swallowing and has been placed on aspiration precautions. Care of this patient will include (select all that apply)?

1. Ensure she is sitting upright or with the head of the bed elevated to eat and drink
2. Break or crush her pills (if appropriate) before administration
3. Provide only thin, clear liquids
4. Keep suction setup available at all times

Answer 25

1. Ensure she is sitting upright or with the head of the bed elevated to eat and drink
2. Break or crush her pills (if appropriate) before administration
3. Keep suction setup available at all times

Question 26

The hospital nurse has orders to administer 0400 medications to Mrs Giovanni. Mrs Giovanni is asleep when the nurse enters the room. She is very hard to arouse and confused. Identify the state of sleep Mrs Giovanni was in when the nurse awakened her.

1. REM Sleep
2. Stage IV
3. Stage III
4. Stage II

Answer 26

2. Stage IV

Question 27

During an admission assessment, the patient reports that he takes vitamin E supplements twice a day. The nurse should explain that taking vitamin E supplements three times a day:

1. Ensures health vision
2. Can lead to toxicity
3. Strengthens the immune system
4. Helps maintain body tissues

Answer 27

2. Can lead to toxicity

Question 28

During parenteral nutrition administration, a nurse breaks sterile technique. For which complication does this place the patient at risk?

1. Air embolism

2.Sepsis

3. Thrombosis
4. Pneumothorax

Answer 28

2.Sepsis

Question 29

4. “The risk of having a heart attack during strenous exercise increases in a high-risk patient such as you””

Answer 29

3. the risk of having heart attack during strenuous exercise is one in 1 million for a healthy 50-yr-old male who does not smoke or have diabetes””

Question 30

4. “From your past experience, I know you feel that exercise didn’t make a difference; however, the problem was probably the exercise program you participated in””

Answer 30

2. From your past experience, I know you feel that exercise didn’t make a difference, but gaining weight and getting out of shape takes time, and reversing these changes also takes time””

Question 31

Which food provides the only animal source of carbohydrate?

1. Beef
2. Eggs
3. Milk
4. Chicken

Answer 31

3 Milk

Question 32

In what structure of the pulmonary system does inhaled air come in contact with the blood of the pulmonary circulation?

1. Apex of the lungs
2. Alveolar-capillary membrane
3. Cilia in the bronchi
4. Right and left main-stem bronchi

Answer 32

2. Alveolar-capillary membrane

Question 33

Which action should the nurse take after administering a dose of medication through a percutaneous endoscopic gastrostomy (PEG) tube?

1. Continue the enteral feeding
2. Flush the tube with 30 ml of water
3. Wait 2 hours before resuming the feeding
4. Check residual volume

Answer 33

2. Flush the tube with 30 ml of water

Question 34

The nurse is counseling a 17-yr-old on smoking cessation. The nurse should include the following helpful tips in her education (select all that apply)

1. Keep healthy snacks or gum available to chew instead of smoking
2. Do not tell your friends and family you are trying to quit, so you will not have to explain if you are unsuccessful
3. Plan a time to quit when you will not have many other demands or stressors in your life.
4. Reward yourself with an activity you enjoy when you quit smoking.

Answer 34

1. Keep healthy snacks or gum available to chew instead of smoking
2. Plan a time to quit when you will not have many other demands or stressors in your life.
3. Reward yourself with an activity you enjoy when you quit smoking.

Question 35

4. “Thanks for reassuring me. I was pretty sure there isn’t any risk to the baby this far along in my pregnancy””

Answer 35

3. If I deliver this early my baby is at risk for Respiratory Distress Syndrome, a condition that can be fatal””

Question 36

A patient who is receiving a continuous enteral feeding at 80 ml/hour has a residual volume of 120 ml 6 hours after the last check. How should the nurse proceed?

1. Continue administering the enteral feeding
2. Hold the enteral feeding and notify the physician immediately
3. Hold the feeding for 1 hour and recheck
4. Hold the feeding for 2 hours, then resume the feeding

Answer 36

3. Hold the feeding for 1 hour and recheck

Question 37

A 45-yr-old woman presents to the emergency department with complaints of shortness of breath, anxiety, dizziness, and numbness and tingling around her mouth. Her respirations are deep, at a rate of 28 per minute. Her lungs are clear with good aeration throughout. Oxygen saturation is 100%. An arterial blood gas shows a PO2 of 110 and PCO2 of 29. Based on this assessment, an appropriate nursing diagnosis would be:

1. Ineffective airway clearance
2. Decreased Cardiac Output
3. Impaired gas exchange
4. Hypocarbia

Answer 37

3. Impaired gas exchange

Question 38

The nurse must verify enteral tube placement before administering a tube feeding. Which method should she use?

1. Place the proximal end of the tube in water, if no bubbling occurs, placement is confirmed
2. Inject 30 cc of air into the proximal end of the feeding tube while auscultating the stomach; a swooshing sound confirms placement

3 Aspirate stomach contents from the proximal end of the tube, and measure the pH

4. Obtain a chest x-ray

Answer 38

3 Aspirate stomach contents from the proximal end of the tube, and measure the pH