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Nursing 231 Final with verified answers
A|manager|who|is|reviewing|the|nurses'|notes|in|a|patient's|medical|record|finds|the|following| entry,|"Patient|is|difficult|to|care|for,|refuses|suggestion|for|improving|appetite."|Which|of|the|following| directions|does|the|manager|give|to|the|staff|nurse|who|entered|the|note? |a.|Avoid|rushing|when|charting|an|entry. |b.|Use|correction|fluid|to|remove|the|entry. |c.|Draw|a|single|line|through|the|statement|and|initial|it. |d.|Enter|only|objective|and|factual|information|about|the|patient.|-|verified|answersd.|Enter|only| objective|and|factual|information|about|the|patient. A|new|graduate|nurse|is|providing|a|telephone|report|to|a|patient's|health|care|provider|and|accepting| telephone|orders|from|the|provider.|Which|of|the|following|actions|requires|the|new|nurse's|preceptor| to|intervene?|The|new|nurse: |a.|Uses|SBAR|(Situation-Background-Assessment-Recommendation)|as|a|format|when|providing|the| report. |b.|Gives|a|newly|ordered|medication|before|entering|the|order|in|the|patient's|medical|record. |c.|Reads|the|orders|back|to|the|health|care|provider|after|receiving|them|and|verifies|their|accuracy. |d.|Asks|the|preceptor|to|listen|in|on|the|phone|conversation.|-|verified|answersb.|Gives|a|newly|ordered| medication|before|entering|the|order|in|the|patient's|medical|record. As|you|enter|the|patient's|room,|you|notice|that|he|is|anxious|to|say|something.|He|quickly|states,|"I| don't|know|what's|going|on;|I|can't|get|an|explanation|from|my|doctor|about|my|test|results.|I|want| something|done|about|this."|Which|of|the|following|is|the|most|appropriate|documentation|of|the| patient's|emotional|status? |a.|The|patient|has|a|defiant|attitude|and|is|demanding|his|test|results. |b.|The|patient|appears|to|be|upset|with|his|nurse|because|he|wants|his|test|results|immediately. |c.|The|patient|is|demanding|and|complains|frequently|about|his|doctor. |d.|The|patient|stated|that|he|felt|frustrated|by|the|lack|of|information|he|received|regarding|his|tests.|-| verified|answersd.|The|patient|stated|that|he|felt|frustrated|by|the|lack|of|information|he|received| regarding|his|tests. You|are|reviewing|Health|Insurance|Portability|and|Accountability|Act|(HIPAA)|regulations|with|your| patient|during|the|admission|process.|The|patient|states,|"I've|heard|a|lot|about|these|HIPAA|regulations| in|the|news|lately.|How|will|they|affect|my|care?"|Which|of|the|following|is|the|best|response?
|a.|HIPAA|allows|all|hospital|staff|access|to|your|medical|record. |b.|HIPAA|limits|the|information|that|is|documented|in|your|medical|record. |c.|HIPAA|provides|you|with|greater|control|over|your|personal|health|care|information. |d.|HIPAA|enables|health|care|institutions|to|release|all|of|your|personal|information|to|improve| continuity|of|care.|-|verified|answersc.|HIPAA|provides|you|with|greater|control|over|your|personal| health|care|information. A|patient|asks|for|a|copy|of|her|medical|record.|The|best|response|by|the|nurse|is|to: |a.|State|that|only|her|family|may|read|the|record. |b.|Indicate|that|she|has|the|right|to|read|her|record. |c.|Tell|her|that|she|is|not|allowed|to|read|her|record. |d.|Explain|that|only|health|care|workers|have|access|to|her|record.|-|verified|answersb.|Indicate|that|she| has|the|right|to|read|her|record. Which|of|the|following|charting|entries|is|most|accurate? |a.|Patient|walked|up|and|down|hallway|with|assistance,|tolerated|well. |b.|Patient|up,|out|of|bed,|walked|down|hallway|and|back|to|room,|tolerated|well. |c.|Patient|up,|walked| 50 |feet|and|back|down|hallway|with|assistance|from|nurse.|Spouse|also| accompanied|patient|during|the|walk. |d.|Patient|walked| 50 |feet|and|back|down|hallway|with|assistance|from|nurse;|HR| 88 |and|regular|before| exercise,| 94 |and|regular|following|exercise.|-|verified|answersd.|Patient|walked| 50 |feet|and|back|down| hallway|with|assistance|from|nurse;|HR| 88 |and|regular|before|exercise,| 94 |and|regular|following|exercise. On|the|nursing|unit|you|are|able|to|access|a|patient's|medical|record|and|review|the|education|that| other|nurses|provided|to|the|patient|during|an|initial|hospitalization|and|three|subsequent|clinic|visits.| This|type|of|feature|is|most|common|in|what|type|of|record|system? |a.|Information|technology. |b.|Electronic|health|record. |c.|Personal|health|information. |d.|Administrative|information|system.|-|verified|answersb.|Electronic|health|record. You|are|giving|a|hand-off|report|to|another|nurse|who|will|be|caring|for|your|patient|at|the|end|of|your| shift.|Which|of|the|following|pieces|of|information|do|you|include|in|the|report?|(Select|all|that|apply.) a.|The|patient's|name,|age,|and|admitting|diagnosis b.|Allergies|to|food|and|medications c.|Your|evaluation|that|the|patient|is|"needy"
|a.|Electronic|health|record |b.|Clinical|documentation |c.|Clinical|decision|support|system |d.|Computerized|physician|order|entry|-|verified|answersc.|Clinical|decision|support|system While|reviewing|the|pulmonary|section|of|a|patient's|electronic|chart,|the|physician|notices|blank|spaces| since|the|initial|assessment|the|previous|day|when|the|nurse|documented|that|the|lung|assessment|was| within|normal|limits.|There|also|are|no|progress|notes|about|the|patient's|respiratory|status|in|the| nurse's|notes.|The|most|likely|reason|for|this|is|because: |a.|The|nurses|forgot|to|document|on|the|pulmonary|system. |b.|The|nurses|were|charting|by|exception. |c.|The|computer|is|not|working|correctly. |d.|The|physician|does|not|have|authorization|to|view|the|nursing|assessment.|-|verified|answersb.|The| nurses|were|charting|by|exception. What|is|an|appropriate|way|for|a|nurse|to|dispose|of|printed|patient|information? |a.|Rip|several|times|and|place|in|a|standard|trash|can |b.|Place|in|the|patient's|paper-based|chart |c.|Place|in|a|secure|canister|marked|for|shredding |d.|Burn|the|documents|-|verified|answersc.|Place|in|a|secure|canister|marked|for|shredding The|nurse's|first|action|after|discovering|an|electrical|fire|in|a|patient's|room|is|to: |a.|Activate|the|fire|alarm. |b.|Confine|the|fire|by|closing|all|doors|and|windows. |c.|Remove|all|patients|in|immediate|danger. |d.|Extinguish|the|fire|by|using|the|nearest|fire|extinguisher.|-|verified|answersc.|Remove|all|patients|in| immediate|danger. A|parent|calls|the|pediatrician's|office|frantic|about|the|bottle|of|cleaner|that|her|2-year-old|son|drank.| Which|of|the|following|is|the|most|important|instruction|the|nurse|gives|to|this|parent? |a.|Give|the|child|milk. |b.|Give|the|child|syrup|of|ipecac. |c.|Call|the|poison|control|center. |d.|Take|the|child|to|the|emergency|department.|-|verified|answersc.|Call|the|poison|control|center.
The|nursing|assessment|on|a|78-year-old|woman|reveals|shuffling|gait,|decreased|balance,|and| instability.|On|the|basis|of|the|patient's|data,|which|one|of|the|following|nursing|diagnoses|indicates|an| understanding|of|the|assessment|findings? |a.|Activity|intolerance |b.|Impaired|bed|mobility |c.|Acute|pain |d.|Risk|for|falls|-|verified|answersd.|Risk|for|falls A|couple|is|with|their|adolescent|daughter|for|a|school|physical|and|state|they|are|worried|about|all|the| safety|risks|affecting|this|age.|What|is|the|greatest|risk|for|injury|for|an|adolescent? |a.|Home|accidents |b.|Physiological|changes|of|aging |c.|Poisoning|and|child|abduction |d.|Automobile|accidents,|suicide,|and|substance|abuse|-|verified|answersd.|Automobile|accidents,| suicide,|and|substance|abuse The|nurse|found|a|68-year-old|female|patient|wandering|in|the|hall.|The|patient|says|she|is|looking|for| the|bathroom.|Which|interventions|are|appropriate|to|ensure|the|safety|of|the|patient?|(Select|all|that| apply.) a.|Insert|a|urinary|catheter. b.|Leave|a|night|light|on|in|the|bathroom. c.|Ask|the|physician|to|order|a|restraint. d.|Keep|the|bed|in|low|position|with|upper|and|lower|side|rails|up. e.|Assign|a|staff|member|to|stay|with|the|patient. f.|Provide|scheduled|toileting|during|the|night|shift. g.|Keep|the|pathway|from|the|bed|to|the|bathroom|clear.|-|verified|answersb.|Leave|a|night|light|on|in| the|bathroom. f.|Provide|scheduled|toileting|during|the|night|shift. g.|Keep|the|pathway|from|the|bed|to|the|bathroom|clear. The|family|of|a|patient|who|is|confused|and|ambulatory|insists|that|all|four|side|rails|be|up|when|the| patient|is|alone.|What|is|the|best|action|to|take|in|this|situation?|(Select|all|that|apply.) a.|Contact|the|nursing|supervisor. b.|Restrict|the|family's|visiting|privileges. c.|Ask|the|family|to|stay|with|the|patient.
c.|Do|not|use|electrical|equipment|around|oxygen. d.|Special|precautions|may|be|required|when|traveling|with|oxygen|-|verified|answersa.|Smoking|is| prohibited|around|oxygen. c.|Do|not|use|electrical|equipment|around|oxygen. d.|Special|precautions|may|be|required|when|traveling|with|oxygen How|does|the|nurse|support|a|culture|of|safety?|(Select|all|that|apply.) a.|Completing|incident|reports|when|appropriate b.|Completing|incident|reports|for|a|near|miss c.|Communicating|product|concerns|to|an|immediate|supervisor d.|Identifying|the|person|responsible|for|an|incident|-|verified|answersa.|Completing|incident|reports| when|appropriate b.|Completing|incident|reports|for|a|near|miss| c.|Communicating|product|concerns|to|an|immediate|supervisor You|are|admitting|Mr.|Jones,|a|64-year-old|patient|who|had|a|right|hemisphere|stroke|and|a|recent|fall.| The|wife|stated|that|he|has|a|history|of|high|blood|pressure,|which|is|controlled|by|an|antihypertensive| and|a|diuretic.|Currently|he|exhibits|left|sided|neglect|and|problems|with|spatial|and|perceptual|abilities| and|is|impulsive.|He|has|moderate|left-sided|weakness|that|requires|the|assistance|of|two|and|the|use|of| a|gait|belt|to|transfer|to|a|chair.|He|currently|has|an|intravenous|(IV)|line|and|a|urinary|catheter|in|place.| What|factors|increase|his|fall|risk|at|this|time?|(Select|all|that|apply.) a.|Smokes|a|pack|a|day b.|Used|a|cane|to|walk|at|home c.|Takes|antihypertensive|and|diuretics d.|History|of|recent|fall e.|Neglect,|spatial|and|perceptual|abilities,|impulsive f.|Requires|assistance|with|activity,|unsteady|gait g.|IV|line,|urinary|catheter|-|verified|answersc.|Takes|antihypertensive|and|diuretics d.|History|of|recent|fall e.|Neglect,|spatial|and|perceptual|abilities,|impulsive f.|Requires|assistance|with|activity,|unsteady|gait g.|IV|line,|urinary|catheter At| 3 |am|the|emergency|department|nurse|hears|that|a|tornado|hit|the|east|side|of|town.|What|action| does|the|nurse|take|first?
|a.|Prepare|for|an|influx|of|patients |b.|Contact|the|American|Red|Cross |c.|Determine|how|to|restore|essential|services |d.|Evacuate|patients|per|the|disaster|plan|-|verified|answersa.|Prepare|for|an|influx|of|patients If|an|infectious|disease|can|be|transmitted|directly|from|one|person|to|another,|it|is|a: |a.|Susceptible|host. |b.|Communicable|disease. |c.|Port|of|entry|to|a|host. |d.|Port|of|exit|from|the|reservoir.|-|verified|answersb.|Communicable|disease. Which|is|the|most|likely|means|of|transmitting|infection|between|patients? |a.|Exposure|to|another|patient's|cough |b.|Sharing|equipment|among|patients |c.|Disposing|of|soiled|linen|in|a|shared|linen|bag |d.|Contact|with|a|health|care|worker's|hands|-|verified|answersd.|Contact|with|a|health|care|worker's| hands Identify|the|interval|when|a|patient|progresses|from|nonspecific|signs|to|manifesting|signs|and| symptoms|specific|to|a|type|of|infection. |a.|Illness|stage |b.|Convalescence |c.|Prodromal|stage |d.|Incubation|period|-|verified|answersc.|Prodromal|stage Which|of|the|following|is|the|most|effective|way|to|break|the|chain|of|infection? |a.|Hand|hygiene |b.|Wearing|gloves |c.|Placing|patients|in|isolation |d.|Providing|private|rooms|for|patients|-|verified|answersa.|Hand|hygiene A|family|member|is|providing|care|to|a|loved|one|who|has|an|infected|leg|wound.|What|would|you| instruct|the|family|member|to|do|after|providing|care|and|handling|contaminated|equipment|or|organic| material? |a.|Wear|gloves|before|eating|or|handling|food.
|a.|Use|an|autoclave. |b.|Use|boiling|water. |c.|Use|ethylene|oxide|gas. |d.|Use|chemicals|for|disinfection.|-|verified|answersb.|Use|boiling|water. A|patient|has|an|indwelling|urinary|catheter.|Why|does|an|indwelling|urinary|catheter|present|a|risk|for| urinary|tract|infection? |a.|It|keeps|an|incontinent|patient's|skin|dry. |b.|It|can|get|caught|in|the|linens|or|equipment. |c.|It|obstructs|the|normal|flushing|action|of|urine|flow. |d.|It|allows|the|patient|to|remain|hydrated|without|having|to|urinate.|-|verified|answersc.|It|obstructs| the|normal|flushing|action|of|urine|flow. Put|the|following|steps|for|removal|of|protective|barriers|after|leaving|an|isolation|room|in|order: a.|Untie|top,|then|bottom|mask|strings|and|remove|from|face. b.|Untie|waist|and|neck|strings|of|gown.|Allow|gown|to|fall|from|shoulders|and|discard.|Remove|gown,| rolling|it|onto|itself|without|touching|the|contaminated|side. c.|Remove|gloves. d.|Remove|eyewear|or|goggles. e.|Perform|hand|hygiene.|-|verified|answersc.|Remove|gloves. d.|Remove|eyewear|or|goggles. b.|Untie|waist|and|neck|strings|of|gown.|Allow|gown|to|fall|from|shoulders|and|discard.|Remove|gown,| rolling|it|onto|itself|without|touching|the|contaminated|side. a.|Untie|top,|then|bottom|mask|strings|and|remove|from|face. e.|Perform|hand|hygiene. Your|ungloved|hands|come|in|contact|with|the|drainage|from|your|patient's|wound.|What|is|the|correct| method|to|clean|your|hands? |a.|Wash|them|with|soap|and|water. |b.|Use|an|alcohol-based|hand|cleaner. |c.|Rinse|them|and|use|the|alcohol-based|hand|cleaner. |d.|Wipe|them|with|a|paper|towel.|-|verified|answersa.|Wash|them|with|soap|and|water. A|patient's|surgical|wound|has|become|swollen,|red,|and|tender.|You|note|that|the|patient|has|a|new| fever|and|leukocytosis.|What|is|the|best|immediate|intervention?
|a.|Notify|the|health|care|provider|and|use|surgical|technique|to|change|the|dressing. |b.|Reassure|the|patient|and|recheck|the|wound|later. |c.|Notify|the|health|care|provider|and|support|the|patient's|fluid|and|nutritional|needs. |d.|Alert|the|patient|and|caregivers|to|the|presence|of|an|infection|to|ensure|care|after|discharge.|-| verified|answersc.|Notify|the|health|care|provider|and|support|the|patient's|fluid|and|nutritional|needs. While|preparing|to|do|a|sterile|dressing|change,|a|nurse|accidentally|sneezes|over|the|sterile|field|that|is| on|the|over-the-bed|table.|Which|of|the|following|principles|of|surgical|asepsis,|if|any,|has|the|nurse| violated? |a.|When|a|sterile|field|comes|in|contact|with|a|wet|surface,|the|sterile|field|is|contaminated|by|capillary| action. |b.|Fluid|flows|in|the|direction|of|gravity. |c.|A|sterile|field|becomes|contaminated|by|prolonged|exposure|to|air. |d.|None|of|the|principles|were|violated.|-|verified|answersc.|A|sterile|field|becomes|contaminated|by| prolonged|exposure|to|air. The|nurse|is|assisting|a|patient|with|rheumatoid|arthritis|to|bathe|at|the|sink.|During|the|bath|the|patient| states|that|she|is|tired.|The|nurse|notices|the|patient|is|breathing|rapidly|and|the|pulse|is|rapid.|What|is| the|nurse's|best|response? |a.|Finish|the|bath|quickly |b.|Help|the|patient|return|to|bed |c.|Leave|the|patient|alone|to|rest|in|the|chair|at|the|sink|for|a|few|minutes |d.|Instruct|the|patient|to|take|deep|breaths|and|try|to|relax|-|verified|answersb.|Help|the|patient|return| to|bed A|patient|who|is|cognitively|impaired|and|has|dementia|requires|hygiene|care.|The|patient|often|displays| aggressive|behavior|such|as|screaming|and|hitting|during|the|bath.|Which|techniques|make|the|bathing| experience|less|stressful|for|both|the|nurse|and|the|patient?|(Select|all|that|apply.) a.|Allow|the|patient|to|perform|as|much|of|the|care|as|possible. b.|Start|by|washing|the|face. c.|Try|an|alternative|to|traditional|bathing|such|as|the|"bag|bath." d.|Use|restraints|to|prevent|the|patient|from|injuring|self|or|the|nurse.|-|verified|answersa.|Allow|the| patient|to|perform|as|much|of|the|care|as|possible. c.|Try|an|alternative|to|traditional|bathing|such|as|the|"bag|bath." What|is|the|priority|concern|when|providing|oral|hygiene|for|a|patient|who|is|unconscious? |a.|Thoroughly|brushing|all|tooth|and|oral|surfaces
d.|See|dentist|regularly. e.|Rinse|dentures|after|meals. A|patient|who|is|receiving|chemotherapy|has|inflamed|gums|and|oral|mucosa|and|painful|sores|in|the| mouth.|Which|of|the|following|oral|care|actions|are|appropriate?|(Select|all|that|apply.) a.|Decreasing|frequency|of|oral|hygiene b.|Applying|water-soluble|moisturizing|gel|on|the|oral|mucosa c.|Encouraging|intake|of|soft|foods d.|Using|commercial|mouthwash|-|verified|answersb.|Applying|water-soluble|moisturizing|gel|on|the|oral| mucosa c.|Encouraging|intake|of|soft|foods While|planning|morning|care,|which|of|the|following|patients|would|receive|the|highest|priority|to| receive|his|or|her|bath|first? |a.|A|patient|who|just|returned|to|the|nursing|unit|from|surgery|and|is|experiencing|pain|at|a|level|of| 7 |on| a|scale|of| 0 |to| 10 |b.|A|patient|who|prefers|a|bath|in|the|evening|when|his|wife|visits|and|can|help|him |c.|A|patient|who|is|experiencing|frequent|incontinent|diarrheal|stools |d.|A|patient|who|has|just|returned|from|diagnostic|testing|and|complains|of|being|very|fatigued|-| verified|answersc.|A|patient|who|is|experiencing|frequent|incontinent|diarrheal|stools During|bathing|your|patient|experiences|shortness|of|breath|and|labored|breathing|with|a|respiratory| rate|of|30.|The|bed|is|in|a|flat|position.|You|change|the|bed|position|to: |a.|Trendelenburg's. |b.|Reverse|Trendelenburg's. |c.|Fowler's. |d.|Semi-Fowler's.|-|verified|answersc.|Fowler's. A|nurse|caring|for|a|male|patient|observes|the|nursing|assistive|personnel|(NAP)|performing|perineal| care.|Which|of|the|following|observed|actions|indicates|a|need|for|further|teaching|for|the|NAP?|The| NAP: |a.|Used|clean|gloves. |b.|Did|not|retract|the|foreskin|before|cleansing. |c.|Used|the|clean|portion|of|washcloth|for|each|cleansing|wipe. |d.|Used|a|circular|motion|to|cleanse|from|urinary|meatus|outward|-|verified|answersb.|Did|not|retract| the|foreskin|before|cleansing.
A|nurse|teaching|a|family|member|caregiver|how|to|bathe|the|patient|explains|the|importance|of|using| long|strokes|on|the|patient's|extremities,|moving|from|distal|to|proximal.|Which|explanation|does|the| nurse|include?|Long|strokes|moving|from|distal|to|proximal|are|used|to: |a.|Decrease|the|chance|of|infection. |b.|Help|remove|dry,|flaky|skin. |c.|Prevent|skin|trauma. |d.|Stimulate|venous|return.|-|verified|answersd.|Stimulate|venous|return. Which|of|the|following|actions|would|best|help|prevent|skin|breakdown|in|a|patient|who|is|incontinent| of|stools|and|very|weak|and|drowsy? |a.|Checking|frequently|for|soiling |b.|Washing|the|perineal|area|with|strong|soap|and|water |c.|Placing|the|call|light|within|easy|reach |d.|Keeping|a|pad|under|the|patient|-|verified|answersa.|Checking|frequently|for|soiling The|nurse|is|caring|for|a|patient|who|has|reduced|sensation|in|both|feet.|Which|of|the|following|should| the|nurse|do?|(Select|all|that|apply.) a.|Avoid|cleaning|the|feet|until|an|order|from|the|health|care|provider|is|received. b.|Wash|the|feet|with|lukewarm|water|and|then|dry|well. c.|Apply|moisturizing|lotion|to|the|feet,|especially|between|the|toes. d.|File|the|toenails|straight|across.|-|verified|answersb.|Wash|the|feet|with|lukewarm|water|and|then|dry| well. d.|File|the|toenails|straight|across. The|nurse|recognizes|that|her|older-adult|patient|needs|additional|teaching|about|skin|care|when|the| older|adult|says,|"I|should: |a.|Bathe|twice|a|week. |b.|Rinse|well|after|using|soap. |c.|Use|hot|water|for|bathing. |d.|Drink|plenty|of|fluids.|-|verified|answersc.|Use|hot|water|for|bathing. You|ask|the|nursing|assistive|personnel|(NAP)|to|clean|a|patient|who|has|been|incontinent|of|urine.| Several|minutes|later|you|pass|the|open|door|of|the|room|and|see|the|NAP|changing|the|patient's|gown| and|linen.|Which|of|the|following|requires|your|immediate|attention? |a.|Room|temperature|is|overly|warm. |b.|Room|door|is|open|to|the|hallway.
|d.|Have|patient|perform|the|Valsalva|maneuver|-|verified|answersb.|Turn|patient|to|left|lateral|decubitus| position Which|action|is|initially|taken|by|the|nurse|to|verify|correct|position|of|a|newly|placed|small-bore|feeding| tube? |a.|Placing|an|order|for|x-ray|film|examination|to|check|position |b.|Confirming|the|distal|mark|on|the|feeding|tube|after|taping |c.|Testing|the|pH|of|the|gastric|contents|and|observing|the|color |d.|Auscultating|over|the|gastric|area|as|air|is|injected|into|the|tube|-|verified|answersa.|Placing|an|order| for|x-ray|film|examination|to|check|position Based|on|knowledge|of|peptic|ulcer|disease|(PUD),|the|nurse|anticipates|the|presence|of|which|bacteria| when|reviewing|the|laboratory|data|for|a|patient|suspected|of|having|PUD? |a.|Micrococcus |b.|Staphylococcus |c.|Corynebacterium |d.|Helicobacter|pylori|-|verified|answersd.|Helicobacter|pylori The|nurse|is|assessing|a|patient|receiving|enteral|feedings|via|a|small-bore|nasogastric|tube.|Which| assessment|findings|need|further|intervention? |a.|Gastric|pH|of|4.0|during|placement|check |b.|Weight|gain|of| 1 |pound|over|the|course|of|a|week |c.|Active|bowel|sounds|in|the|four|abdominal|quadrants |d.|Gastric|residual|aspirate|of| 350 |mL|for|the|second|consecutive|time|-|verified|answersd.|Gastric| residual|aspirate|of| 350 |mL|for|the|second|consecutive|time The|home|care|nurse|is|seeing|the|following|patients.|Which|patient|is|at|greatest|risk|for|experiencing| inadequate|nutrition? |a.|A|55-year-old|obese|man|recently|diagnosed|with|diabetes|mellitus |b.|A|recently|widowed|76-year-old|woman|recovering|from|a|mild|stroke |c.|A|22-year-old|mother|with|a|3-year-old|toddler|who|had|tonsillectomy|surgery |d.|A|46-year-old|man|recovering|at|home|following|coronary|artery|bypass|surgery|-|verified|answersb.| A|recently|widowed|76-year-old|woman|recovering|from|a|mild|stroke Which|statement|made|by|a|patient|of|a|2-month-old|infant|requires|further|education? |a.|I'll|continue|to|use|formula|for|the|baby|until|he|is|a|least|a|year|old. |b.|I'll|make|sure|that|I|purchase|iron-fortified|formula.
|c.|I'll|start|feeding|the|baby|cereal|at| 4 |months. |d.|I'm|going|to|alternate|formula|with|whole|milk|starting|next|month.|-|verified|answersd.|I'm|going|to| alternate|formula|with|whole|milk|starting|next|month. The|nurse|is|teaching|a|program|on|healthy|nutrition|at|the|senior|community|center.|Which|points| should|be|included|in|the|program|for|older|adults?|(Select|all|that|apply.) a.|Avoid|grapefruit|and|grapefruit|juice,|which|impair|drug|absorption. b.|Increase|the|amount|of|carbohydrates|for|energy. c.|Take|a|multivitamin|that|includes|vitamin|D|for|bone|health. d.|Cheese|and|eggs|are|good|sources|of|protein. e.|Limit|fluids|to|decrease|the|risk|of|edema.|-|verified|answersa.|Avoid|grapefruit|and|grapefruit|juice,| which|impair|drug|absorption. c.|Take|a|multivitamin|that|includes|vitamin|D|for|bone|health. d.|Cheese|and|eggs|are|good|sources|of|protein. The|nurse|sees|the|nursing|assistive|personnel|(NAP)|perform|the|following|for|a|patient|receiving| continuous|enteral|feedings.|What|intervention|does|the|nurse|need|to|address|immediately|with|the| NAP?|The|NAP: |a.|Fastens|the|tube|to|the|gown|with|tape. |b.|Places|the|patient|supine|while|giving|a|bath. |c.|Performs|oral|care|for|the|patient. |d.|Elevates|the|head|of|the|bed| 45 |degrees.|-|verified|answersb.|Places|the|patient|supine|while|giving|a| bath. The|patient|receiving|total|parenteral|nutrition|(TPN)|asks|the|nurse|why|his|blood|glucose|is|being| checked|since|he|does|not|have|diabetes.|What|is|the|best|response|by|the|nurse? |a.|TPN|can|cause|hyperglycemia,|and|it|is|important|to|keep|your|blood|glucose|level|in|an|acceptable| range. |b.|The|high|concentration|of|dextrose|in|the|TPN|can|give|you|diabetes;|thus|you|need|to|be|monitored| closely. |c.|Monitoring|your|blood|glucose|level|helps|to|determine|the|dose|of|insulin|that|you|need|to|absorb| the|TPN. |d.|Checking|your|blood|glucose|level|regularly|helps|to|determine|if|the|TPN|is|effective|as|a|nutrition| intervention.|-|verified|answersa.|TPN|can|cause|hyperglycemia,|and|it|is|important|to|keep|your|blood| glucose|level|in|an|acceptable|range.
|c.| 400 |to| 750 |mL. |d.| 750 |to| 1000 |mL.|-|verified|answersd.| 750 |to| 1000 |mL. A|patient|starts|to|experience|pain|while|receiving|an|enema.|The|nurse|notes|blood|in|the|return|fluid| and|rectal|bleeding.|What|action|does|the|nurse|take|first? |a.|Administers|pain|medication |b.|Slows|down|the|rate|of|instillation |c.|Tells|the|patient|to|breathe|slowly|and|relax |d.|Stops|the|instillation|and|obtains|vital|signs|-|verified|answersd.|Stops|the|instillation|and|obtains|vital| signs A|patient|is|admitted|for|lower|gastrointestinal|(GI)|bleeding.|What|color|of|stool|does|the|nurse| anticipate|the|patient|to|have? |a.|Red |b.|Black |c.|Green |d.|Orange|-|verified|answersa.|Red The|nurse|is|caring|for|a|patient|with|a|colostomy.|Which|intervention|is|most|important? |a.|Cleansing|the|stoma|with|hot|water |b.|Inserting|a|deodorant|tablet|in|the|stoma|bag |c.|Selecting|a|bag|with|an|appropriate-size|stoma|opening |d.|Wearing|sterile|gloves|while|caring|for|the|stoma|-|verified|answersc.|Selecting|a|bag|with|an| appropriate-size|stoma|opening The|nurse|understands|that,|when|comparing|nasogastric|tubes|used|for|gastric|decompression,|a|Salem| sump|is|specifically|designed|to: |a.|Minimize|the|risk|of|a|bowel|obstruction. |b.|Ensure|drainage|of|the|intestines. |c.|Prevent|gastric|mucosal|damage. |d.|Promote|resting|the|gut.|-|verified|answersc.|Prevent|gastric|mucosal|damage. Before|collecting|a|stool|sample|for|occult|blood,|the|nurse|instructs|the|nursing|assistive|personnel|to: |a.|Ask|the|patient|to|void. |b.|Wash|the|patient's|perineum.
|c.|Secure|a|sterile,|specimen|container. |d.|Plan|to|collect|the|first|specimen|of|the|day.|-|verified|answersa.|Ask|the|patient|to|void. The|nurse|is|taking|a|health|history|of|a|newly|admitted|patient|with|a|diagnosis|Rule/out|bowel| obstruction.|Which|of|the|following|is|the|priority|question|to|ask|the|patient? |a.|Describe|your|bowel|movements. |b.|How|often|do|you|have|a|bowel|movement? |c.|When|was|the|last|time|you|moved|your|bowels? |d.|Do|you|routinely|use|stool|softeners,|laxatives,|or|enemas?|-|verified|answersc.|When|was|the|last| time|you|moved|your|bowels? The|nurse|is|caring|for|a|78-year-old|man|with|diarrhea.|Of|the|following|problems,|which|is|the|most| important|to|consider? |a.|Malnutrition |b.|Dehydration |c.|Skin|breakdown |d.|Incontinence|-|verified|answersb.|Dehydration The|nurse|recognizes|which|patient|needs|to|use|a|fracture|pan|for|a|bowel|movement? |a.|The|patient|who|is|obese |b.|The|patient|experiencing|confusion |c.|The|patient|on|bed|rest |d.|A|patient|recovering|from|hip|surgery|-|verified|answersd.|A|patient|recovering|from|hip|surgery The|nurse|is|having|difficulty|reading|a|physician's|order|for|a|medication.|He|or|she|knows|that|the| physician|is|very|busy|and|does|not|like|to|be|called.|What|is|the|most|appropriate|next|step|for|the| nurse|to|take? |a.|Call|a|pharmacist|to|interpret|the|order |b.|Call|the|physician|to|have|the|order|clarified |c.|Consult|the|unit|manager|to|help|interpret|the|order |d.|Ask|the|unit|secretary|to|interpret|the|physician's|handwriting|-|verified|answersb.|Call|the|physician| to|have|the|order|clarified The|patient|has|an|order|for| 2 |tablespoons|of|Milk|of|Magnesia.|How|much|medication|does|the|nurse| give|him|or|her? |a.| 2 |mL
