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48 Cards in this Set
- Front
- Back
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A patient is at risk for developing hypoxemia. Which signs would indicate that the condition is still in an early stage?
A. Cyanosis B. Intercostal retractions C. Confusion D. Hypotension |
C. Confusion
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A patient has been placed on a pulse oximeter to measure oxygen saturation. Which of the following should be incorporated into the plan of care for this patient?
A. Check the machine calibration once per month. B. rotate the site of the clip-on probe every hour. C. Allow 30 minutes for the machine to warm up. D. remove nail polish or articifical nails if fingertip is used. |
D. remove nail polish or articifical nails if fingertip is used.
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The nurse is monitoring patients who are eating in the dining room. She notes that a patient begins choking. As the nurse prepares to deliver the correct heimlich position. He should position his fist:
A. halfway between the ixphoid process and the umbilicus. B. Directly over the sternum. C. Between the umbilicus and the symphysis pubis. D. Directly over the umbilicus. |
A. halfway between the xiphoid process and the umbilicus.
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A patient has collapsed and cannot be aroused by asking loudly, "Are you ok?" What action should be taken next?
A. Position the fingers over the carotid artery to feel for a pulse. B. Tilt the head by placing one hand on the forehead and lift the chin C. Call for help or, if there is assistance, have that person get help D. Deliver two quick short breaths into the patient's airway |
C. Call for help or, if there is assistance, have that person get help.
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Patient has difficulty coughing up secretions and is only clearing their throat during coughing attempts. Nurse should tell patient to inhale e deeply and cough forcefully during exhalation of the
A. 1st breath B. 2nd breath C. 3rd breath D. 5th breath |
C. 3rd breath
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A patient who is having difficulty mobilizing respiratory secretions is having postural drainage treatments. The best time for the treatments to be scheduled is:
A. Shortly after the patient arises in the morning, before breakfast. B. In the morning immediately after breakfast. C. 30 minutes after lunch. D. 1 hour after supper. |
A. Shortly after the patient arises in the morning, before breakfast.
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A patient who will begin oxygen therapy has a history of sinus disorcers, This patient would benefit most from which oxygen setup?
A. high oxygen flow rate B. A humidifier C. A Venturi mask D. A nasal cannula |
B. A humidifier
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A patient has a history of chronic obstructive pulmonary disease. The patient's oxygen flow rate should be set to no more than:
A. 5 to 10 L/min B. 4 to 5 L/min C. 2 to 3 L/min D. 1 to 2 L/min. |
C. 2 to 3 L/min
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9. A patient requires oxygen during meals. The best type of oxygen delivery method for this patient is a
A. simple face mask B. nasal cannula C. partial rebreather mask D. Venturi mask |
B. nasal cannula
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Patient requires a precise concentration of 40% of oxygen. Which of the following devices would best allow for this?
A. A simple mask B. A nasal cannula C. venturi mask D. partial rebreather mask |
C. venturi mask
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A sleeping patient can breathe independently but has trouble maintaining an airway because her tongue falls back into her throat. The airway assistive device that would be most beneficial to this patient is a(n):
A. Nasopharyngeal airway. B. Endotracheal tube. C. Tracheostomy D. partial rebreather oxygen mask. |
A. nasopharyngeal airway
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An adult patient with a tracheostomy requires suctioning. The nurse should set the wall suction machine so that the suction pressure is between
A. 25 to 50 mmHg B. 50 to 75 mmHg C. 80 to 120 mmHg D. 120 to 180 mmHg |
C. 80 to 120 mmHg
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A nurse is caring for a patient with a tracheotomy. The best way for the nurse to determine whether patient needs suctioning is to.
A. Monitor heart rate B. Determine the last time suctioned C, Review patient’s physician’s order for suctioning D. Auscultate breath sounds |
D. Auscultate breath sounds
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Patient requires suctioning via nasotracheal route. In order to perform this procedure safely, the nurse should
A,. apply suction while advancing catheter into airway B. suction the nasotracheal passage way after suctioning mouth C. Hold catheter with dominant hand after donning sterile gloves. D. insert the catheter into the nasal passage without lubricating it |
C. Hold catheter with dominant hand after donning sterile gloves.
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In some states and/or health care facilities, the LVN is allowed to deflate the cuff of a tracheostomy tube. if able to perform the procedure, the nurse recognizes that, immediately before cuff deflation, the patient should:
A. Be administer extra oxygen B. Have the pharynx suctioned C. have the cuff pressure checked D. Be monitored for respiratory rate. |
B. Have the pharynx suctioned
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A nurse is trying to increase fluid intake for a patient who needs to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least:
A. 500 - 1000 mL/day B. 1000 - 1500 mL/day C. 1500 - 2000 mL/day D. 2500- 3000 mL/day |
C. 1500 - 2000 mL/day
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A patient with emphysema tells the nurse that she is having difficult breathing. The most appropriate position for this patient is:
A. Semi-fowler's position with a single pillow behind the head. B. High-fowler's position without a pillow behind the head C. Right lateral with the head of bed elevated 45 degrees D. Sitting upright and forward with arms supported on an over the bed table |
D. Sitting upright and forward with arms supported on an over the bed table
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Patient is due for tracheotomy care. Appropriate actions is to
A. raise head of the bed to high Fowler’s position. B. use half-strength peroxide and normal saline to wash and saline to rinse. C. reinsert inner cannula while drenched with secretions D. Change tracheotomy ties, that where changed 4 hours ago. |
B. use half-strength peroxide and normal saline to wash and saline to rinse.
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Nurse is caring for obese patient. Nurse realizes that patient is at risk for becoming?
A. Asepsis B. Hypocapnic C. Hypoxic D. Tachypaneic |
C. Hypoxic
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When assessing lungs of patient nurse observes muscle of the neck and that the chest moves inward on inspiration. The appropriate tem for this is?
A. Apnea B. Dysapnea C. Stridor D. Retractions |
D. Retractions
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Patient has difficulty with urinary elimination has a foley catheter in place. When observing urine output, it is important to note whether it drops below how many milliliters/ per hour?
A. 15 ml/hr B. 30 ml / hr C. 45 ml/hr D. 60 ml/hr |
B. 30 ml / hr
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Female patient complains of contracting frequent urinary tract infections. To help reduce patient’s risk of cystitis, nurse teaches the patient to:
A. eat citrus fruits to alkalinize the urine B. always wipe perinea area from front to back C. take long, warm bubble baths D. wear cotton underwear and avoid nylon or constrictive clothing. |
D. wear cotton underwear and avoid nylon or constrictive clothing.
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Patient without urinary drainage catheter is having intake and output monitored. The nurse should measure amount voided and verify that patient voids at least every
A. 16 hours B. 12 hours C. 8 hours D. 4 hours |
C. 8 hours
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Prevent changes in chemical characteristics of urine, a nurse sends a sample of fresh urine to laboratory for urinalysis with at least
A. 1 to 2 minutes B. 3 to 5 minutes C. 5 to 10 minutes D. 20 to 30 minutes |
C. 5 to 10 minutes
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A Patient is ordered to have a 24 hour urine collection as part of a diagnostic workup. The action taken to perform this procedure correctly is to
A. continual collection if patient accidentally voids directly into the toilet. B. Obtain a container and put it in a warm water bath in the bathroom C. have patient void at the beginning of the collection and throw away to rest. D. Apply a small condom catheter. |
C. have patient void at the beginning of the collection and throw away to rest.
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A urine sample is needed from a baby. Which measure should be used to obtain a sample from the patient age group?
A. Place infant on a bedpan after removing diaper B. Remove diaper after infant voids and send diaper to lab. C. Attach bag with adhesive backing to skin surrounding the genitals. D. Apply small condom catheter. |
C. Attach bag with adhesive backing to skin surrounding the genitals.
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The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing action is to obtain a
A. Sieve B. indwelling catheter C. Graduated cylinder D. Urinary bag |
A. Sieve
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A patient has an order to get out of bed but feels to weak to walk to bathroom. Which is the most useful in assisting this patient with urinary elimination?
A. Use a slandered size bed pan and elevate the head of the bed B. Use a fracture bed pan and keep patient flat C. Obtain a raised toilet seat. D. Place a commode at bedside |
A. Use a slandered size bed pan and elevate the head of the bed
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A nurse is observing a nursing assistant offering a bedpan to a patient. The nurse will intervene if the nursing assistant?
A. closes the bedside curtain B. dons clean gloves C. keeps the head of the bed flat after placing the bedpan D. asks the patient to bend his knees and press down with his feet. |
C. keeps the head of the bed flat after placing the bedpan
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A patient who needs to void can’t begin the urinary stream . Which action is most helpful in assisting this patient?
A. Run water in a nearby sink B. Pour cool water of the perineum C. Insert an indwelling catheter D. Insert a coude catheter |
A. Run water in a nearby sink
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Elder male patient needs to have a condom catheter applied. An appropriate technique is to
A. Shave the perinea area before beginning B. apply poeridone -iodine to the penis before catheter application C. Apply adhesive strip in a circle around base of penis D. Leave 1 to 2 inches between the tip of the penis and drainage catheter. |
D. Leave 1 to 2 inches between the tip of the penis and drainage catheter.
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When attempting to catherize a male patient there is resistance to catherter insertion which action should the nurse take first?
A. withdraw catherter and start all over again B. Ask the patient to take a deep breath C. Ask patient to bear down and hold his breath D. ask patient to lie on the right side. |
B. Ask the patient to take a deep breath
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A patient's stool has changed from brown to dark black and sticky. The nurse suspects:
A. blockage of the bile duct. B. Blockage of the pancreatic duct. C. Recent excessive intake of milk products. D. Presence of occult blood. |
D. Presence of occult blood.
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A patient has stools that are foul smelling and that float on water. The nurse documents that this patient is having:
A. Rhinorrhea B. Steatorrhea C. Amenorrhea D. Diarrhea |
B. Steatorrhea
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the nurse is most concerned about the risk of constipation in a patient:
A. Being treated for diabetes mellitus B. Who has a routine order for Metamucil C. Who just completed barium studies of the bowel. D. With orders to ambulate with assistance. |
C. Who just completed barium studies of the bowel.
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An elderly patient routinely takes the bulk forming laxative psyllium (Metamucil). To prevent constipation and possible fecal impaction, the nurse ensures that this patient:
A. Takes extra vitamin C B. Also takes a fat soluble vitamin C. Takes the medication with a large amount of fluid D. Temporarily reduces intake of high fiber foods. |
C. Takes the medication with a large amount of fluid
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A patient with inflammatory bowel disease is experiencing diarrhea. The nurse checks the medication administration record to see whether there is an order for:
A. Docusate sodium (colace) B. Loperamide (Imodium) C. Polycarbophil (Fibercon) D. Senna (Senokot) |
B. Loperamide (Imodium)
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The nurse is caring for a patient with complaints of constant diarrhea for 3 days. The patient is exhibiting signs and symptoms of dehydration. The best fluid source for this patient to drink small amounts of is:
A. A Cola beverage B. Gingerale C. Gatorade D. Kool-Aid |
C. Gatorade
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A patient who has started antibiotic therapy is having diarrhea as a side effect of the medication. The nurse should encourage the patient to eat:
A. Yogurt B. Raisins C. Gelatin fruit flavored dessert (like Jello) D. Poultry |
A. Yogurt
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During an admission interview, a patient states that she has diarrhea after drinking milk or milk products, This is typically found with:
A. Fecal incontinence B. Bowel inflammatory disease C. Gluten intolerance D. Lactose intolerance |
D. Lactose intolerance
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A nurse has performed abdominal assessments on four patients. After reviewing the findings, the nurse is least concerned about problems with bowel elimination for the patient with:
A. Abdomen nondistended, firm, with hypoactive bowel sounds in all four quadrants. B. Abdomen nondistended, soft, with active bowel sounds in all four quadrants. C. Abdomen distended, firm, with hypoactive bowel sounds in all four quadrants. D. Abdomen distended, soft, with hyperactive bowel sounds in all four quadrants. |
B. Abdomen nondistended, soft, with active bowel sounds in all four quadrants.
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A nurse is monitoring bowel elimination of a patient who has a history of constipation. The nurse implements measure to assist with bowel elimination if the patient has not had a bowel movement within how many days?
A. 5 days B. 3 days C. 2 days D. 1 day |
B. 3 days
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A patient has just completed a series of upper gastrointestinal tract x-rays that involved the use of barium as a contrast agent. Which measure will this patient need to help excrete the barium?
A. Diuretics and fluid restriction to 1.5 L B. Diuretics and fluid intake increased to 3.5 L C. Laxatives and fluid restriction to 1.5 L D. Laxatives and fluid intake increase dot 3.5 L |
D. Laxatives and fluid intake increase dot 3.5 L
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An ambulatory clinic patient telephones to report diarrhea and to ask for advice on medication to manage it. The best response by the nurse to the patient is, "Do not use antidiarrheal medication for longer than:
A. 24 hours without calling back for an appt. B. 48 hours without calling back for an appt. C. 72 hours without calling back for an appt. D. 96 hours without calling back for an appointment |
B. 48 hours without calling back for an appt.
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There is an order to administer a cleansing enema to an adult patient before bowel surgery. The enema bag is filled with how many milliliters of fluid for this procedure?
A. 500 - 1000 mL B. 300 - 500 mL C. 200-300 mL D. 50-150 mL |
A. 500 - 1000 mL
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A patient who is badly constipated has just received an oil retention enema. The nurse encourages this patient to try to hold the enema for at least how long before trying to have a bowel movement?
A. 10 minutes B. 15 minutes C. 30 minutes D. 60 minutes |
C. 30 minutes
*Note, the book says 20 minutes, Jamal said go with 30 minutes, as this is what his "answer" key says! |
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A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should:
A. Cool the solution to 70 degrees F. B. Warm the solution in the microwave. C. Keep the solution at room temperature D. Warm the solution to 105 degrees F. |
D. Warm the solution to 105 degrees F
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A patient scheduled for bowel surgery has an order to receive enemas until clear. The nurse is aware than no more than 3 enemas should be given because:
A. Repeated enemas may cause more flatus B. The patient may develop an irritated rectum C. Repeated enemas may cause electrolyte imbalance. D. The patient may develop severe diarrhea. |
C. Repeated enemas may cause electrolyte imbalance.
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