An adult is now alert and oriented following abdominal surgery. What position is most appropriate for the client?
A. Semi-Fowler's
B. Prone
C.
... [Show More] Supine
D. Sim's
A
This position allows for greater thoracic expansion and puts less pressure on the suture line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason?
A. To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload
B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which action is least appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day
C
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair. How should the nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
d. Facing the bed in the left side of the bed
A
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client?
a. Flat in bed with legs elevated
b. Flat in bed
c. Trendelenburg position
d. Semi-Fowler's position
A
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?
a. Shave the neck
b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV
B
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during tracheal suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning
B--To prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?
a. Use sterile tube each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift
B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions
D
During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal walls and creates a pulling sensation. What is the best action for the nurse to take?
a. Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper
A
Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?
a. Use sterile technique when applying the dressing
b. Leave the compresses on the area continuously, pouring warm solution on the area when it cools down
c. Alternate warm compressed with cold ones
d. Apply wet dressing, cover with dry dressing
A
The day after surgery in which a colostomy was performed, the client says "I know the doctor did not really do a colostomy". The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery, with nursing action is indicated at this time?
a. Agree with the client until he is ready to accept the colostomy
b. Say "It must be difficult to have this kind of surgery"
c. Force the client to look at his colostomy
d. Ask the surgeon to explain the surgery to the client
B
The nurse is preparing to insert an indwelling catheter. What type of technique should the nurse observe to perform this procedure?
a. Clean technique
b. Medical Asepsis
c. Isolation Protocol
d. Sterile Technique
D
. The nurse is performing a urethral catheterization on a female. After separating the labia, where would the nurse observe the urethral meatus?
a. Between the vaginal orifice and the anus
b. Between the clitoris and the vaginal orifice
c. Just above the clitoris
d. Within the vaginal canal
B
The nurse is attempting to pass an indwelling catheter in an adult male and is having difficulty. What is the most appropriate action for the nurse?
a. Remove the catheter and reinsert it with the client positioned differently
b. Try a straight catheter instead
c. Try a smaller catheter
d. Discontinue the procedure and notify the physician
D-- This may indicate an obstruction
After insertion of the indwelling catheter, how should the nurse position the drainage container?
a. With the drainage tubing taut to maintain maximum suction on the urinary bladder.
b. Lower than the bladder to maintain a constant downward flow of urine from the bladder.
c. At the head of the bed for easy and accurate measurement of urine.
d. Beside the patient in his bed to avoid embarrassment.
B
An adult had an indwelling catheter removed, after she voids for the first time, the nurse catheterizes her as ordered and obtained 200 cc of urine. What is the best interpretation of this finding? The client:
a. Is voiding normally
b. Has urinary retention
c. Has developed renal failure
d. Needs an indwelling catheter
B
The nurse plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the nurse:
a. Work on establishing a friendship with the patient
b. Use humour to diffuse emotionally charged topics of discussion
c. Sympathize with the patient when the patient shares sad feelings
d. Demonstrate respect when discussing emotionally charged topics
D
The main purpose of the working phase of the nurse-patient relationship is to:
a. Establish a formal or informal contract that adheres to the patient's problems.
b. Implement nursing interventions that are designed to achieve expected patient outcome.
c. Develop rapport and trust so the patient feels protected and initial plan can be identified.
d. Clearly identify the role of the nurse and establish the parameters of the professional relationship.
B
A patient says, "I don't know if I'll make it through this surgery", which response by the nurse may block further communication?
a. "You sound scared"
b. "You think you will die."
c. "Surgery can be frightening"
d. "Everything will be alright"
C
A patient, who is to receive nothing by mouth (NPO) in preparation for bronchoscopy says "I'm worried about the test and I can't even have a drink of water." What is the best response by the nurse?
a. "Lets talk about your concerns regarding the test".
b. "I'll see if the doctor will let you have some ice chips".
c. "The doctor will review the results of the test as soon as possible".
d. "As soon as the test is over, I'll get you whatever you would like to drink".
A
Which are components of a complete health history? Select all that apply.
a. Chief complain
b. History of the present illness
c. Past medical/surgical history
d. Family, personal, and social history
e. Review of systems
f. Physical exam
A-E, physical exam is not part of the health history
Following amputation of a lower extremity, a patient with prosthesis, should be educated by the nurse to
a. Wear the prosthesis daily, but remove immediately when discomfort is experienced
b. Adjust the fit of the prosthesis by wearing a heavier sock to insure a tight fit
c. To put the prosthesis on immediately upon rising in the morning and keep it on all day
d. To apply oil or lotion to the stump before applying prosthesis
C
When preparing a client for a blood transfusion, the nurse should consider for which of the following? (Select all that apply)
a. Blood typing and cross-matching must be completed prior to a blood transfusion
b. Clients with type A should only receive Type A blood but may receive type O in an emergency
c. clients with type B blood should only receive type B blood, but may receive type A in an emergency
d. Clients with type AB blood are "universal recipients" and should only receive type AB blood but may, in an emergency receive all four types of blood
A, B, D
During a skin assessment, a client asks a question about what the skin does. The nurse's response would be based on the knowledge that the functions of the skin include (Select all that apply.)
a. Temperature regulation
b. Sensory perception
c. Identification
d. Protection
All answers are correct
The skin regulates temperature through changes in its blood flow and through sweating. The skin provides sensory information through its nerve endings. Fingerprints allow for identification of individuals. The skin and mucous membranes are the first line of defense against injury and invasion of microorganisms.
Which of the following is an ABNORMAL finding when observing Water Sealed Chest Drainage for proper functioning?
a. Bubbling initially with coughing and deep inspiration
b. Continuous bubbling where the water seal is maintained
c. Water level fluctuations with breathing
d. A collection chamber that is less than 1/2 full
B
Hyperolality
Symptom of dementia associated with the 3rd stage of Alzheimer's disease
An elderly patient has been living in a nursing home for several years. The nursing staff has begun to notice a change in her behavior. All of the following are symptoms of depression except:
a. Changes in sleep patterns
b. Changes in eating patterns with weight loss
c. Excessive fatigue and increased concern with bodily functions
d. Hyperorality
D
The census on the unit is 90 percent and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?
a. A double room with a client admitted for impetigo.
b. A double room with another client with the same diagnosis.
c. A four-bed room with three clients who have had orthopedic surgery.
d. A double room with an elderly client with a diagnosis of chickenpox.
B
If a private room is not available, the client should be placed with another client with the same diagnosis where droplet precautions would already be in place. The staff and visitors should be told to stay at least 3 feet away without a mask because large-particle droplets travel only about 3 feet before falling from the air. [Show Less]