Fundamentals of Nursing
Midterm Exam
Course Introduction
Fundamentals of Nursing introduces students to the essential concepts, skills, and attitudes required to provide safe, effective, and patient-centered care in a variety of healthcare settings. The course covers foundational topics such as professional roles and responsibilities, communication, health assessment, infection control, vital signs, basic patient care, and ethical and legal considerations in nursing practice. Emphasis is placed on understanding the nursing process, critical thinking, and cultural competence to promote holistic care. Through a combination of classroom instruction, laboratory practice, and clinical experiences, students develop the competencies needed to support patients physical, emotional, and psychological well-being.
Recommended Textbook
Clinical Nursing Skills and Techniques 9th Edition by Perry
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44 Chapters
1281 Verified Questions
1281 Flashcards
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Chapter 1: Using Evidence in Practice
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Sample Questions
Q1) A systematic review explains whether the evidence that you are searching for exists and whether there is good cause to change practice.In _____________,all entries include information on systematic reviews.Individual randomized controlled trials (RCTs)are the gold standard for research.
Answer: The Cochrane Database
Q2) _________________ is a guide for making accurate,timely,and appropriate clinical decisions.
Answer: Evidence-based practice
Q3) Six months after an early mobility protocol was implemented,the incidence of deep vein thrombosis in patients was decreased.This is an example of what stage in the EBP process?
A)Asking a clinical question
B)Applying the evidence
C)Evaluating the practice decision
D)Communicating your results
Answer: C
Q4) __________________ are the gold standard for research.
Answer: Randomized controlled trials
Q5) While caring for patients,the professional nurse must question ________________.
Answer: what does not make sense
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Chapter 2: Admitting, transfer, and Discharge
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) If a patient is having acute physical problems,postpone routine admission procedures until the patient's immediate needs are met.A ________________ assessment is needed at this point.
Answer: focused
Q2) The patient is admitted to the unit for a cardiac catheterization.Which of the following can be delegated to nursing assistive personnel (NAP)?
A)Obtaining admission vital signs
B)Preparing the patient's room
C)Gathering and securing personal care items
D)Orienting patient and family to the nursing unit
Answer: B,C,D
Q3) Which of the following are considered "advance directives"?
A)Living will
B)Power of attorney for health care
C)Notarized handwritten document
D)Nursing progress note
Answer: A,B,C
Q4) The greatest challenge in effective discharge planning is _______________. Answer: communication
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Chapter 3: Communication and Collaboration
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) The patient states,"I don't know what my family will think about this." The nurse wishes to use the communication technique of clarification.Which of the following statements would fit that need best?
A)"You don't know what your family will think?"
B)"I'm not sure that I understand what you mean."
C)"I think it would be helpful if we talk more about your family."
D)"I sense that you may be anxious about something."
Answer: B
Q2) Directing the conversation back to patient ideas,feelings,questions,or content is known as ___________________.
Answer: reflection
Q3) Lack of verbal communication for a therapeutic reason is known as ___________________.
Answer: therapeutic silence
Q4) An active process of receiving information that nonverbally communicates to the patient the nurse's interest and acceptance is classified as _____________.
Answer: listening
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5
Chapter 4: Documentation and Informatics
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Sample Questions
Q1) The nurse manager is attempting to determine the staffing needs of the unit.One tool that she may use to determine the level of care needed would be:
A)the standardized care plan.
B)the acuity record.
C)the patient care summary.
D)flow sheets.
Q2) Patients on the unit have their vital signs taken routinely at 0800,1200,1600,and 2000.At 1000,a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes,the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?
A)Document the 1000 vital signs in the graphic record only.
B)Not report the incident because it was a transient episode.
C)Document the vital signs in the graphic and progress record.
D)Document the vital signs as 12 o'clock signs.
Q3) To limit liability,nursing documentation must clearly indicate that the nurse provided individualized,goal-directed nursing care to a patient based on the
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6
Chapter 5: Vital Signs
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Sample Questions
Q1) The patient has an order to be off the floor for 15 minutes every 2 hours to smoke a cigarette.The patient has just returned from his "cigarette break." The nurse is about to take the patient's temperature orally and should:
A)wait about 15 minutes before taking his temperature.
B)give him oral fluids to rinse the nicotine away before taking his temperature.
C)give him a stick of chewing gum to chew and then take his temperature.
D)take his oral temperature and record the findings.
Q2) The nurse is caring for a 2-year-old child who is admitted with croup and crying.To take the child's vital signs,the nurse should:
A)place the pediatric blood pressure cuff on the left arm.
B)place the blood pressure cuff on the right thigh.
C)skip the blood pressure measurement.
D)place the blood pressure cuff on the left thigh.
Q3) When evaluating the patient's temperature levels,the nurse expects the patient's temperature to be lower:
A)in the morning.
B)after exercising.
C)during periods of stress.
D)during the postoperative period.
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Page 7
Chapter 6: Health Assessment
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Sample Questions
Q1) The patient has been immobile at home after having had leg trauma in an automobile accident and is now being admitted with calf pain and localized swelling of the calf muscle.One test that is contraindicated in assessment of this patient is testing for _____________.
Q2) A late sign of decreased oxygen levels may cause a change in skin color known as _________.
Q3) The nurse is providing health education to a group of adolescent females.The topic is "Preventing Skin Cancer." As part of the health promotion education,the nurse recommends that they avoid tanning under direct sun at midday and avoid
Q4) A nurse is documenting a patient's breath sounds.Rhonchi are heard as:
A)loud,low-pitched,coarse sounds.
B)high-pitched,musical squeaks.
C)dry,grating sounds on inspiration.
D)high-pitched,fine sounds at the end of inspiration.
Q5) A nurse is documenting a patient's breath sounds.Crackles are heard as:
A)loud,low-pitched,coarse sounds.
B)high-pitched,musical squeaks.
C)dry,grating sounds on inspiration.
D)high-pitched,fine sounds at the end of inspiration.
Page 8
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Chapter 7: Specimen Collection
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Sample Questions
Q1) The nurse evaluates that an expected outcome for analysis of gastric secretions is:
A)inability of the patient to discuss the rationale for the test.
B)negative occult blood.
C)the presence of clumps or clots.
D)the presence of brown,"coffee-ground" secretions.
Q2) A patient asks what food may be eaten before a stool specimen is obtained for occult blood.What food should the nurse allow the patient to eat?
A)Fish
B)Apples
C)Red meats
D)Green leafy vegetables
Q3) When collecting specimens,the nurse should:
A)wear gloves and perform hand hygiene.
B)handle excretions discreetly.
C)explain the procedure to the patient.
D)allow patients to collect their own urine specimens.
Q4) ______________ is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis.
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Chapter 8: Diagnostic Procedures
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Sample Questions
Q1) Under which circumstances should a nurse contact the physician to postpone an angiography?
A)If a patient has been nothing by mouth (NPO)for only 1 hour.
B)If a patient's femoral site has been shaved and cleansed with an antiseptic.
C)If the patient received Benadryl as a preprocedure medication.
D)When test results reveal a blood urea nitrogen (BUN)level of 15 mg/100 mL and a creatinine level of 0.8 mg/mL.
Q2) ____________ are sterile invasive procedures involving the removal of body fluids or tissue for diagnostic procedures.
Q3) The patient will be undergoing moderate intravenous (IV)sedation.The nurse needs to assess which of the following during the procedure?
A)Airway compromise
B)Hemodynamic instability
C)Agitation
D)Combativeness
Q4) _____________________ is often used for diagnostic or surgical procedures that do not require complete anesthesia in acute care,surgical care,and outpatient care settings.
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Page 10
Chapter 9: Medical Asepsis
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26 Verified Questions
26 Flashcards
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Sample Questions
Q1) The nurse is preparing to provide care for the patient.Before making patient contact,she washes her hands.This practice is known as __________________.
Q2) The patient is admitted with mumps.The nurse knows that she will have to:
A)put the patient in a private room.
B)place the patient on standard precautions.
C)wear a mask when closer than 3 feet to the patient.
D)place the patient on contact precautions.
Q3) ________________ is the absence of pathogenic (disease-producing)microorganisms.
Q4) Infection control practices that reduce and eliminate sources and transmission of infection are known as _______________.
Q5) The patient is admitted to the pediatric unit with severe pertussis.The nurse explains to the parents and the child that the patient will be treated with the use of:
A)airborne precautions.
B)standard precautions only.
C)droplet precautions.
D)contact isolation.
Q6) _______________,also known as sterile technique,includes procedures used to eliminate all microorganisms from an area.
Page 11
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Chapter 10: Sterile Technique
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16 Flashcards
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Sample Questions
Q1) When removing the mask after an aseptic procedure,what should the nurse do first?
A)Remove gloves.
B)Untie top strings of mask.
C)Untie bottom strings of mask.
D)Untie top strings and let mask hang.
Q2) A sterile field consists of which of the following?
A)Sterile tray
B)Work surface draped with a sterile towel
C)Table covered by a large sterile drape
D)Patient's bedside table
Q3) Which of the following is an appropriate technique for the nurse to use when performing sterile gloving?
A)Put the glove on the nondominant hand first.
B)Interlock the hands after both gloves are applied.
C)Pull the cuffs down on both gloves after gloving.
D)Grasp the outside cuff of the other glove with the gloved hand.
Q4) When performing sterile aseptic procedures,the nurse must create a _____________ in which objects can be handled with minimal risk for contamination.
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Page 12
Chapter 11: Safe Patient Handling, transfer, and Positioning
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) To position a patient with hemiplegia in Fowler's position,the nurse should:
A)elevate the head of the bed 15 to 30 degrees.
B)place the patient in the prone position.
C)position a spastic hand with the fingers extended using hand rolls.
D)position the patient's head with slight hyperextension of the neck.
Q2) Patients at risk for complications and/or injury from improper positioning include patients with which of the following?
A)Poor nutrition
B)Loss of sensation
C)Impaired muscle development
D)Poor circulation
Q3) Body balance is achieved when a wide _____________ exists.
Q4) A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal independence is known as ________________.
Q5) The patient is immobile and is being placed in the supine position.To reduce extension of the fingers and abduction of the thumb,the nurse places _________________ in the patient's hands.
Q6) Awareness of posture and changes in equilibrium is known as _______________.
Page 13
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Chapter 12: Exercise Mobility
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) An appropriate procedure for the nurse to use when applying an elastic stocking is to:
A)remove the stockings every 24 hours.
B)keep the tops of the stockings rolled down slightly.
C)turn the stocking inside out to apply from the toes up.
D)wash stockings daily and dry in a dryer.
Q2) The patient is an elderly gentleman who has been on bed rest for the past several days.When getting the patient up,the nurse should:
A)tell the patient not to move his legs when dangling.
B)tell the patient to hold his breath while dangling.
C)raise the head of the bed and allow a few minutes before dangling.
D)have the patient stand without dangling.
Q3) The patient is performing range of motion (ROM)exercises independently.These are known as __________ exercises.
Q4) A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.
Q5) Virchow's triad (hypercoagulability of blood,venous wall damage,and stasis of blood flow)has been found to contribute to ________________.
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Chapter 13: Support Surfaces and Special Beds
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Sample Questions
Q1) A patient is on bed rest after sustaining injuries in a car accident.Which nursing action helps prevent complications of immobility?
A)Decreasing fluid intake to ease dependent edema
B)Turning the patient every 2 hours and providing a low-air-loss mattress
C)Raising the head of the bed to maximize the patient's lung inflation
D)Bathing and feeding the patient to decrease energy expenditure
Q2) A ______________ serves as an artificial layer of fat to protect bony surfaces.
Q3) When working with a patient who is being placed on an air mattress/overlay,the nurse should:
A)apply the preinflated overlay over the standard mattress.
B)bring any plastic strips or flaps around the corners of the bed mattress.
C)administer an analgesic after the patient is moved onto the mattress.
D)keep clamps or pins attached to the sheets to keep them in place over the mattress.
Q4) Which of the following is a limitation of the bariatric bed?
A)Lack of an in-bed scale
B)The narrowness of the bed
C)Lack of pressure reduction
D)Increased liability to the institution
Q5) A full or double-wide _____________ can accommodate a patient up to 1000 pounds.
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Chapter 14: Patient Safety
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Sample Questions
Q1) __________ are the most common type of inpatient accident.
Q2) In a long-term care facility,an elderly patient drops his burning cigarette into a trash can and starts a fire.A type _____ fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation.
A)A
B)B
C)C
D)D
Q3) Which of the following alternatives to physical restraints should the nurse use to promote patient safety?
A)Environmental modifications
B)Less frequent patient observation
C)Involvement of family during visitation
D)Frequent reorientation of the patient
Q4) Effective fall prevention programs include which of the following?
A)Risk assessment
B)Medication reviews
C)Use of assistive devices
D)Exercise and strength training
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Chapter 15: Disaster Preparedness
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Sample Questions
Q1) Personal protective equipment (PPE)is categorized by the level of safety provided.Standard work uniforms or work clothes offer what level of protection?
A)Level A
B)Level B
C)Level C
D)Level D
Q2) Releasing nuclear energy in an explosive manner as the result of a nuclear chain reaction is known as a ________________.
Q3) In the event of a mass casualty incident,part of the Centers for Disease Control & Prevention (CDC)'s disaster preparedness program involves backup plans for maintaining public and intraagency/interagency ____________.
Q4) Disaster nursing differs from general nursing because when caring for patients during a disaster:
A)the focus is on caring for the sickest people first.
B)using a color tag system reduces the amount of emotional stress on the nurse.
C)the focus is no longer on airway,breathing,and circulation.
D)the focus is on caring for those most likely to survive.
Q5) It is recommended that every household prepares a ____________.
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Chapter 16: Pain Management
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Sample Questions
Q1) The _______________ is a potential space between the vertebral bones and the dura mater,the outermost meninges covering the brain and spinal cord.
Q2) A nonpharmacological approach that the nurse may implement for patients who are experiencing pain that focuses on diverting the patient's attention away from the pain sensation by promoting pleasurable and meaningful stimuli is:
A)massage.
B)heat/cold.
C)guided imagery.
D)distraction.
Q3) The patient is admitted for chronic pain.He states that morphine sulfate has been used to relieve his pain,but recently he has been needing to use more of the medication to relieve pain.This patient's plan of care will have to incorporate interventions to deal with which of the following?
A)Addiction
B)Pseudoaddiction
C)Drug tolerance
D)Physical dependence
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18
Chapter 17: Palliative Care
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Sample Questions
Q1) A new staff member is working with a patient who is dying.A nurse evaluates that this new employee requires additional teaching when he or she is observed:
A)limiting the family's visiting hours.
B)staying with the patient and family as much as possible.
C)finding a quiet place for family members to gather.
D)asking the family if they would like to help with preparing the body.
Q2) After the death of a patient and before other nursing interventions are implemented,the nurse should:
A)place the patient in a supine position and elevate the head of the bed 30 degrees.
B)wait an hour to prepare the patient for viewing.
C)place the patient in a side-lying position to allow drainage.
D)exclude the family while the body is being prepared.
Q3) Hospice care can be provided in which of the following settings?
A)Home
B)Freestanding hospice facilities
C)Extended care facilities
D)Acute care facilities
Q4) _____________ helps people live as well as possible through the dying process.
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Page 19
Chapter 18: Personal Hygiene and Bed Making
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Sample Questions
Q1) While washing the patient's face,the nurse should:
A)wash the eyes using soap and warm water.
B)wash the eyes from outer canthus to inner canthus.
C)wash the eyes with plain warm water.
D)use the same portion of the washcloth.
Q2) The home care nurse is getting ready to help the patient prepare a tub bath.What should the nurse be sure to do?
A)Instruct the patient to use safety bars.
B)Use the patient's favorite bath oil for aroma therapy.
C)Instruct the patient to stay in the tub no longer than 30 minutes.
D)Check on the patient every 20 minutes.
Q3) Regular oral hygiene is necessary to maintain the integrity of tooth surfaces and to prevent gum inflammation known as ____________.
Q4) The optimal position for a female patient for the provision of perineal care is:
A)prone.
B)side-lying.
C)high-Fowler's.
D)dorsal recumbent.
Q5) The act of chewing is also known as ________________.
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Chapter 19: Care of the Eye and Ear
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Sample Questions
Q1) The nurse caring for a comatose patient determines that he is wearing contact lenses.Which of the following nursing interventions will the nurse use when removing the contact lenses?
A)Put on snug,powdered,clean gloves.
B)Ask the patient to look down to expose the lower eyeball.
C)Use the fingernail to slide the lens off of the cornea.
D)Inspect the eye after the lenses have been removed.
Q2) The substance found in the ear canal that has an antibacterial effect and maintains an acid pH is called ______________.
Q3) A _____________ is a small,battery-powered,electronic device that amplifies sound.
Q4) When providing care to a patient who has splashed bleach into his eye,the nurse will:
A)remove the patient's contacts immediately.
B)flush the eye from the outer to the inner canthus.
C)reinsert contacts as soon as irrigation is done.
D)irrigate toward the lower conjunctival sac.
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21
Chapter 20: Safe Medication Preparation
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Sample Questions
Q1) The hospital has implemented a computerized physician order entry system (CPOE)to eliminate the need for written orders.The benefits of this system include which of the following?
A)Automatic drug allergy checks
B)Automatic dosage indications
C)Identification of potential drug interactions
D)Reduced number of medical errors
Q2) The nurse administers 650 mg of acetaminophen orally to a patient with a pain level of 4 out of 10.The nurse is aware that the onset of action is 30 minutes to 1 hour,the peak action is 1 to 3 hours,and the duration of action is 3 to 8 hours.After _____ hours,the nurse should assess the patient to determine the maximum effectiveness of the drug.
Q3) The patient reports taking an opioid medication in large dosages for the past several years.While in the hospital,the patient is not prescribed the medication and develops tachycardia,hypertension,sweating,and tremors.He becomes confused and experiences visual hallucinations.The nurse recognizes these signs as indicative of
Q4) The patient is to receive 200 mg of a medication.There are 100-mg scored tablets available.The nurse prepares _________ tablets.
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Page 22
Chapter 21: Administration of Nonparenteral Medications
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Sample Questions
Q1) The nurse is preparing a medication for a small child.The medication comes in pill or liquid form,but the liquid preparation has a bitter taste.Which action by the nurse is most appropriate?
A)Give the pill form.
B)Mix the liquid with honey.
C)Mix the liquid in milk.
D)Mix the liquid in applesauce.
Q2) The easiest and most desirable way to administer medications is via the _________ route.
Q3) Handheld devices that disperse medications through an aerosol spray or mist to penetrate lung airways are known as ___________.
Q4) The nurse is to administer several medications to a patient via a nasogastric (NG)tube.What should the nurse do first?
A)Add the medications to the tube feeding being given.
B)Crush all tablets and capsules before administration.
C)Administer all of the medications mixed together.
D)Check for placement of the NG tube.
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Chapter 22: Administration of Parenteral Medications
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Sample Questions
Q1) The nurse injects the medication into the loose connective tissue just under the dermis when giving a _____________ injection.
Q2) A patient with a continuous IV infusion has an order for ciprofloxacin to be given IV piggyback.Which action by the nurse is appropriate for administering the medication?
A)Hang the bag with ciprofloxacin higher than the continuous infusion bag.
B)Stop the continuous infusion while running the ciprofloxacin.
C)Connect the piggyback tubing into the Y-port on the tubing of the continuous infusion that is closest to the patient.
D)Occlude the tubing of the continuous infusion just above the injection port while injecting the medication.
Q3) The nurse is preparing a medication that comes in an ampule.Which action by the nurse is appropriate?
A)Tapping the ampule so fluid moves from the bottom of the ampule to the neck
B)Avoiding inversion of the ampule after opening to prevent spillage of the medication
C)Using a filter needle long enough to reach the bottom of the ampule
D)Guiding the needle against the rim of the ampule to access the medication
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Chapter 23: Oxygen Therapy
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Sample Questions
Q1) The amount of air inspired and expired with each breath while a patient is on mechanical ventilation is known as the ________________.
Q2) A patient with chronic obstructive pulmonary disease (COPD)has carbon<sub> </sub>dioxide retention and is ordered oxygen therapy.The nurse anticipates the use of which oxygen delivery system?
A)Face tent
B)Face mask
C)Nasal cannula
D)Nonrebreathing mask
Q3) The ________,also called a Briggs adaptor,connects an oxygen source to an artificial airway such as an endotracheal tube.
Q4) A patient with a nasal cannula at 5 L/min has skin irritation around the nares and complains of a dry mouth and nose.Which action by the student nurse should be questioned by the nursing instructor?
A)Using humidification
B)Applying petroleum-based gel to the nares
C)Providing frequent oral care
D)Asking the physician for an order for sterile nasal saline
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Page 25
Chapter 24: Performing Chest Physiotherapy
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Sample Questions
Q1) The nurse is planning to perform postural drainage on a patient who is receiving continuous tube feedings.What should the nurse do before performing the treatment?
A)Stop the tube feedings for 1 to 2 hours before and after postural drainage.
B)Check for residual feeding in the patient's stomach and hold treatment if greater than 100 mL.
C)Give the prescribed inhaled bronchodilator 20 minutes before the procedure.
D)Auscultate all lung fields,assess vital signs,and draw arterial blood gas levels (ABG).
Q2) The health care provider orders percussion on a patient to help clear airway secretions.Which action by the nurse is appropriate?
A)Performing percussion over the ribs,while avoiding the clavicles and sternum
B)Administering pain medication before performing the percussion because the vibrations will be painful
C)Performing percussion during exhalation only with the flat part of the palm
D)Creating a rocking motion by slightly leaning on the patient's chest
Q3) The system that lines the internal lumen of the tracheobronchial tree and consists of a thin layer of mucus that constantly is propelled toward the larynx by cilia is called the
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26
Chapter 25: Airway Management
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Sample Questions
Q1) Too much oxygen reduces the drive to breathe in patients with chronic
Q2) A patient has been on mechanical ventilation with an endotracheal tube for 1 week.Which intervention by the nurse will help prevent ventilator-associated pneumonia (VAP)?
A)Providing oral care with a toothbrush at least twice daily
B)Changing the ventilator circuits at least every 72 hours
C)Removing subglottal secretions before every position change
D)Maintaining endotracheal cuff pressures at 10 cm H<sub>2</sub>O
Q3) The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties.Which action by the student should the nursing instructor question?
A)Suctioning the tracheostomy tube before removing the soiled tracheostomy dressing
B)Assisting the patient to semi-Fowler's position
C)Placing new tracheostomy ties before cutting the old ties
D)Cutting gauze pads to place around the tracheostomy tube
Q4) A patient has extremely copious and thick oral secretions.The nurse provides oropharyngeal suctioning using a _________________ suction device.
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Chapter 26: Cardiac Care
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Sample Questions
Q1) Proper placement of the ECG electrodes is essential for which reason?
A)To ensure real-time detection of arrhythmias
B)To prevent painful removal of the electrodes
C)To facilitate capture of all leads
D)To reduce ventricular arrhythmias
Q2) The nurse is caring for a 6-year-old child after open-heart surgery.When assessing the patient,the nurse notes that the position of the leads may be different in the pediatric population.Which lead placement explains this special consideration?
A)The position of the green lead can be changed to mirror one of the precordial lead positions.
B)The standard placement for V1 is at the fifth intercostal space,right sternal border.
C)The standard placement for V1 is at the fourth intercostal space,left sternal border.
D)In general,mechanisms of dysrhythmias are the same in children as they are in adults.
Q3) When preparing the skin before ECG electrode placement,clipping the hair in the electrode area is preferred over shaving due to risk of _________________.
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Chapter 27: Closed Chest Drainage Systems
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Q1) The nurse is caring for a patient with a chest tube that was inserted 4 days earlier.She notices that the drainage contains a large amount of pus.What does the presence of the pus indicate?
A)Malignancy
B)Pulmonary infarction
C)Empyema
D)Hemothorax
Q2) What is the expected amount of drainage for an adult patient with a mediastinal chest tube?
A)Less than 100 mL/hr during the immediate postoperative period
B)Less than 10 mL/hr during the immediate postoperative period
C)1000 mL/hr during the first 24-hour period
D)200 mL/hr during the first 24-hour period
Q3) The nurse is caring for a patient with a chest tube connected to water-seal drainage.The nurse may delegate which of the following tasks to nursing assistive personnel (NAP)?
A)Changing the chest tube drainage system
B)Milking the chest tube
C)Measuring chest tube output
D)Turning and positioning the patient
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Chapter 28: Emergency Measure for Life Support
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29 Flashcards
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Sample Questions
Q1) During the secondary survey of the code event,the nurse realizes that the patient is not breathing on his own.What should the nurse do next?
A)Immediately intubate the patient.
B)Have a laryngoscope handle and curved blades available.
C)Ensure that the light source on the laryngoscope is functional.
D)Have a laryngoscope handle and straight blades available.
Q2) Which of the following is the appropriate technique for a nurse to implement when inserting an oral airway?
A)Insert the airway with the curved end up,then rotate it 180 degrees at the back of the throat.
B)Insert the airway with the curved end down along the curve of the tongue.
C)Use a tongue blade to insert and push the airway into position.
D)Insert the airway sideways,then rotate it with the curved end up.
Q3) Many cardiac arrests are caused by irregular heart rhythms known as ________________.
Q4) The most common cause of airway obstruction in an unresponsive patient is the
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Chapter 29: Intravenous and Vascular Access Therapy
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Q1) _________________________ are surgically inserted through a tunnel into subcutaneous tissue,usually between the clavicle and the nipple,into the internal jugular or subclavian vein,with the catheter tip resting in the distal end of the superior vena cava.The subcutaneous tunnel allows the catheter to remain in place for months to years.
Q2) Which patient would a nurse anticipate would be a candidate for a peripherally inserted central catheter (PICC)?
A)An older adult who is having cataracts removed
B)A perinatal patient who is having prolonged labor
C)A neonate requiring blood therapy
D)An adolescent who is having surgery for reduction of a fracture
Q3) What should the nurse do to decrease the potential for infection related to intravenous (IV)infusion therapy?
A)Use the clean technique for dressing changes.
B)Change the IV tubing every 12 hours.
C)Palpate the insertion site daily through the intact dressing.
D)After cleansing the skin,dab it dry with a sterile gauze pad.
Q4) _________________________ pull fluid into the vascular space by osmosis,resulting in an increased vascular volume that possibly will result in pulmonary edema.
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Chapter 30: Blood Therapy
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Sample Questions
Q1) The patient is scheduled to receive 1 unit of packed red blood cells (RBCs).She has small,fragile veins,and a 22-gauge intravenous (IV)patent catheter is in place.What should the nurse do?
A)Cancel the blood transfusion.
B)Insert a 16-gauge IV catheter into the antecubital fossa.
C)Use the IV catheter that is in place.
D)Transfuse the blood over 6 hours.
Q2) The patient is receiving a unit of packed red blood cells (RBCs).Fifteen minutes into the procedure,he complains of severe kidney pain,and his temperature increases by 3°F.The nurse stops the transfusion immediately,suspecting that which of the following reactions is occurring?
A)Delayed hemolytic transfusion reaction
B)Nonhemolytic febrile reaction
C)Acute hemolytic transfusion reaction
D)Severe allergic reaction
Q3) Under the ABO system,the blood type __________ can be given to any individual and is known as the "Universal Donor."
Q4) A transfusion in which the donor is the patient is known as an ______________ transfusion or autotransfusion.
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Chapter 31: Oral Nutrition
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28 Flashcards
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Sample Questions
Q1) Which of the following is a sign of vitamin C deficiency?
A)Cheilosis (redness/swelling of the lips)
B)Glossitis
C)Spongy,bleeding,abnormal redness of the gingiva
D)Spoon-shaped,brittle,ridged fingernails
Q2) The nurse is preparing to assess the nutritional status of an 80-year-old patient in a long-term care agency.What screening tool would best suit this purpose?
A)The Malnutrition Universal Screening Tool (MUST)
B)Mini Nutritional Assessment (MNA)
C)Anthropometric measurements
D)A daily nutrition intake log
Q3) The nurse is caring for a patient who is believed to be suffering from malnutrition.The nurse calculates that the patient's body mass index (BMI)is 16.4 kg/m<sup>2</sup>.What does this indicate about the patient's weight?
A)The patient is underweight.
B)The patient's weight is normal.
C)The patient is overweight.
D)The patient is obese (class 1).
Q4) _______________ is useful for monitoring short-term changes in visceral protein.
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Chapter 32: Enteral Nutrition
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Sample Questions
Q1) The nurse determines that a nasogastric (NG)tube needs irrigation when she:
A)obtains more than 200 mL of residual volume.
B)obtains a small amount of thin watery residual.
C)does not encounter resistance when aspirating the residual.
D)obtains an unusually thick secretions.
Q2) The nurse is caring for a patient who is receiving continuous tube feedings.What must the nurse do to care for this patient?
A)Verify tube position every 4 to 6 hours.
B)Obtain a radiograph every 4 to 12 hours.
C)Instill air into the stomach via the tube and listen for bubbles.
D)Do not worry about tube placement because the tube has already been determined to be in the right place.
Q3) The home health nurse evaluates the provision of intermittent tube feedings by the patient's family member.The nurse notes that additional teaching is required when she notices that the family member:
A)keeps the formula refrigerated between feedings.
B)keeps the feeding tube capped between feedings.
C)begins the feeding before checking tube placement.
D)irrigates the tube with 30 to 60 mL of water before and after feedings.
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Chapter 33: Parenteral Nutrition
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Q1) The nurse is caring for a patient receiving parenteral nutrition (PN).In planning the patient's care for the day,which nursing assessment is most essential?
A)Electrolyte levels
B)Weight
C)Temperature
D)Condition of catheter insertion site
Q2) A 72-year-old patient is admitted to the hospital with a medical diagnosis of intestinal failure.Which intervention should the nurse include in the plan of care to deliver nutritional needs?
A)Enteral nutrition (EN)
B)Parenteral nutrition (PN)
C)A combination of enteral and parenteral nutrition
D)Oral nutrition
Q3) If parenteral nutrition (PN)must be discontinued suddenly,hang __________ in water at the same infusion rate to prevent hypoglycemia.
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Chapter 34: Urinary Elimination
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Sample Questions
Q1) The nurse has inserted an indwelling catheter and secured the catheter to the patient's thigh,making sure that there is enough slack that movement will not create tension on the catheter.The nurse understands that the chief purpose of properly securing Foley catheters is to obtain which outcome?
A)Minimized risk for bleeding
B)Reduced risk for bladder spasm
C)Reduced risk for meatal necrosis
D)Reduced risk for trauma
E)Increased bladder relaxation
Q2) A single-lumen catheter that is inserted into the bladder through the urethra only to empty the bladder and then is removed is known as a _______________ catheter.
Q3) When the balloon on an indwelling urinary catheter is inflated and the patient expresses discomfort,it is essential for the nurse to take which action?
A)Remove the catheter.
B)Continue to blow up the balloon because discomfort is expected.
C)Aspirate the fluid from the balloon and advance the catheter.
D)Pull back on the catheter slightly to determine tension.
Q4) _________________ is the volume of urine in the bladder after a normal voiding.
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Chapter 35: Bowel Elimination and Gastric Intubation
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Sample Questions
Q1) When providing care for a patient who is disoriented during a nasogastric (NG)tube placement,which intervention is important for the nurse to implement?
A)Halt the procedure.
B)Request assistance with insertion.
C)Administer a hypnotic medication.
D)Continue the procedure as with any other patient.
Q2) The nurse is preparing to administer an enema to an adult patient who has normal sphincter control.For administration of the enema,the patient is placed in which position?
A)Right side-lying
B)Dorsal recumbent
C)Sims'
D)Prone
Q3) An ___________ is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis.
Q4) A bedpan that is designed for patients with body or leg casts or for patients restricted from raising their hips (e.g.,following total joint replacement)is known as a
Q5) __________________ is strongest during the hour after the first meal of the day.
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Chapter 36: Ostomy Care
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Sample Questions
Q1) When planning care for a patient who has a colostomy,which intervention is important for the nurse to perform when pouching the colostomy?
A)Leave an intact skin barrier in place for 3 to 7 days.
B)Use soap and water to cleanse the peristomal skin.
C)Empty the pouch when it is two-thirds full.
D)Use tape to secure pouches that have minor leaks.
Q2) The nurse is caring for a patient who has a urinary diversion.The nurse notices that the patient has a temperature of 102° F and foul-smelling urine.What action should the nurse take?
A)Obtain a urine culture from the patient's pouch.
B)Catheterize the patient to obtain a sterile urine specimen.
C)Notify the physician.
D)Realize that these are normal findings.
Q3) An ostomy that is created from a portion of the ileum to form a stoma through which urine can exit the body is called a(n)_____________.
Q4) A ______________ is an opening in the large intestine or colon for elimination of fecal material.
Q5) The output from a urinary or fecal stoma is called the _______________.
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Chapter 37: Preoperative and Postoperative Care
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Sample Questions
Q1) The nurse is planning care for a preoperative patient.Which intervention is implemented to ensure safe nursing care?
A)Allowing the patient to have ice chips
B)Always keeping the patient NPO for 12 to 14 hours before
C)Allowing the patient to brush teeth and swallow water
D)Allowing the patient to take specifically ordered oral medications with small amounts of water
Q2) The nurse is to obtain an informed consent for a patient before surgery is performed.The nurse recognizes that which of the following statements is true?
A)Informed consent is required by law to protect the surgeon in case of an adverse outcome.
B)Only the patient can sign a surgical consent.
C)The nurse's legal responsibility is to ensure that the patient understands the information presented.
D)The surgeon should give the patient information about the surgery.
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Chapter 38: Intraoperative Care
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Q1) The _________________ is a nurse with advanced education who assists the surgeon with the surgical procedure,performing a combination of nursing and delegated medical functions and/or skills.
Q2) When one prepares to enter the operating room,which technique demonstrates the safest outcome?
A)Keeping the hands below the elbows
B)Applying surgical gloves before the scrub
C)Scrubbing for at least 3 to 5 minutes with an antimicrobial
D)Drying the hands and arms,starting at the elbow and moving toward the fingers
Q3) Which of the following are principles of sterile procedure?
A)Gowns are sterile from the chest and shoulder to table level.
B)Sterile persons must keep hands in view and above the waist and below the neck.
C)Sterile persons must fold arms across chest with hands tucked into the axillary region.
D)Unscrubbed persons must stay at least 6 inches away from the sterile field.
E)Sterile persons may position themselves with their back to the sterile field.
Q4) The _______________ phase begins when the patient enters the operating room suite and ends with admission to the postanesthesia care unit (PACU).
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Chapter 39: Pressure Injury Prevention and Care
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Sample Questions
Q1) In a patient with a stage II pressure ulcer,the nurse describes the wound as:
A)superficial blistering.
B)nonblanchable redness.
C)loss of skin without bone exposure.
D)loss of skin with exposed muscle.
Q2) In a long-term care agency,how often should the nurse reassess a patient for risk of a pressure ulcer?
A)Every 1 to 2 days
B)Every time the nurse sees the patient
C)Weekly for the first few weeks of stay
D)Monthly for the first 4 months of stay
Q3) A nurse classifies a pressure ulcer according to the type of tissue in the wound bed.What does it indicate if the wound bed has granulation in it?
A)Wound needs debridement
B)The presence of significant infection
C)Colonization by bacteria
D)Movement toward healing
Q4) When skin layers adhere to the linens and deeper tissue layer move downward,________ damage occurs.
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Chapter 40: Wound Care and Irrigations
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Q1) What should the nurse do when removing intermittent sutures?
A)Snip both sides of the suture before removing.
B)Snip the suture as close to the knot as possible.
C)Snip the suture as close to the skin as possible.
D)Pull up the knot to apply as much tension as possible.
Q2) The nurse is caring for a patient who has a dressing over a surgical wound created the night before.The dressing has never been changed.How should the nurse proceed?
A)Change the dressing so she can assess the wound.
B)Administer an analgesic 30 to 45 minutes before a dressing change.
C)Culture the wound if wound exudate is present.
D)Administer an analgesic 30 minutes after a dressing change.
Q3) What is an appropriate technique for the nurse to implement for drainage evacuation?
A)Replace the Hemovac drain fully expanded.
B)Attach the drainage tubing to the patient's gown.
C)Tilt the evacuator of the Hemovac away from the plug.
D)Complete the dressing change before the drainage evacuation.
Q4) ___________ is black,brown,or tan tissue in the wound that should be removed before wound healing can begin.
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Chapter 41: Dressings,bandages,and Binders
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Q1) Hydrocolloid dressings are used for which of the following?
A)Maintaining a moist wound environment
B)Autolytic debriding of necrotic wounds
C)Absorption of moderately draining wounds
D)Protecting from friction
Q2) The nurse would consider a dry dressing appropriate for a wound that requires which of the following?
A)Protection
B)Debridement
C)Absorption of heavy exudate
D)Healing by second intention
Q3) What should the nurse remember to do when applying a hydrocolloid dressing?
A)Apply granules after applying the wafer.
B)Never use a secondary dressing.
C)Hold the dressing in place.
D)Use silk tape to hold the dressing in place.
Q4) _____________ dressings cover or hold primary dressings in place.
Q5) _______________ dressings are used for wounds that require debridement.
Q6) ___________ healing takes place when tissue is cleanly cut and the margins are reapproximated.
Page 43
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Chapter 42: Therapeutic Use of Heat and Cold
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Q1) ___________ exerts a profound physiological effect on the body,reducing inflammation caused by injury to the musculoskeletal system.
Q2) If a patient is ordered to receive a cold application for a sprain,the nurse should ensure:
A)a prolonged application time is available.
B)the body part is carefully aligned.
C)a colder temperature is applied.
D)extra packing is available under the cooling device.
Q3) Hot applications are used with caution in which of the following conditions?
A)Pregnancy
B)Laminectomy sites
C)Malignancy
D)Spinal cord injury
Q4) Which of the following conditions are best treated with cold therapy?
A)Localized inflammatory responses
B)Hemorrhage
C)Muscle spasm
D)Pain
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Chapter 43: Home Care Safety
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Q1) A patient with a cognitive deficit becomes agitated and upset about not being able to remember daily activities.How should the nurse respond to this agitation?
A)Tell the patient not to worry about it.
B)Provide an easy-to-follow calendar and reinforce the information.
C)Explain that becoming upset is not going to help the situation.
D)Remind the patient that now is the time to rest and relax.
Q2) Activities of daily living (ADLs)include the patient's ability to bathe,dress,go to the toilet,transfer,maintain continence,and feed himself; _______ include the ability to use a telephone,prepare meals,travel,do housework,take medication,and shop.
Q3) The patient has been brought to the emergency department by a family member,who states that she just "doesn't know what to do." The patient often forgets where he is and refuses to bathe or change clothes.He will put things on the stove and forget that he has something cooking.She is obviously concerned for her loved one's safety.The nurse is likely to interpret these symptoms as signs of:
A)depression.
B)amnesia.
C)aphasia.
D)Alzheimer's disease.
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Chapter 44: Home Care Teaching
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Sample Questions
Q1) What is an expected outcome after tracheostomy care is successfully performed?
A)A stoma site that is hard to the touch
B)An inner cannula that is free of secretions
C)Copious secretions obtained from suctioning
D)Bloody secretions that have been suctioned
Q2) What does the nurse teach the patient and caregiver to do when setting up and changing administration sets for continuous tube feedings to preserve medical asepsis?
A)Add formula to formula already hung to prevent waste.
B)Store unused formula at room temperature to prevent spasm.
C)Hang only enough formula that will be infused in a 4- to 6-hour period.
D)Change the administration set every 48 hours.
Q3) Which of the following is an appropriate step when teaching temperature monitoring in the home?
A)Suggest aspirin to decrease fevers.
B)Recommend using only tympanic membrane sensors.
C)Encourage the use of alcohol rubs to reduce fevers.
D)Demonstrate the technique and have the patient/caregiver perform it.
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