Introduction to Clinical Practice
Exam Solutions
Course Introduction
Introduction to Clinical Practice offers students an immersive overview of the foundational skills and knowledge essential for effective patient care within healthcare settings. The course covers principles of patient assessment, history-taking, communication, clinical reasoning, ethical considerations, and teamwork. Through a combination of lectures, simulations, and supervised clinical exposure, students will develop critical observational, interpersonal, and technical skills necessary to interact with patients and healthcare professionals. Emphasis is placed on professional behavior, confidentiality, and cultural sensitivity, preparing students for ongoing clinical education and future roles in patient-centered care.
Recommended Textbook
Clinical Nursing Skills and Techniques 8th Edition by
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44 Chapters
1316 Verified Questions
1316 Flashcards
Source URL: https://quizplus.com/study-set/2003
Page 2
Anne Griffin Perry
Chapter 1: Using Evidence in Nursing Practice
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20 Verified Questions
20 Flashcards
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Sample Questions
Q1) While caring for patients, the professional nurse must question
Answer: what does not make sense
Always think about your practice when caring for patients.Question what does not make sense to you, and question what you think needs clarification.
Q2) When evidence-based practice is used, patient care will be:
A)standardized for all.
B)unhampered by patient culture.
C)variable according to the situation.
D)safe from the hazards of critical thinking.
Answer: C
Q3) The nurse is getting ready to develop a plan of care for a patient who has a specific need.The best source for developing this plan of care would probably be:
A)The Cochrane Library.
B)MEDLINE.
C)NGC.
D)CINAHL.
Answer: C
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3
Chapter 2: Admitting, Transfer, and Discharge
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25 Verified Questions
25 Flashcards
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Sample Questions
Q1) The patient is admitted to the ICU after having been in a motor vehicle accident.He was intubated in the emergency department and needs to receive two units of packed red blood cells.He is conscious but is indicating that he is in pain by guarding his abdomen.To admit this patient, the nurse first will focus on:
A)examining the patient and treating the pain.
B)orienting the family to the ICU visitation policy.
C)making sure that the consent forms are signed.
D)informing the patient of his HIPAA rights.
Answer: A
Q2) The patient is being transferred from the emergency department to another institution for treatment.Which of the following cannot be delegated to nursing assistive personnel (NAP)?
A)Helping the patient get dressed
B)Gathering IV equipment to go with the patient
C)Escorting the patient to the transport area
D)Assessing the patient's respiratory status before transport
Answer: D
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Chapter 3: Communication
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) The patient is talking about his fear of having surgery but is being vague and is using a lot of jargon.The nurse states, "I'm not sure what you mean.Could you tell me again?" This is an example of __________________.
Answer: clarification
Clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse's understanding, or asking the patient to explain what he or she means.This may help to clarify the patient's feelings, ideas, and perceptions, and may provide an explicit correlation between them and the patient's actions.
Q2) A patient tells the nurse, "I think that I must be really sick.All of these tests are being done." Which response by the nurse uses the specific communication technique of reflection?
A)"I sense that you are worried."
B)"I think that we should talk about this more."
C)"You think that you must be very sick because of all the tests."
D)"I've noticed that this is an underlying issue whenever we talk."
Answer: C
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Chapter 4: Documentation and Informatics
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25 Flashcards
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Sample Questions
Q1) The patient has been transferred to the nursing home from the acute care hospital.A report was called from the hospital and was received by the RN in charge of the nursing home unit.Upon arrival, which approach is used to assess the patient?
A)The Long-Term Care Facility Resident Assessment Instrument
B)The case management model
C)Collaborative pathways
D)The charting by exception model
Q2) The abbreviation for every day (___) is no longer used.
Q3) ___________________ provide a format for documenting a patient's health status and progress.
Q4) 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.
Q5) ________________ provide a quick, easy reference for health care team members in assessing the patient's status.
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Chapter 5: Vital Signs
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45 Verified Questions
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Sample
Questions
Q1) When the benefits of the different types of blood pressure monitoring devices are compared, which of the following patients would be the best candidate for noninvasive electronic blood pressure measurement?
A)A 49-year-old postsurgical patient with no history of heart disease on q15min vital signs
B)A 22-year-old patient undergoing active grand mal seizures
C)A 68-year-old patient with diagnosed peripheral vascular disease
D)A 54-year-old patient with chronic atrial fibrillation
Q2) The patient is returning from a cardiac catheterization.The puncture site is in the right femoral artery.The patient is having vital signs assessed every 15 minutes.Along with vital signs, the nurse assesses the pedal pulses of the right and left feet.Which of the following would be of major concern?
A)Both pedal pulses were bounding.
B)The femoral artery could be palpated.
C)The right pedal pulse was weaker than the left.
D)The radial artery pulse was 88.
Q3) The patient has been sleeping and has been lying on his right side.The nurse is ready to take his temperature using a tympanic thermometer.She needs to insert the thermometer into his ___________ ear.
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Page 7
Chapter 6: Health Assessment
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45 Flashcards
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Sample Questions
Q1) Measurement of the patient's ability to differentiate between sharp and dull sensations over the forehead tests which cranial nerve?
A)Abducens
B)Facial
C)Trigeminal
D)Oculomotor
Q2) When performing an assessment of the cardiovascular system, the nurse evaluates the skin and nails of the patient.Inadequate tissue perfusion is known as
Q3) The nurse is caring for a patient who is recovering from an acute myocardial infarction.While providing cardiac education, the nurse realizes that the patient needs more education when he:
A)describes changes in his behavior that may improve cardiovascular function.
B)describes the schedule, dosage, and purpose of his medication.
C)states that he will take his medication when he has chest pain or when his heart rate is greater than 100.
D)describes the benefits of taking his medication regularly.
Q4) ________________ is a major cause of lung cancer, cerebrovascular disease, heart disease, and chronic lung disease.
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Chapter 7: Medical Asepsis
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26 Verified Questions
26 Flashcards
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Sample Questions
Q1) The nurse is planning to care for a patient diagnosed with possible tuberculosis ( TB ).Assessment of possible TB may be based on which of the following? (Select all that apply.)
A)A positive AFB smear or culture
B)Signs or symptoms of TB
C)Cavitation on chest x-ray study
D)History of recent exposure
E)TB skin test
Q2) Infection control practices that reduce and eliminate sources and transmission of infection are known as _______________.
Q3) For patients with which of the following conditions should the nurse implement airborne precautions?
A)Rubella
B)Influenza
C)Tuberculosis
D)Pediculosis
Q4) The nurse knows that the basic concept of all patient care that is implemented to prevent the spread of infection from blood, body fluids, secretions, excretions, nonintact skin, and mucus membranes is __________________.
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Chapter 8: Sterile Technique
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18 Verified Questions
18 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) The nurse is applying for a job at a local hospital.She wants to look her best for the interview and decides to wear artificial nails.She does this knowing that artificial nails:
A)are appropriate in the ICU setting as long as the nurse washes her hands frequently.
B)can lead to fungal growth under the nail.
C)can actually lower the bacterial count on the hands because they cover the natural nail.
D)are banned only in areas where patients are critically ill.
Q3) Which patient may the nurse suspect will be at risk for a latex allergy?
A)Patient with food allergies
B)Patient with diabetes
C)Patient with arthritis
D)Patient with hypertension
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Chapter 9: Safe Patient Handling, Transfer, and Positioning
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to:
A)lower the height of the bed.
B)lower the head of the bed.
C)place the sling from shoulders to knees.
D)deep the check valve open when the patient is seated in the chair.
Q2) 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.
Q3) The patient is immobile and has been repositioned in bed using a drawsheet.When finished, the patient is in a supported Fowler's position with the head of the bed elevated 45 degrees.Also important for positioning this patient is to:
A)support his calves with pillows.
B)place a large pillow behind his head to prevent extension.
C)place a pillow behind his upper back.
D)avoid using pillows if the patient does not have use of the hands and arms.
Q4) Awareness of posture and changes in equilibrium is known as _______________.
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Chapter 10: Exercise and Ambulation
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31 Verified Questions
31 Flashcards
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Sample Questions
Q1) The patient has been using crutches for the past 2 weeks.When she comes for her follow-up examination, she complains of tingling and numbness in her hands and upper torso.Possible causes of these symptoms are:
A)the patient's elbows are flexed 15 to 30 degrees when using the crutches.
B)crutch pad is approximately 2 inches below the patient's axilla.
C)patient holds the cane 4 to 6 inches to the side of her foot.
D)handgrip does not allow for elbow flexion.
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) While ambulating, the patient becomes light-headed and starts to fall.What should the nurse do first?
A)Call for help.
B)Try to reach for a chair.
C)Ease the patient down to the floor.
D)Push the patient back toward the bed.
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Page 12
Chapter 11: Orthopedic Measures
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30 Verified Questions
30 Flashcards
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Sample Questions
Q1) According to the National Association of Orthopaedic Nurses (NAON), which of the following is possibly the most effective cleansing solution for pin-site care?
A)Normal saline
B)Hydrogen peroxide
C)Chlorhexidine
D)None of the above
Q2) _____________________ applies a pull indirectly to the bone via straps attached to the skin around the structure.
Q3) The patient is admitted for a fractured tibia.The nurse is preparing for cast application and expects to administer a(n) _____ to the patient minutes before the procedure.
A)oral analgesic 10
B)intramuscular (IM) analgesic 10
C)intravenous (IV) analgesic 2 to 5
D)muscle relaxant 10
Q4) ____________________ consists of a metal frame that secures pins inserted through the bone above and below the fracture site.It stabilizes a fracture with hardware visible outside the body.
Q5) _________________ may occur when pressure within a casted extremity increases.
Page 13
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Chapter 12: Support Surfaces and Special Beds
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) It is recommended that the Rotokinetic bed stay in the rotation mode for at least _______ hours a day.
Q2) 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
Q3) A ______________ serves as an artificial layer of fat to protect bony surfaces.
Q4) The patient is admitted with a large stage IV pressure ulcer on his coccyx.After comparing the benefits of the following support surfaces, the nurse would choose which of the following as most appropriate for this patient?
A)Water mattress
B)Gel overlay
C)Foam overlay
D)Air-fluidized bed
Q5) Use of the bariatric bed is contraindicated in patients with
Q6) The major cause of pressure ulcers is ________________.
Q7) A full or double-wide_____________ can accommodate a patient up to 1000 lb.
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Chapter 13: Safety and Quality Improvement
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) Which of the following fall prevention strategies should the nurse perform on all hospitalized patients? (Select all that apply.)
A)Conduct hourly rounds.
B)Provide the patient regular toileting.
C)Assess the patient's comfort needs.
D)Evaluate the effectiveness of pain medication.
Q2) What should the nurse do to promote patient understanding and security in the health care setting?
A)Restrain the patient as necessary.
B)Explain all procedures to the patient.
C)Allow the patient more time alone.
D)Restrict activity as much as possible.
Q3) After recognizing that a patient has received an electrical shock and removing the source of the shock, what should the nurse do next?
A)Call for assistance.
B)Immediately start CPR.
C)Obtain emergency equipment.
D)Assess for the presence of a pulse.
Q4) __________ are the most common type of inpatient accident.
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Chapter 14: Disaster Preparedness
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32 Verified Questions
32 Flashcards
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Sample Questions
Q1) Which of the following should make the nurse suspect a biological event? (Select all that apply.)
A)Large numbers of ill persons with unexplained similar symptoms
B)Unexplained deaths among young and healthy populations
C)A patient population with symptoms suggestive of a common agent
D)An unusual geographical pattern associated with the symptoms
Q2) The patient is admitted with exposure to an unknown chemical.His clothing appears to be grossly contaminated.What should the nurse do? (Select all that apply.)
A)Avoid touching contaminated parts of clothing.
B)Pull the patient's tee shirt off over his head.
C)Cut the patient's clothes off.
D)Wash the patient with large amounts of soap and water.
Q3) How is a disaster best defined?
A)Any event or situation that results in multiple casualties and/or deaths
B)A catastrophic and/or destructive event that disrupts normal functioning
C)An industrial accident and unplanned release of nuclear waste
D)An event that results in human casualties that overwhelm available health care resources
Q4) It is recommended that every household prepare a ____________.
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Chapter 15: Pain Assessment and Basic Comfort Measures
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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) Pain is experienced differently by different people, because pain perception is based on which of the following? (Select all that apply.)
A)Past pain experiences
B)Personal values
C)Cultural expectations
D)Emotions
E)None of above
Q3) ___________ has an identifiable cause and rapid onset and generally disappears with healing.
Q4) The nurse frequently must assess a patient who is experiencing pain.When assessing the intensity of the pain, the nurse should:
A)ask whether there are any precipitating factors.
B)question the patient about the location of the pain.
C)offer the patient a pain scale to objectify the information.
D)use open-ended questions to find out about the sensation.
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Chapter 16: Palliative Care
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Sample Questions
Q1) The irreversible absence of all brain function is termed ______________.
Q2) Nurses provide _______________ that is defined as care of the body after death in a manner consistent with the patient's religious and cultural beliefs.
Q3) An appropriate technique for the nurse to implement when caring for a patient's body after death is to:
A)remove the patient's ID band and put a new gown on the patient.
B)cover the patient with a sheet and transfer him or her to the morgue.
C)inquire about particular cultural or spiritual practices.
D)remove tubes and lines if the patient is to be autopsied.
Q4) 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.
Q5) _____________ helps people live as well as possible through the dying process.
Q6) A person experiences an actual _________ when an object or a person can no longer be felt, heard, or experienced.
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Chapter 17: Personal Hygiene and Bed Making
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Sample Questions
Q1) Critically ill patients on a ventilator are at risk for ventilator-associated pneumonia (VAP).Sources of VAP include: (Select all that apply.)
A)bacteria in the oral pharynx.
B)dental plaque.
C)chlorhexidine rinses.
D)frequent oral hygiene.
Q2) When evaluating the shaving of a patient done by a family member, the nurse determines that the technique is done appropriately when:
A)long strokes are used.
B)the razor is held at a 45-degree angle to the skin.
C)shaving is done against the direction of hair growth.
D)a cool cloth is used on the skin before the shave.
Q3) The nurse is preparing to provide a complete bed bath to a patient who has a running IV.She places a bath blanket over the patient and:
A)removes the gown from the arm with the IV first.
B)removes the gown from the arm without the IV first.
C)removes the gown after the bath to keep the patient warm.
D)readjusts the IV rate before removing the gown.
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Chapter 18: Pressure Ulcer Care
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Sample Questions
Q1) Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to: A)16.
B)18.
C)20.
D)24.
Q2) 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.
Q3) In a long-term care facility, 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
Q4) When skin layers adhere to the linens and deeper tissue layer move downward, ________ damage occurs.
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Chapter 19: Care of the Eye and Ear
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Sample Questions
Q1) The nurse decides that assistive personnel can provide care to a patient with contact lenses when the assistive personnel states:
A)"If I am in a hurry, I will use tap water for rinsing the lenses."
B)"Gloves aren't necessary; the eye is a clean organ."
C)"I will check with the patient to see if the lenses are disposable."
D)"It is normal for contact lens wearers to have red, teary eyes."
Q2) When removing a soft contact lens, the nurse finds that it is sticking together.What should the nurse do next?
A)Rub the lens briskly.
B)Soak the lens in saline.
C)Place cleansing solution on the lens.
D)Pry the lens apart with the fingertips.
Q3) When caring for the patient with an artificial eye, the nurse realizes that:
A)the prosthesis must be cleansed daily.
B)implants are always visible.
C)modern implants move as the companion eye moves.
D)the prosthesis always is made of glass.
Q4) The substance found in the ear canal that has an antibacterial effect and maintains an acid pH is called ______________.
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Chapter 20: Safe Medication Preparation
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Sample Questions
Q1) A patient receives the usual dose of a medication for the first time and develops severe hypotension and bradycardia.The nurse reports this event as an __________ type of medication action.
Q2) A drug interaction in which the combined effect of drugs is greater than the sum of the effects of each individual agent acting independently is known as a _____________.
Q3) When medications are administered, which action by the nurse is appropriate?
A)Administering medications prepared by another nurse
B)Using sterile technique for nonparenteral medications
C)Leaving medication at the bedside when the patient is in the bathroom
D)Documenting the reason for medication refusal in the nurse's notes
Q4) The nurse is aware that a patient with liver disease and a decreased albumin level may develop which of the following effects?
A)Toxicity on normal doses of medication
B)Less active medication available in the body
C)Reduction in therapeutic effect
D)Accelerated biotransformation of the medication
Q5) Medication safety is always one of the ______________ set by The Joint Commission.
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Chapter 21: Oral and Topical Medications
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39 Flashcards
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Sample Questions
Q1) The nurse is preparing several topical medications for a patient.The nurse identifies which of the following as ways to administer a topical medication? (Select all that apply.)
A)Administering through an enteral tube placed in the jejunum
B)Inhaling an aerosol spray into the lungs
C)Spraying a mist into the nose
D)Dissolving a medication under the tongue
Q2) The patient has a bronchodilator and an inhaled steroid scheduled for the same time.What teaching should the nurse provide to the patient about administering these medications?
A)Inhale the bronchodilator, wait 20 to 30 seconds, then inhale the steroid.
B)Inhale the bronchodilator, wait 2 to 5 minutes, then inhale the steroid.
C)Inhale the steroid, wait 20 to 30 seconds, then inhale the bronchodilator.
D)Inhale the steroid, wait 2 to 5 minutes, then inhale the bronchodilator.
Q3) The nurse is applying a new nitroglycerin transdermal patch.Which action by the nurse is appropriate?
A)Instructing the patient to wear the patch 24 hours a day every day
B)Applying the new patch to the same site as the previous patch
C)Cutting the patch in half when a change of dose is ordered
D)Instructing the patient to avoid heat sources over the patch
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Chapter 22: Parenteral Medications
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Sample Questions
Q1) The patient is complaining of tenderness at his intravenous (IV) insertion site.The nurse examines the site and notices that the site is swollen, warm, and reddened.The nurse stops the intravenous infusion, realizing that the patient has
Q2) The nurse is teaching a patient how to inject low-molecular-weight heparin.What instruction should be included in the teaching plan?
A)The injection can be given in the abdomen or the upper thighs.
B)Before injecting the medication, be sure to expel the air bubble in the syringe.
C)After inserting the needle, pull back on the plunger of the syringe before injecting the medication.
D)After injecting the medication, apply gentle pressure to the injection site for 30 to 60 seconds.
Q3) The most frequent route of exposure to bloodborne disease for health care workers is needlestick injury.The nurse recognizes that implementation of _________________ can prevent needlestick injury.
Q4) An experienced nurse recognizes that the dorsogluteal injection site is no longer used for intramuscular injections because of the risk of damaging the
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Page 24
Chapter 23: Oxygen Therapy
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Sample Questions
Q1) The patient is placed on mechanical ventilation.After the initial settings have been applied, the nurse should watch for which of the following complications? (Select all that apply.)
A)Signs of decreased cardiac output
B)Tension pneumothorax
C)Pneumonia
D)Failure to wean
Q2) In noninvasive ventilation, ________________ keeps the terminal airways (alveoli) partially inflated, reducing the risk for atelectasis.
Q3) A patient on mechanical ventilation has an FiO<sub>2</sub> setting of 38%.The nurse is reviewing arterial blood gas results and pulse oximetry readings.The nurse is aware that the desired level of oxygen is which of the following?
A)PaO<sub>2</sub> greater than 90 mm Hg
B)SpO<sub>2</sub> greater than 60%
C)PaO<sub>2</sub> greater than 60 mmHg
D)SpO<sub>2</sub> greater than 95%
Q4) A curved oxygen delivery device with an adjustable strap that fits around the patient's neck is known as a _______________.
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Page 25
Chapter 24: Performing Chest Physiotherapy
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Sample Questions
Q1) The nurse auscultates the patients' lung fields and notes congestion in several patients.The nurse anticipates that postural drainage may be used for the patient with which condition?
A)Congestive heart failure with pulmonary edema
B)History of cigarette smoking with recent hemoptysis
C)Chronic bronchitis with frequent coughing
D)Pulmonary embolism after a long international flight
Q2) The nurse is teaching family members how to perform postural drainage at home for a patient with chronic bronchitis.What instruction should the nurse provide?
A)Plan to perform postural drainage 3 times a day about 1 hour after meals.
B)Don't give any pain medication within 2 hours of performing postural drainage.
C)Perform postural drainage 20 minutes after the patient uses the inhaler.
D)Encourage the patient to remain in each position for 30 minutes to adequately drain the area.
Q3) The patient is complaining of feeling congested.After assessing the patient, the nurse places the patient in the proper position and claps her cupped hands against the patient's thorax.She does this because she is aware that ______________ assists in loosening retained secretions from the airway.
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Chapter 25: Airway Management
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Sample Questions
Q1) A patient with a tracheostomy tube has thick, tenacious mucus that is difficult to remove.The nurse should choose which technique to suction the airway?
A)Normal saline instillation (NSI) before suctioning
B)Dry suctioning 1 time followed by NSI with suctioning 2 more times
C)Dry suctioning as long as the heart rate is above 60 beats/min
D)Dry suctioning
Q2) The nurse is performing nasotracheal suctioning on a patient.The nurse should discontinue the suctioning if which of the following occurs?
A)The patient coughs as the catheter is inserted.
B)The heart rate decreases from 84 beats per minute to 60 beats per minute.
C)An increase in pulse occurs from 74 beats per minute to 94 beats per minute.
D)Oxygen saturation levels decrease from 97% to 94%.
Q3) The nurse has completed suctioning a patient's airway.Which action should the nurse take first?
A)Reduce the suction level to medium.
B)Remove the face shield and save for future suctioning.
C)Reposition the patient and assist with oral hygiene using sterile gloves.
D)Pull the gloves off over the rolled catheter and discard.
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27
Chapter 26: Closed Chest Drainage Systems
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Sample Questions
Q1) What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without a change in pulse or blood pressure?
A)Pneumonitis
B)Tube displacement
C)A myocardial infarction
D)A tension pneumothorax
Q2) Appropriate intervention for the patient who is having a reinfusion of chest tube drainage is noted when the nurse:
A)Hangs the reinfusion lower than the usual intravenous (IV) bag
B)Uses a microaggregate filter on the reinfusion bag
C)Maintains 500 mm Hg pressure in the gravity blood cuff
D)Keeps the clamps open on the drainage tubing during bag transfer
Q3) The patient's chest tube is attached to a one-way flutter valve that allows air to escape the chest cavity and prevents air from reentering.How does the nurse document this finding?
A)Heimlich chest drain valve
B)Pneumovax
C)Water seal
D)Pleurovac
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Page 28
Chapter 27: Emergency Measures for Life Support
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29 Flashcards
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Sample Questions
Q1) The nurse in the ICU is caring for a newly admitted patient with chest pain.She is aware that dysrhythmia may be caused by which of the following? (Select all that apply.)
A)Electrolyte disturbances
B)Heart damage
C)Medications
D)Respiratory arrest
E)None of above
Q2) For which of the following patients would the nurse request the rapid response team's immediate intervention?
A)A patient complaining of severe postoperative incisional pain
B)A patient with no pulse who is not breathing
C)A patient complaining of chest pain, hypotension, and shortness of breath
D)A patient with blood pressure of 164/96
Q3) A semicircular, minimally flexible, curved piece of hard plastic that is inserted into the mouth so it extends from just outside the lips to the pharynx is known as an
Q4) Many cardiac arrests are caused by irregular heart rhythms known as
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Chapter 28: Intravenous and Vascular Access Therapy
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Sample Questions
Q1) Fluids that have the same osmolality as body fluids are used most often to replace extracellular volume and are known as _______________ fluids.
Q2) The nurse needs to specifically prevent air emboli that may result from IV therapy.What should the nurse make sure to do to prevent air emboli?
A)Use a needleless system.
B)Prime the tubing completely.
C)Check for medication compatibility.
D)Select a larger-gauge needle or catheter.
Q3) The nurse is caring for a patient who has a peripheral IV.While performing her routine assessment, she notes that the insertion site is pale, cool, and edematous.The patient indicates that the site is also painful to the touch.The nurse recognizes these symptoms as revealing a possible _______________.
Q4) What should the nurse do to decrease the potential for infection related to IV 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.
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Chapter 29: Blood Transfusions
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Sample Questions
Q1) Under the ABO system, the blood type __________ can be given to any individual and is known as the "Universal Donor."
Q2) The patient is to receive 2 units of packed RBCs.Before administering the blood, what does the nurse need to do? (Select all that apply.)
A)Insert an 18-gauge IV cannula.
B)Have the patient complete a consent form.
C)Obtain pretransfusion vital signs.
D)Notify the physician for a temperature of 37° C.
Q3) The presence or absence of specific antigens on the surface of red blood cells determines ___________________ in the ABO system.
Q4) What is the purpose of administering a transfusion? (Select all that apply.)
A)Restore intravascular volume.
B)Restore the oxygen-carrying capacity of blood.
C)Provide clotting factors.
D)Improve blood pressure.
Q5) A transfusion in which the donor is the patient is known as an ______________ transfusion or autotransfusion.
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Page 31
Chapter 30: Oral Nutrition
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Sample Questions
Q1) The NCP provides structure for the provision of nutritional care to all patients and provides a framework for the RD to make decisions regarding medical nutrition therapy.The steps involved in this process include which of the following? (Select all that apply.)
A)Nutrition assessment
B)Nutrition diagnosis
C)Nutrition intervention
D)Nutrition evaluation
E)None of above
Q2) The nurse will collaborate with a ___________ to develop a nutritional plan for a patient identified as being at nutritional risk.
Q3) The nurse is assessing the patient for nutritional status.Which laboratory value may indicate compromised protein status?
A)Serum albumin level of 4.0 g/dL
B)Prealbumin level of 12 g/dL
C)Total lymphocyte count of 1600 cells/mm<sup>3</sup>
D)Prealbumin level of 35 g/dL
Q4) _______________ is useful for monitoring short-term changes in visceral protein.
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Chapter 31: Enteral Nutrition
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Sample Questions
Q1) The nurse, physician, and dietitian collaborate to select an enteral feeding formula for the patient.Their decision should be based on which of the following? (Select all that apply.)
A)Protein requirements of the patient
B)Digestive ability of the patient
C)Amount of lactose required
D)The patient's disease process
Q2) A tube passed through the nose or mouth with the end terminating in the stomach or the small bowel, and used in feeding the patient for short periods is known as a
Q3) Of the patients listed below, which would be a candidate for nasoenteric feeding tube placement?
A)Post-motor vehicle accident victim with a broken nose and jaw
B)Patient with a bleeding ulcer and possible esophageal varices
C)Elderly patient with a diagnosis of failure to thrive and an inability to chew
D)Patient with an esophageal tumor
Q4) The nurse is caring for a patient in a chronic vegetative state with inadequate gastric emptying.The nurse would anticipate finding in a ________ tube placed to assist with this patient's nutritional needs.
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Chapter 32: Parenteral Nutrition
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Sample Questions
Q1) The patient has been receiving PN but has not been given lipid emulsion therapy.The nurse notices that the patient is developing dry, scaly skin, his wound is healing more slowly than expected, and he is anemic.Which condition should the nurse anticipate as a potential problem?
A)Excess linoleic acid
B)Omega-6 fatty acid excess
C)Essential fatty acid deficiency
D)Electrolyte instability
Q2) Which assessment should a nurse expect to see for a patient receiving PN?
A)Weight gain of 1 to 2 pounds per week
B)Serum calcium level of 10 mEq/L
C)Serum potassium level of 2.8 mEq/L
D)Serum glucose level of more than 200 mg/100 mL
Q3) For patients receiving PN, ___________ provide supplemental kilocalories and prevent essential fatty acid deficiencies.
Q4) If PN must be discontinued suddenly, hang __________ in water at the same infusion rate to prevent hypoglycemia.
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34
Chapter 33: Urinary Elimination
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Sample Questions
Q1) The risk for catheter-associated urinary tract infection can be reduced by using ___________ when inserting the catheter.
Q2) The nurse is planning care for a 12-year-old female patient who needs a Foley catheter inserted.It is most important for the nurse to use a catheter of which size?
A)5 to 6 French (Fr)
B)8 to 10 Fr
C)12 Fr
D)14 to 16 Fr
Q3) The nurse is preparing the patient for a bladder scan to determine PVR.Which of the following is part of the preparation?
A)Limit food intake for 2 hours before the scan.
B)Begin scan 10 minutes after the patient has voided.
C)Limit liquid intake for 30 minutes before the scan.
D)Administer an analgesic 30 minutes before the scan.
Q4) Antimicrobial catheters coated with silver or antibiotics have been shown to reduce the incidence of ________________.
Q5) _________________ is the volume of urine in the bladder after a normal voiding.
Q6) Catheter use in older adults has been associated with increased
Page 35
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Chapter 34: Bowel Elimination and Gastric Intubation
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Sample Questions
Q1) While the nurse is administering an enema, the patient complains of some cramping.Which action should the nurse take next?
A)Discontinue the procedure completely.
B)Increase the height of the solution.
C)Slow the rate of infusion.
D)Have the patient roll into a supine position.
Q2) The nurse prepares to exercise a digital removal of feces.To detect an untoward effect of this procedure, the nurse should assess the patient history for which condition?
A)Heart disease
B)Abdominal pain
C)Urinary infection
D)Diabetes mellitus
Q3) Infrequent bowel movements (less often than every 3 days), difficulty in evacuating feces, inability to defecate, and hard feces are signs of ________________.
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) The inability to pass a hard collection of stool is known as ______________.
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Chapter 35: Ostomy Care
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Sample Questions
Q1) In caring for a patient who had a fecal surgical diversion, which nursing intervention is essential?
A)Place a pouch over the newly created stoma.
B)Place a dressing over the stoma.
C)Wait several days before placing a pouch.
D)Prepare several pouches in advance.
Q2) In caring for a patient who has a pouching for a noncontinent urinary diversion, which nursing intervention is essential?
A)Empty the pouch when it is one-third to one-half full.
B)Remove the ureteral stents after 2 days.
C)Pouch the stoma with the patient sitting up.
D)Dispose of used pouches in the toilet.
Q3) The nurse is caring for a patient who had a colostomy placed 5 days earlier.The nurse notes that the stoma is red and moist.Which action should the nurse take?
A)Notify the physician immediately.
B)Apply pressure.
C)Note the condition of the stoma in her notes.
D)Change the appliance pouch.
Q4) The output from a urinary or fecal stoma is called the _______________.
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Chapter 36: Preoperative and Postoperative Care
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Sample Questions
Q1) The nurse understands that paralytic ileus is a possible postoperative complication.Which assessment provides the nurse with information about this postoperative complication?
A)Auscultating for bowel sounds every 4 hours
B)Checking blood pressure while sitting and standing
C)Observing the patient's performance of leg exercises
D)Palpating the suprapubic region for distention
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 37: Intraoperative Care
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Sample Questions
Q1) The charge nurse is assigning duties in the surgical arena.Which member of the surgical team should be assigned to the role of circulating nurse?
A)Registered nurse (RN)
B)Licensed practical nurse (LPN)
C)Certified surgical technologist (CST)
D)Licensed nursing assistant
Q2) While the patient is in the OR and the OR team is gowned and gloved, the nurse recommends completion of a safety checklist.The nurse understands that the checklist verifies which of the following? (Select all that apply.)
A)Patient identity
B)Patient allergies
C)Accurate marking of surgical site
D)Patient cultural preferences
E)Questions posed by the patient
Q3) 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 38: Wound Care and Irrigations
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Sample Questions
Q1) When should a nurse consider culturing a wound?
A)When the tissue is clean and dry
B)When exudate is not present
C)When the patient is afebrile
D)When the surrounding area shows inflammation
Q2) 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.
Q3) The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock.How should the nurse proceed?
A)Use irrigation pressures of less than 4 psi.
B)Cleanse in a direction from most contaminated to least contaminated.
C)Irrigate so that the solution flows from least contaminated to most contaminated.
D)Irrigate with clean irrigation solution only.
Q4) ___________ are threads of wire or other materials used to sew body tissues together.
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Chapter 39: Dressings, Bandages, and Binders
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Sample Questions
Q1) _____________ dressings cover or hold primary dressings in place.
Q2) Serious hemorrhaging has resulted in the patient experiencing a fluid and electrolyte imbalance.How should the nurse respond?
A)Initiate intravenous (IV) therapy.
B)Order blood for transfusions.
C)Remove and reapply any dressings.
D)Monitor vital signs every 15 minutes.
Q3) The nurse is caring for a patient who is bleeding.To control bleeding, she would apply a _____ dressing.
A)pressure
B)alginate
C)foam
D)hydrocolloid
Q4) What should the nurse do for a patient with a sudden severe hemorrhage?
A)Go for help.
B)Drape the patient.
C)Apply direct pressure.
D)Put on clean or sterile gloves.
Q5) _______________ dressings are used for wounds that require debridement.
Page 41
Q6) A __________ dressing comes in direct contact with the wound bed.
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Chapter 40: Therapeutic Use of Heat and Cold
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Sample Questions
Q1) Which of the following would require using caution in applying cold therapy?
A)Chronic pain
B)Joint trauma
C)Circulatory insufficiency
D)Sprains
Q2) You are explaining to the patient the reason why you are using dry heat.Which of the following statements indicates understanding of the advantage of dry heat application for the patient?
A)It maintains temperature changes longer.
B)It reduces drying of the skin.
C)It penetrates tissue layers deeply.
D)It conforms better to body surfaces.
Q3) If a patient on a hypothermia blanket starts to shiver, what action should the nurse take?
A)Discontinue treatment.
B)Place more padding around the patient.
C)Discuss with the physician the use of a metabolic stimulant.
D)Increase the temperature to a more comfortable range.
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Chapter 41: Home Care Safety
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Sample Questions
Q1) The nurse is assessing the home of an elderly patient for safety issues.Which of the following would reassure the nurse? (Select all that apply.)
A)Cleaning the stove top
B)Putting a shower chair in the bathroom
C)Installing adequate lighting in all living areas
D)Placing emergency numbers close to the telephone
E)None of above
Q2) When teaching about medication use in the home, what instructions should the nurse provide to the patient?
A)Always keep insulin in the refrigerator.
B)Put used needles in double paper bags.
C)Put all of the medication to be taken in one bottle.
D)Discard unused or expired medication in a bag containing coffee grounds.
Q3) When a caregiver is communicating with a patient, which of the following may facilitate communication? (Select all that apply.)
A)Face the patient who has a hearing impairment.
B)Avoid eye contact.
C)Use simple words.
D)Be aware of nonverbal gestures.
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Page 43
Chapter 42: Home Care Teaching
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Sample Questions
Q1) What is an appropriate technique to use when teaching an older patient about self-medication in the home?
A)Speak very loudly.
B)Teach the family separately.
C)Provide frequent pauses.
D)Provide fewer but longer teaching sessions.
Q2) The nurse is teaching the patient and family how to perform tracheal suctioning.What does proper technique include?
A)Teaching how to instill normal saline before suctioning
B)Suctioning the nasal and oral pharynx before the trachea
C)Encouraging daily brushing of the teeth and oral hygiene
D)Having the patient take two to three deep breaths after the procedure
Q3) While teaching how to check for gastric residual, the nurse instructs the caregiver to delay the tube feeding if he or she obtains more than _________ mL of gastric aspirate.
Q4) Which of the following are signs of hyperthermia? (Select all that apply.)
A)Dry, warm, flushed skin
B)Chills and piloerection
C)Uncontrolled shivering
D)Loss of memory
Page 44
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Chapter 43: Specimen Collection
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Sample Questions
Q1) In explaining to the patient about obtaining a sputum specimen to diagnose tuberculosis, the nurse explains which of the following? (Select all that apply.)
A)Specimens are best obtained in the early morning.
B)Acid-fast bacilli ( AFB ) smears require three consecutive morning samples.
C)Bacteria accumulate as secretions pool.
D)Specimens should be obtained at bedtime.
Q2) When performing a venipuncture, the nurse should:
A)inject with the needle at a 45-degree angle.
B)select a vein that is rigid and cordlike, and that rolls when palpated.
C)perform the needle insertion immediately after cleansing the skin with alcohol.
D)place the thumb of the nondominant hand about 1 inch below the site and pull the skin taut.
Q3) The nurse is drawing blood from a patient to determine the blood alcohol level.Which step is an appropriate action for the nurse to take?
A)Swab the area with an antiseptic swab.
B)Swab the area with an alcohol swab.
C)Do not swab the area at all.
D)Apply the tourniquet for 5 minutes.
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45
Chapter 44: Diagnostic Procedures
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Sample Questions
Q1) The nurse is preparing to assist with a bone marrow aspiration on a 3-month-old infant.The nurse may expect that the physician will use which site to perform the aspiration?
A)Sternum
B)Anterior iliac crest
C)Proximal tibia
D)Posterior iliac crest
Q2) The patient has undergone a cardiac catheterization.It has been 2 hours since the catheter and sheath have been removed.Which of the following would be a concern for the nurse recovering the patient after the procedure? (Select all that apply.)
A)Swelling and hardness at the catheter insertion site
B)Complaints of itching and urticaria
C)Urine output less than 30 mL/hour
D)Low back pain radiating to both sides of the body
E)None of above
Q3) An _______________ permits visualization of the vasculature of an organ and the organ's arterial system.
Q4) ____________ are sterile invasive procedures involving the removal of body fluids or tissue for diagnostic procedures.
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