Exam 2 (Ch. 30,36,40,41)

77問 • 3年前

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1. The nurse is providing education to a patient about the difference between simple and complex carbohydrates. Which statement by the patient indicates a need for further education?

b. “Complex carbohydrates come from fruit.”

2. The nurse teaches the family member to provide the patient with how much dietary fiber per day?

b. 20 to 35 g

3. The nurse is providing education to an older adult around a healthy diet to support the challenges related to aging. Which statement indicates a need for further education?

c. “I should eat more calories to avoid malnutrition.”

4. When caring for an adolescent patient with anorexia nervosa, the nurse knows what would be the best treatment option for this patient?

c. Individually determined by a collaborative team

5. A new UAP is measuring a patient’s height. Which step of the procedure indicates a need for the registered nurse to provide further education on this skill?

b. The UAP measures from the top of the patient’s head to the bottom of the patient’s foot arch.

6. The nurse is performing an oral examination on a patient and notices a beefy-red tongue. The nurse identifies this as a characteristic finding for what condition?

d. Pernicious anemia

7. The nurse has delegated the feeding of a patient who has recently had a stroke to the UAP. Which procedure that the UAP performs would demonstrate a need for further education?

b. Puts the bed at 25 degrees

8. The nurse recognizes which outcome statement to be appropriate for the nursing diagnosis impaired swallowing?

c. Patient will not show any signs of aspiration during meals.

9. The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation?

c. “I can give the patient oatmeal.”

10. The nurse is educating a patient about a renal diet. Which statement by the patient indicates a need for further education?

c. “I can drink unlimited cola if it is diet.”

11. The nurse knows that initial verification of a nasogastric placement is important. Which method is considered the only reliable method to determine enteral tube placement?

c. Radiographic image

12. The nurse is attempting to open an occluded PEG tube. Which intervention by the nurse requires re-education?

c. Reinserts the stylet to break up the clot

13. When the nurse is caring for a patient who is receiving total parenteral nutrition (TPN), the nurse will change the tubing at which interval?

c. Every 24 hours

14. The nurse is preparing to insert a nasogastric (NG) tube in a patient. Which step in the process indicates a need for further education?

b. The nurse marks the length of the tube with a marker for insertion.

15. The nurse has received an order from the health care provider to discontinue the nasogastric tube. Which action by the nurse indicates a need for further education?

c. The nurse instructs the patient to cough while pulling out the tube.

1. The nurse is caring for a patient recovering from knee replacement surgery. The patient complains of severe pain in the knee after receiving hydrocodone with acetaminophen (Vicodin) 2 hours previously. What is the nurse’s best action?

b. Apply ice packs to the knee.

2. The nurse is checking on the patient after administering pain medication 30 minutes previously. Which assessment finding best indicates to the nurse that the pain medication was effective?

b. The patient states a reduction of the pain.

3. The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. The nurse recognizes which type of pain is this patient experiencing?

a. Visceral pain

4. The nurse knows which is the best pain medication option for a patient to manage severe long-term cancer pain at home?

a. Fentanyl (Duragesic) 50 mcg transdermal patch q 72 hours

5. The nurse is caring for a patient with severe chronic pain and applied the first 50 mcg transdermal fentanyl (Duragesic) patch 2 hours ago. The patient states that the pain is presently rated at 9 on a 1 to 10 scale. What is the nurse’s best action?

b. Check the provider’s orders for a short-acting narcotic medication to administer for breakthrough pain.

6. The nurse is caring for a patient who has been taking ibuprofen (Motrin) 800 mg TID for the last several months to relieve knee pain from arthritis. Which assessment finding must be reported by the nurse to the provider promptly?

a. The patient has abdominal pain and pale skin.

7. The nurse is caring for a patient who just underwent laparoscopic appendectomy. The patient complains of severe postoperative pain between the shoulder blades. Which term best describes the pain that this patient is having?

a. Referred pain

8. The nurse administered 100 mcg sublingual fentanyl spray (Subsys) at 10:00 a.m. to a patient experiencing severe breakthrough pain. At what time will the nurse ask the patient if pain relief was obtained?

a. 10:30 a.m.

9. The nurse is caring for a patient who will be using a hydromorphone (Dilaudid) PCA analgesia pump following surgery. Which intervention is the highest priority for the nurse to include in the patient’s care plan related to this pump?

a. Assess the patient’s respiratory status frequently after PCA pump started.

10. The nurse is caring for a 6-month-old infant who has just undergone surgery. The infant’s facial muscles are tight with a furrowed brow and the infant’s respirations are shallow and irregular. The infant is mildly fussy and softly crying without muscular rigidity in the arms and legs. What score will the nurse give to the infant on the Neonatal Infant Pain Scale?

c. 4

11. The nurse is caring for a patient who is recovering from thoracotomy surgery and notes that the patient’s pain is rated 9/10 and is unable to focus on anything. Which intervention by the nurse is the highest priority?

a. Administer prescribed IV pain medication and evaluate impact in 30 minutes.

12. The nurse is caring for a patient with rheumatoid arthritis who is in constant severe pain. Which nursing diagnosis is the highest priority for this patient?

d. Chronic pain r/t ongoing inflammatory tissue damage and joint destruction.

13. The nurse is caring for a cancer patient with ongoing pain from widespread metastasis to the bones. The nurse notes that the patient’s morphine dosage had to be increased to sufficiently manage the discomfort. What is the nurse’s interpretation of this assessment finding?

a. The patient became tolerant to the previous morphine dosage.

14. The nurse identifies which patient to be best suited for PCA analgesia?

b. A patient recovering from total hysterectomy surgery.

15. What is the priority nursing assessment for a patient who is receiving postoperative epidural analgesia with hydromorphone (Dilaudid)?

a. Respiratory rate, depth, and pattern

16. The nurse is caring for a diabetic patient who has painful foot neuropathy. The patient asks why the nurse is administering gabapentin (Neurontin) when there is no history of seizure disorder. What is the nurse’s best response?

d. “Gabapentin works on the nervous system to help relieve the burning pain in your feet.”

17. The nurse is caring for a patient who has a PCA pump following total hysterectomy surgery. The nurse sees the visitor push the PCA button while the patient is sleeping quietly. What is the best response of the nurse?

b. “Please do not push the button for the patient—she could receive more medication than she needs.”

18. Which assessment question helps the nurse determine the character of the patient’s pain?

a. “What does the pain feel like?”

19. The nurse is caring for a patient who only speaks a foreign language. What is the best method for the nurse to assess the patient’s pain level?

a. Perform a pain assessment using a translator.

20. The nurse is caring for a trauma patient with the nursing diagnosis of acute pain r/t fracture and muscle spasms. Which is an appropriate goal for this Nursing diagnosis?

b. The patient will describe meditation techniques that can be used to cope with pain.

1. The nurse is caring for a patient who periodically has small streaks of fresh red blood in the stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be the most likely cause of this patient’s bleeding?

a. Hemorrhoids

2. The nurse is caring for a patient who has diarrhea and identifies which priority nursing diagnosis for this patient?

c. Diarrhea related to excessive loss of fluid through stool.

3. The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse indicates a need to contact the prescriber and question the order?

b. The patient is constipated with last BM 3 days ago.

4. The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority?

c. Check the patient for a fecal impaction.

5. The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon?

a. The patient has bowel sounds  4 quadrants and is passing gas.

6. The nurse is caring for a patient who has an ileostomy. Which nursing diagnosis has the highest priority for the patient?

a. Impaired skin integrity r/t localized skin irritation from liquid stool.

7. The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function?

a. Raisin bran with skim milk, fresh fruit, and wheat toast.

8. The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient?

d. Assess the patient’s usual pattern of bowel movements.

9. The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam?

c. “You will be given a milky liquid to drink shortly before the test starts.”

10. The nurse is caring for a patient who will undergo colonoscopy testing. Which intervention will the nurse include in the patient’s plan of care for the day before the test?

a. Provide the patient with zinc oxide skin barrier cream for the perineal area.

11. The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing?

c. Inform the patient that several stool samples will be needed.

12. The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding by the nurse indicates a need to contact the prescriber and question the order?

a. The patient is recovering from a traumatic brain injury.

13. The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient’s abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse?

a. Keep the patient NPO and document the findings in the chart.

14. The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement?

d. An oil retention enema

15. The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient’s new symptoms?

a. Clostridium difficile infection

16. The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse?

a. Assist the patient to ambulate in the hall.

17. The nurse is caring for a patient with a history of dementia who is incontinent of stool because of the inability to communicate the need to defecate. What is the priority action of the nurse?

d. Begin a prompted toileting program to facilitate bowel continence.

18. The nurse is caring for a patient who is recovering after hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis impaired self-toileting?

a. The patient will demonstrate safe transfer technique between wheelchair and toilet.

19. The nurse is caring for a patient who is recovering from diarrhea. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed?

d. Coffee with cream

20. The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient?

a. The patient will remain continent with no perineal skin breakdown.

21. A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor?

c. The patient is positioned comfortably in the modified left lateral recumbent position.

1. The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. The nurse recognizes which type of renal failure the patient most likely developed?

a. Prerenal

2. The nurse is caring for a patient with a neurological condition that causes constant severe thirst, drinking fluids continuously, and voiding 3 to 4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this patient’s urinary output?

c. Polyuria

3. The nurse is caring for a patient who is experiencing stress incontinence. The nurse identifies which goal to be the most important for this patient?

b. The patient will not experience involuntary urination during coughing or sneezing.

4. The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse?

d. Obtain an order to straight-catheterize the patient.

5. The nurse is caring for a patient who recently underwent ileal conduit surgery. Which nursing diagnosis is the highest priority for this patient?

c. Lack of knowledge related to care and maintenance of ostomy appliance

6. The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine in the toilet. Which is the priority assessment to be performed by the nurse?

a. Bladder scan to determine the amount of urine in the bladder.

7. The nurse is caring for a seriously ill patient whose laboratory results show a serum creatinine level of 3.5 mg/dL and a serum BUN of 35 mg/dL. Which conclusion can the nurse draw from these test results?

b. The patient’s kidneys have been damaged.

8. The nurse is caring for a patient who has developed kidney failure. Which test finding leads the nurse to contact the nephrologist and arrange for emergency hemodialysis?

a. Potassium level 6.8 mmol/L

9. The nurse is caring for a patient who will undergo ultrasound testing of the bladder and kidneys the next morning. Which instruction will the nurse provide to the patient about the test?

b. “You will need to drink lots of water but not use the toilet.”

10. The nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder. Which action will the nurse take to facilitate this procedure?

a. Obtain a Coudé catheter for insertion.

11. The nurse is caring for an incontinent male patient who has a deep decubitus ulcer on his sacrum. Which intervention will best manage the patient’s urinary incontinence and facilitate healing of the ulcer?

c. Careful perineal care and application of a condom catheter

12. The nurse is caring for a patient who has urinary frequency. Which nursing diagnosis is the highest priority for this patient?

d. Risk for fall-related injury r/t hurried trips to the bathroom during the day and night

13. The nurse is caring for a patient who has just had an intravenous pyelography (IVP) completed. Which assessment is the nurse’s highest priority after the patient returns from the test?

a. Calculate the patient’s intake and output.

14. The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient’s bladder. What is the priority nursing diagnosis for this patient?

c. Impaired urination r/t obstruction of urinary bladder outlet

15. The nurse is caring for a patient who had prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake. The patient’s urine from the indwelling catheter is cherry red with occasional small clots. What is the appropriate action of the nurse?

b. Gently irrigate the catheter using room-temperature sterile irrigation solution.

16. The nurse is caring for a patient with the nursing diagnosis of urge incontinence of urine related to urinary tract infection. Which statement is appropriate for the “as evidenced by” portion of the patient’s diagnosis?

a. Sudden leakage of urine when patient is unable to get to the toilet in time

17. The nurse is caring for a patient with an indwelling urinary catheter caused by severe prostate enlargement. Which is the priority nursing diagnosis for this patient?

a. Risk for infection r/t indwelling urinary catheter

18. The preceptor is watching a nursing student care for a male patient who requires a condom catheter. Which action by the nursing student indicates that the procedure is performed correctly?

d. The foreskin is returned to its natural position before the catheter is applied.

19. The nurse is caring for a patient with a history of type 1 diabetes. Which assessment finding indicates to the nurse that the patient may not be compliant with the diabetic treatment regimen?

a. The patient is always thirsty and frequently voids very large amounts of urine.

20. The nurse is caring for a patient who is to undergo computed tomography (CT) of the kidneys and ureters. Which assessment finding by the nurse must be reported to the provider and radiologist before the patient has the procedure?

b. The patient thinks that she might be pregnant.

21. The nurse is caring for an elderly patient with a history of arthritis, urinary incontinence and poor perineal hygiene practices. The patient has had four urinary tract infections in the past year. Which is the priority goal for the nursing diagnosis Impaired health maintenance for this patient?

b. The patient will allow family members to assist with daily bathing and perineal care.

NUR 170 exam 4

V Farris · 50問 · 3年前

NUR 170 exam 4