114 FINAL EXAM REVIEW QUESTIONS
WITH VERIFIED ANSWERS
A nnclient nnvomits nnas nna nnnurse nnis nninserting nnhis nnoropharyngeal nnairway. nnWhat
nnwould nnbe nnthe nnmost nnappropriate nnintervention nnin nnthis nnsituation? nn
A. nnremove nnthe nnairway, nnturn nnthe nnclient nnto nnthe nnside nnand nnprovide nnmouth
nnsuction, nnif nnnecessary. nn
B. nnimmediately nnremove nnthe nnairway, nnrinse nnthe nnclients nnmouth nnwith nnsterile
nnwater, nnand nnreport nnthis nnto nnthe nnphysician. nn
C. nnleave nnthe nnairway nnin nnplace nnand nnpromptly nnnotify nnthe nnphysician nnfor
nnfurther nninstructions. nn
D. nnsuction nnthe nnclients nnmouth nnthrough nnthe nnoropharyngeal nnairway nnto nnprevent
nnaspiration. nn- nnAnswer nnA
A nnnurse nnis nnimplementing nnthe nnprinciples nnof nnsurgical nnasepsis nnwhile nninserting
nna nnclients nninter nndwelling nncatheter. nnWhich nnof nnthe nnfollowing nnactions nnshould
nnthe nnnurse nnperform?
A. nnhold nnsterile nnobjects nnabove nnwas nnit nnlevel nnto nnprevent nnaccidental
nncontamination.
B. nnconsider nnthe nnoutside nnof nnthe nnsterile nnpackage nnto nnbe nnpartially nnsterile.
C. nnconsider nnthe nnouter nn3 nninch nnedge nnof nnthe nnsterile nnfield nnto nnbe
nncontaminated.
D. nnopen nnthe nnsterile nnpackages nnso nnthat nnthe nnfirst nnedge nnof nnthe nnwrapper nnis
nndirected nntoward nnyou. nn- nnAnswer nnA
A nnnurse nnis nncaring nnof nnt nna nnclient nnwho nnhas nna nnsurgical nnwound nnfollowing nna
nnbowel nnresection. nnThe nnnurses nnassessment nnreveals nndehiscence nnof nnthe
nnwound nnand nnthe nnnurse nncontacts nnthe nnsurgeon. nnWhat nncomplication nnof
nnsurgery nnhas nnthis nnclient nnexperienced? nn
A. nnthe nnedges nnof nnthe nnwound nnare nnmisaligned. nn
B. nnthere nnis nnan nnaccidental nnseparation nnof nnthe nnwound.
C. nntehre nnis nnan nnaccumulation nnof nnfluid nnin nnthe nninterstitial nntissue nnsurrounding
nnthe nnwound. nn
D. nnthere nnis nnredness nnor nninflammation nnof nnan nnarea nnas nna nnresult nnof nnpossible
nnwound nninfection. nn- nnAnswer nnB
A nnnurse nnis nnusing nna nnpulse nnoximeter nnto nnmeasure nna nnclients nnSpO2 nnobtains
nna nnreading nnof nn90%. nnWhat nnis nnthe nnnurse's nnmost nnappropriate nnaction? nn
A. nnencourage nnthe nnclient nnto nndo nndeep-breathing nnexercises.
B. nnRaise nnthe nnhead nnof nnthe nnclients nnbed nnslightly, nnif nntolerated. nn
, C. nnreview nnthe nnmedications nnthat nnthe nnclient nnhas nntaken nnin nnthe nnpast nn90
nnminutes. nn
D. nndocument nnthis nnexpected nnassessment nnfinding. nn- nnAnswer nnA
A nnclient nnhas nnundergone nnfoot nnsurgery nnand nnwill nnuse nncrutches nnin nnthe nnshort
nnterm. nnWhich nnof nnthe nnfollowing nnteaching nnpoints nnshould nnthe nnnurse nnprovide
nnto nnthe nnclient? nn
A. nnIf nnyou nnfeel nntired nnwhile nnwalking nnwith nnyour nncrutches, nnrest nnyour nnweight
nnon nnyour nnarmpits nnfor nna nnmoment nnand nnthen nncontinue nnslowly. nn
B. nnYour nnelbows nnwill nnbe nnslightly nnbend nnwhen nnyou nnare nnusing nnyour nncrutches.
C. nnwhen nnyour nncrutches nnfit nnright, nnmost nnof nnyour nnbody nnweight nnwill nnbe
nnsupported nnby nnyour nnarmpits.
D. nnwe'll nnhave nnthe nnnursing nnassistant nnwatch nnyou nnwhile nnyou nnwalk nnaround
nnthe nnunit nnthe nnfirst nntime. nn- nnAnswer nnB
A nnnurse nnis nnteaching nna nnclient nnhow nnto nncare nnfor nnher nndementia. nnWhich nnof
nnthe nnfollowing nnis nna nnrecommended nnteaching nnguideline? nn
A. nnremove nnyour nndentures nnwhenever nnpossible nnin nnorder nnto nnrest nnyour nngums.
B. nnwrap nnyour nndentures nnin nna nnclean nnnapkin nnor nnfacecloth nnwhen nnnot nnusing
nnthem.
C. nnrinse nnyour nndentures nnin nna nndilute nnbleach nnsolution nnat nnleast nnonce nnper
nnweek.
D. nnstore nnyour nndentures nnin nncold nnwater nnwhenever nnthey're nnnot nnin nnuse. nn-
nnAnswer nnD
Incentive nnSpirometer= nninstruct nnclient nnto nn________ nnslowly nnand nnas nndeeply
nnas nnpossible nnthrough nnthe nnmouthpiece nnwithout nnusing nnthe nnnose. nn- nnAnswer
nninhale
A nnnurse nnis nninspecting nna nnclients nnpressure nnulcer nndocuments nnthe nnfollowing:
nnfull nnthickness nntissue nnloss; nnvisible nnsubcutaneous nnfat; nnno nnbone, nntendon, nnor
nnmuscle nnvisible. nnTh nnnurse nnshould nnrecognize nnwhat nnstage nnof nnpressure
nnulcer? nn
A. nnstage nn1
B. nnstage nn2
C. nnstage nn3
D. nnstage nn4 nn- nnAnswer nnC
Negative nnpressure nnwound nntherapy nnhas nnbeen nnordered nnfor nna nnpatient nnwho
nnneeds nnto nnbe nntreated nnfor nna nnchronic nnwound. nnWhich nnof nnthe nnfollowing
nnwould nnbe nnincluded nnin nnthis nnclients nnplan nnof nnnursing nncare? nn
A. nnto nnfacilitate nnadequate nnrest, nndisconnect nnNPWT nneach nnnight nnbetween nn2200
nnand nn0700.
B. nnrecord nnthe nnquantity nnof nndrainage nnonce nnprettify nnand nndocument nnon nnthe
nnintake nnand nnoutput nnrecord.
WITH VERIFIED ANSWERS
A nnclient nnvomits nnas nna nnnurse nnis nninserting nnhis nnoropharyngeal nnairway. nnWhat
nnwould nnbe nnthe nnmost nnappropriate nnintervention nnin nnthis nnsituation? nn
A. nnremove nnthe nnairway, nnturn nnthe nnclient nnto nnthe nnside nnand nnprovide nnmouth
nnsuction, nnif nnnecessary. nn
B. nnimmediately nnremove nnthe nnairway, nnrinse nnthe nnclients nnmouth nnwith nnsterile
nnwater, nnand nnreport nnthis nnto nnthe nnphysician. nn
C. nnleave nnthe nnairway nnin nnplace nnand nnpromptly nnnotify nnthe nnphysician nnfor
nnfurther nninstructions. nn
D. nnsuction nnthe nnclients nnmouth nnthrough nnthe nnoropharyngeal nnairway nnto nnprevent
nnaspiration. nn- nnAnswer nnA
A nnnurse nnis nnimplementing nnthe nnprinciples nnof nnsurgical nnasepsis nnwhile nninserting
nna nnclients nninter nndwelling nncatheter. nnWhich nnof nnthe nnfollowing nnactions nnshould
nnthe nnnurse nnperform?
A. nnhold nnsterile nnobjects nnabove nnwas nnit nnlevel nnto nnprevent nnaccidental
nncontamination.
B. nnconsider nnthe nnoutside nnof nnthe nnsterile nnpackage nnto nnbe nnpartially nnsterile.
C. nnconsider nnthe nnouter nn3 nninch nnedge nnof nnthe nnsterile nnfield nnto nnbe
nncontaminated.
D. nnopen nnthe nnsterile nnpackages nnso nnthat nnthe nnfirst nnedge nnof nnthe nnwrapper nnis
nndirected nntoward nnyou. nn- nnAnswer nnA
A nnnurse nnis nncaring nnof nnt nna nnclient nnwho nnhas nna nnsurgical nnwound nnfollowing nna
nnbowel nnresection. nnThe nnnurses nnassessment nnreveals nndehiscence nnof nnthe
nnwound nnand nnthe nnnurse nncontacts nnthe nnsurgeon. nnWhat nncomplication nnof
nnsurgery nnhas nnthis nnclient nnexperienced? nn
A. nnthe nnedges nnof nnthe nnwound nnare nnmisaligned. nn
B. nnthere nnis nnan nnaccidental nnseparation nnof nnthe nnwound.
C. nntehre nnis nnan nnaccumulation nnof nnfluid nnin nnthe nninterstitial nntissue nnsurrounding
nnthe nnwound. nn
D. nnthere nnis nnredness nnor nninflammation nnof nnan nnarea nnas nna nnresult nnof nnpossible
nnwound nninfection. nn- nnAnswer nnB
A nnnurse nnis nnusing nna nnpulse nnoximeter nnto nnmeasure nna nnclients nnSpO2 nnobtains
nna nnreading nnof nn90%. nnWhat nnis nnthe nnnurse's nnmost nnappropriate nnaction? nn
A. nnencourage nnthe nnclient nnto nndo nndeep-breathing nnexercises.
B. nnRaise nnthe nnhead nnof nnthe nnclients nnbed nnslightly, nnif nntolerated. nn
, C. nnreview nnthe nnmedications nnthat nnthe nnclient nnhas nntaken nnin nnthe nnpast nn90
nnminutes. nn
D. nndocument nnthis nnexpected nnassessment nnfinding. nn- nnAnswer nnA
A nnclient nnhas nnundergone nnfoot nnsurgery nnand nnwill nnuse nncrutches nnin nnthe nnshort
nnterm. nnWhich nnof nnthe nnfollowing nnteaching nnpoints nnshould nnthe nnnurse nnprovide
nnto nnthe nnclient? nn
A. nnIf nnyou nnfeel nntired nnwhile nnwalking nnwith nnyour nncrutches, nnrest nnyour nnweight
nnon nnyour nnarmpits nnfor nna nnmoment nnand nnthen nncontinue nnslowly. nn
B. nnYour nnelbows nnwill nnbe nnslightly nnbend nnwhen nnyou nnare nnusing nnyour nncrutches.
C. nnwhen nnyour nncrutches nnfit nnright, nnmost nnof nnyour nnbody nnweight nnwill nnbe
nnsupported nnby nnyour nnarmpits.
D. nnwe'll nnhave nnthe nnnursing nnassistant nnwatch nnyou nnwhile nnyou nnwalk nnaround
nnthe nnunit nnthe nnfirst nntime. nn- nnAnswer nnB
A nnnurse nnis nnteaching nna nnclient nnhow nnto nncare nnfor nnher nndementia. nnWhich nnof
nnthe nnfollowing nnis nna nnrecommended nnteaching nnguideline? nn
A. nnremove nnyour nndentures nnwhenever nnpossible nnin nnorder nnto nnrest nnyour nngums.
B. nnwrap nnyour nndentures nnin nna nnclean nnnapkin nnor nnfacecloth nnwhen nnnot nnusing
nnthem.
C. nnrinse nnyour nndentures nnin nna nndilute nnbleach nnsolution nnat nnleast nnonce nnper
nnweek.
D. nnstore nnyour nndentures nnin nncold nnwater nnwhenever nnthey're nnnot nnin nnuse. nn-
nnAnswer nnD
Incentive nnSpirometer= nninstruct nnclient nnto nn________ nnslowly nnand nnas nndeeply
nnas nnpossible nnthrough nnthe nnmouthpiece nnwithout nnusing nnthe nnnose. nn- nnAnswer
nninhale
A nnnurse nnis nninspecting nna nnclients nnpressure nnulcer nndocuments nnthe nnfollowing:
nnfull nnthickness nntissue nnloss; nnvisible nnsubcutaneous nnfat; nnno nnbone, nntendon, nnor
nnmuscle nnvisible. nnTh nnnurse nnshould nnrecognize nnwhat nnstage nnof nnpressure
nnulcer? nn
A. nnstage nn1
B. nnstage nn2
C. nnstage nn3
D. nnstage nn4 nn- nnAnswer nnC
Negative nnpressure nnwound nntherapy nnhas nnbeen nnordered nnfor nna nnpatient nnwho
nnneeds nnto nnbe nntreated nnfor nna nnchronic nnwound. nnWhich nnof nnthe nnfollowing
nnwould nnbe nnincluded nnin nnthis nnclients nnplan nnof nnnursing nncare? nn
A. nnto nnfacilitate nnadequate nnrest, nndisconnect nnNPWT nneach nnnight nnbetween nn2200
nnand nn0700.
B. nnrecord nnthe nnquantity nnof nndrainage nnonce nnprettify nnand nndocument nnon nnthe
nnintake nnand nnoutput nnrecord.
