EXAM QUESTIONS AND ANSWERS
Thegwnursegwobservesgwthatgwagwmalegwclientgwhasgwremovedgwthegwcoveringgwfromgwangwi
cegwparkgwappliedgwtogwhisgwknee.gwWhatgwactiongwshouldgwthegwnursegwtakegwfirst?gw
A.gwObservegwthegwappearancegwofgwthegwskingwundergwthegwicegwpack.
B.gwInstructgwthegwclientgwregardinggwthegwneedgwforgwthegwcovering.
C.gwReapplygwthegwcoveringgwaftergwfillinggwwithgwfreshgwice.
D.gwAskgwthegwclientgwhowgwlonggwthegwicegwwasgwappliedgwtogwthegwskin.gw-gwanswer--
Observegwthegwappearancegwofgwthegwskingwundergwthegwicegwpackgw(Thegwfirstgwactiongwta
kengwbygwthegwnursegwshouldgwbegwtogwassessgwthegwskingwforgwanygwpossiblegwthermalgwinj
ury.gwIfgwnogwinjurygwtogwthegwskingwhasgwoccurred,gwthegwnursegwcangwtakegwthegwothergwact
ions.)
Thegwnursegwmixesgw50gwmggwofgwNipridegwingw250gwmLgwofgwD5Wgwandgwplansgwtogwadmin
istergwthegwsolutiongwatgwagwrategwofgw5gwmcg/kg/
mingwtogwagwclientgwweightinggw182gwlbs.gwUsinggwagwdripgwfactorgwofgw60gwgtt/
mL,gwhowgwmanygwdropsgwpergwminutegwshouldgwthegwclientgwreceive?gw-gwanswer--
124gwgtt/min
ThegwhealthcaregwprovidergwprescribesgwangwIVgwinfusiongwofgw1000gwmlgwofgwRinger'sgwLa
ctategww/
gw30gwunitsgwofgwPitocingwtogwrungwingwovergw4gwhoursgwforgwagwclientgwwhogwhasgwjustgwdeliv
eredgwagw10gwpoundgwinfantgwbygwcesareangwsection.gwThegwtubinggwhasgwbeengwchangedg
wtogwagw20gwgtt/
mlgwadministrationgwset.gwThegwnursegwplansgwtogwsetgwthegwflowgwrategwatgwhowgwmanygwgt
t/min?gw-gwanswer--83gwgtt/min
Whichgwassessmentgwdatagwprovidesgwthegwmostgwaccurategwdeterminationgwofgwpropergw
placementgwofgwagwnasogastricgwtube?gw-gwanswer--Examininggwagwchestgwx-
raygwobtainedgwaftergwthegwtubinggwwasgwinserted
Threegwdaysgwfollowinggwagwsurgery,gwagwmalegwclientgwobservesgwhisgwcolostomygwforgwth
egwfirstgwtime.gwHegwbecomesgwquitegwupsetgwandgwtellsgwthegwnursegwthatgwitgwisgwmuchgwbi
ggergwthangwhegwexpected.gwWhatgwisgwthegwbestgwresponsegwbygwthegwnurse?
A.gwReassuregwthegwclientgwthatgwhegwwillgwbecomegwaccustomedgwtogwthegwstomagwappea
rancegwingwtime.gw
B.gwInstructgwthegwclientgwthatgwthegwstomagwwillgwbecomegwmuchgwsmallergwwhengwthegwini
tialgwswellinggwdiminishes.gw
C.gwOffergwtogwcontactgwagwmembergwofgwthegwlocalgwostomygwsupportgwgroupgwtogwhelpgwhi
mgwwithgwhisgwconcerns.
D.gwEncouragegwthegwclientgwtogwhandlegwthegwstomagwequipmentgwtogwgaingwconfidencegw
withgwthegwprocedure.gw-gwanswer--
B.gwInstructgwthegwclientgwthatgwthegwstomagwwillgwbecomegwsmallergwwhengwthegwinitialgwsw
ellinggwdiminishesgw(Postoperativegwswellinggwcausesgwenlargementgwofgwthegwstoma.gwT
hegwnursegwcangwteachgwthegwclientgwthatgwthegwstomagwwillgwbecomegwsmallergwwhengwsw
,ellinggwisgwdiminishedgw(B).gwThisgwwillgwhelpgwreducegwthegwclient'sgwanxietygwandgwpromo
tegwacceptancegwofgwthegwcolostomy.gw(A)gwdoesgwnotgwprovidegwhelpfulgwteachinggworgwsu
pport.gw(C)gwisgwagwusefulgwaction,gwandgwmaygwbegwtakengwaftergwthegwnursegwprovidesgwp
ertinentgwteaching.gwThegwclientgwisgwnotgwyetgwdemonstratinggwreadinessgwtogwlearngwcolo
stomygwcare.gw(D)
Agwfemalegwclientgwwithgwagwnasogastricgwtubegwattachedgwtogwlowgwsuctiongwstatesgwthatgw
shegwisgwnauseated.gwThegwnursegwassessesgwthatgwtheregwhasgwbeengwnogwdrainagegwthr
oughgwthegwnasogastricgwtubegwingwthegwlastgwtwogwhours.gwWhatgwactiongwshouldgwthegwnu
rsegwtakegwfirst?
A.gwIrrigategwthegwnasogastricgwtubegwwithgwsterilegwnormalgwsaline.
B.gwRepositiongwthegwclientgwongwhergwside.
C.gwAdvancegwthegwnasogastricgwtubegwangwadditionalgwfivegwcentimeters.
D.gwAdministergwangwintravenousgwantiemeticgwprescribedgwforgwPRNgwuse.gw-gwanswer--
B.gwRepositiongwthegwclientgwongwhergwside.gw(Thegwimmediategwprioritygwisgwtogwdetermine
gwifgwthegwtubegwisgwfunctioninggwcorrectly,gwwhichgwwouldgwthengwrelievegwthegwclient'sgwna
usea.gwThegwleastgwinvasivegwinterventiongw(B)gwshouldgwbegwattemptedgwfirst,gwfollowedgw
bygw(AgwandgwC),gwunlessgweithergwofgwthesegwinterventionsgwisgwcontraindicated.gwIfgwthes
egwmeasuresgwaregwunsuccessful,gwthegwclientgwmaygwrequiregwangwantiemeticgw(D))
Agwhospitalizedgwmalegwclientgwisgwreceivinggwnasogastricgwtubegwfeedingsgwviagwagwsmall-
boregwtubegwandgwagwcontinuousgwpumpgwinfusion.gwHegwreportsgwthatgwhegwhadgwagwbadgw
boutgwofgwseveregwcoughinggwagwfewgwminutesgwago,gwbutgwfeelsgwfinegwnow.gwWhatgwactio
ngwisgwbestgwforgwthegwnursegwtogwtake?
A.gwRecordgwthegwcoughinggwincident.gwNogwfurthergwactiongwisgwrequiredgwatgwthisgwtime.
B.gwStopgwthegwfeeding,gwexplaingwtogwthegwfamilygwwhygwitgwisgwbeinggwstopped,gwandgwnoti
fygwthegwHCP.
C.gwAftergwclearinggwthegwtubegwwithgw30gwmlgwofgwair,gwcheckgwthegwpHgwofgwfluidgwwithdraw
ngwfromgwthegwtube.
D.gwInjectgw30gwmlgwofgwairgwintogwthegwtubegwwhilegwauscultatinggwthegwepigastriumgwforgwg
urgling.gw-gwanswer--
C.gwAftergwclearinggwthegwtubegwwithgw30gwmlgwofgwair,gwcheckgwthegwpHgwofgwfluidgwwithdraw
ngwfromgwthegwtube.
Agwmalegwclientgwtellsgwthegwnursegwthatgwhegwdoesgwnotgwknowgwwheregwhegwisgworgwwhatgw
yeargwitgwis.gwWhatgwdatagwshouldgwthegwnursegwdocumentgwthatgwisgwmostgwaccurate?
A.gwdemonstratesgwlossgwofgwremotegwmemory
B.gwexhibitsgwexpressivegwdysphasia
C.gwhasgwagwdiminishedgwattentiongwspan
D.gwisgwdisorientedgwtogwplacegwandgwtimegw-gwanswer--
D.gwisgwdisorientedgwtogwplacegwandgwtimegw(Thegwclientgwisgwexhibitinggwdisorientationgw(D
).gw(A)gwrefersgwtogwmemorygwofgwthegwdistantgwpast.gwThegwclientgwisgwablegwtogwexpressgwh
imselfgwwithoutgwdifficultygw(B),gwandgwdoesgwnotgwdemonstrategwdiminishedgwattentiongws
pan.gw(C).
Agwclientgwwithgwchronicgwkidneygwdiseasegw(CKD)gwselectsgwagwscrambledgwegggwforgwhisg
wbreakfast.gwWhatgwactiongwshouldgwthegwnursegwtake?
A.gwCommendgwthegwclientgwforgwselectinggwagwhighgwbiologicgwvaluegwprotein.
B.gwRemindgwthegwclientgwthatgwproteingwingwthegwdietgwshouldgwbegwavoided.
C.gwSuggestgwthatgwthegwclientgwalsogwselectgworangegwjuice,gwtogwpromotegwabsorption.
, D.gwEncouragegwthegwclientgwtogwattendgwclassesgwongwdietarygwmanagementgwofgwCKD.gw
-gwanswer--
A.gwCommendgwthegwclientgwforgwselectinggwagwhighgwbiologicgwvaluegwprotein.gw(Foodsgws
uchgwasgweggsgwandgwmilkgw(A)gwaregwhighgwbiologicgwproteinsgwwhichgwaregwallowedgwbec
ausegwtheygwaregwcompletegwproteinsgwandgwsupplygwthegwessentialgwaminogwacidsgwthatgw
aregwnecessarygwforgwgrowthgwandgwcellgwrepair.gwOrangegwjuicegwisgwrichgwingwpotassiumgw
andgwshouldgwnotgwbegwencouraged.gwThegwclientgwhasgwmadegwagwgoodgwdietgwchoicegwso
gw(D)gwisgwnotgwnecessary.)
Whengwassistinggwangw82gwyeargwoldgwclientgwtogwambulate,gwitgwisgwimportantgwforgwthegwnu
rsegwtogwrealizegwthatgwthegwcentergwofgwgravitygwforgwangwelderlygwpersongwisgwthe--gw-
gwanswer--
Uppergwtorsogw(Thegwcentergwofgwgravitygwforgwadultsgwisgwthegwhips.gwHowever,gwasgwthegw
persongwgrowsgwolder,gwagwstoopedgwposturegwisgwcommongwbecausegwofgwthegwchangesg
wfromgwosteoporosisgwandgwnormalgwbonegwdegeneration,gwandgwthegwknees,gwhips,gwandg
welbowsgwflex.gwThisgwstoopedgwposturegwresultsgwingwthegwuppergwtorsogwbecominggwthegw
centergwofgwgravitygwforgwoldergwpersons.)
Ingwdevelopinggwagwplangwofgwcaregwforgwagwclientgwwithgwdementia,gwthegwnursegwshouldgwr
emembergwthatgwconfusiongwingwthegwelderlygw
A.gwisgwtogwbegwexpected,gwandgwprogressesgwwithgwage
B.gwoftengwfollowsgwrelocationgwtogwnewgwsurroundings
C.gwisgwagwresultgwofgwirreversiblegwbraingwpathologygw
D.gwcangwbegwpreventedgwwithgwadequategwsleepgw-gwanswer--
B.gwoftengwfollowsgwrelocationgwtogwnewgwsurroundingsgw(Relocationgw(B)gwoftengwresultsgw
ingwconfusiongwamonggwelderlygwclients--
gwmovinggwisgwstressfulgwforgwanyone.gw(A)gwisgwstereotypicalgwjudgement.gwStressgwingwth
egwelderlygwoftengwmanifestsgwitselfgwasgwconfusion,gwsogw(C)gwisgwwrong.gwAdequategwsle
epgwisgwnotgwagwpreventiongw(D)gwforgwconfusion.)
Agwpostoperativegwclientgwwillgwneedgwtogwperformgwdailygwdressinggwchangesgwaftergwdisc
harge.gwWhichgwoutcomegwstatementgwbestgwdemonstratesgwthegwclient'sgwreadinessgwtog
wmanagegwhisgwwoundgwcaregwaftergwdischarge?gwThegwclient
A.gwasksgwrelevantgwquestionsgwregardinggwthegwdressinggwchange
B.gwstatesgwhegwwillgwbegwablegwtogwcompletegwthegwwoundgwcaregwregimengw
C.gwdemonstratesgwthegwwoundgwcaregwproceduregwcorrectlygw
D.gwhasgwallgwthegwnecessarygwsuppliesgwforgwwoundgwcaregw-gwanswer--
C.gwdemonstratesgwthegwwoundgwcaregwproceduregwcorrectlygw
(Agwreturngwdemonstrationgwofgwagwproceduregw(C)gwprovidesgwangwobjectivegwassessmen
tgwofgwthegwclient'sgwabilitygwtogwperformgwagwtask,gwwhilegw(AgwandgwB)gwaregwsubjectivegwm
easures.gw(D)gwisgwimportant,gwbutgwisgwlessgwofgwagwprioritygwthangwthegwthegwnurse'sgwass
essmentgwofgwthegwclient'sgwabilitygwtogwcompletegwwoundgwcare.)
Agwclientgwwhogwisgw5gw'5"gwtallgwandgwweighsgw200gwpoundsgwisgwscheduledgwforgwsurgerygw
thegwnextgwday.gwWhatgwquestiongwisgwmostgwimportantgwforgwthegwnursegwtogwincludegwduri
nggwthegwpreoperativegwassessment?
A.gwWhatgwisgwyourgwdailygwcaloriegwconsumption?
B.gwWhatgwvitamingwandgwmineralgwsupplementsgwdogwyougwtake?"
C.gw"Dogwyougwfeelgwthatgwyougwaregwoverweight?"