Level 2 Nursing Skills (MGCCC level 2 Nursing
Skills) Questions With Complete Solutions
A patient has a new colostomy after a partial
colectomy for colon cancer in which the surgeon
was able to completely remove the colorectal
tumor. The patient is crying and keeps saying,
"Nothing will ever be the same." Which action by
the nurse is best?
Ask the patient to describe feelings about having a
colostomy.
Teach the patient how to care for and manage the
colostomy.
Provide information about colon cancer survivor
support groups.
Reassure the patient that the surgery was
successful and that cure is likely. Correct Answers
Ask the patient to describe feelings about having a
colostomy.
Rationale
Patients' reactions to colostomy surgery often
include fears about not being accepted by others,
grieving over disturbances in body image, and
concerns about sexuality; therefore, the nurse
should help the patient explore feelings about the
,colostomy. Reassuring the patient that the surgery
was successful and giving information about
support groups assumes that the patient is worried
about the cancer. Providing teaching about the
colostomy will be necessary for home management
but is not appropriate while the patient is
expressing feelings of grief.
p. 1134
A patient is admitted with peritonitis due to a
perforated appendix. Which intervention can be
delegated to unlicensed assistive personnel (UAP)?
Measuring intake and output
Assessing for signs of sepsis
Administering pain medication
Performing nasogastric tube suctioning Correct
Answers Measuring intake and output
Rationale
UAPs can measure intake and output.
Administering pain medication, performing
nasogastric tube suctioning, and assessing for
signs of sepsis would be beyond the scope of
practice for UAP and should be performed by a
registered nurse.
p. 1146
,A patient is receiving oxygen therapy. What are
potential sources of infection the nurse should
address? Select all that apply.
Oxygen tubing pulling on the airway
Use of nonpetroleum lotion for dry skin
Use of a heated humidifier or nebulizer
Use of an oral suction catheter in the endotracheal
tube
Rising white blood cell count noted on recent blood
work Correct Answers Use of a heated humidifier
or nebulizer
Use of an oral suction catheter in the endotracheal
tube
Rationale
Humidifiers and nebulizer containers can harbor
organisms, which can lead to infections in patients
receiving oxygen therapy. Organisms in the oral
cavity can cause respiratory infections when
transferred to the trachea via a suction catheter.
Although oxygen tubing tension on an airway can
cause pressure and potential breakdown, the more
immediate concerns are the heated fluid in the
, containers and transference via suction catheters.
The nonpetroleum lotions are preferred for dry skin
that can result from oxygen therapy. A rise in the
white blood cell count may indicate the presence of
an infection, but it is not a source of infection.
p. 531
A patient who is receiving long-term intravenous
therapy experiences edema around the
intravenous insertion site, along with fluid leakage
from the punctured site. The patient reports
blanching and skin tightness. The nurse should
perform what interventions? Select all that apply.
Apply a sterile dressing
Apply a cold compress
Clean the exit site with alcohol
Temporarily slow the infusion rate
Encourage the patient to elevate the extremity
Correct Answers Apply a sterile dressing
Apply a cold compress
Encourage the patient to elevate the extremity
Rationale
Edema around the intravenous insertion site,
leakage of fluid from the punctured site, and
Skills) Questions With Complete Solutions
A patient has a new colostomy after a partial
colectomy for colon cancer in which the surgeon
was able to completely remove the colorectal
tumor. The patient is crying and keeps saying,
"Nothing will ever be the same." Which action by
the nurse is best?
Ask the patient to describe feelings about having a
colostomy.
Teach the patient how to care for and manage the
colostomy.
Provide information about colon cancer survivor
support groups.
Reassure the patient that the surgery was
successful and that cure is likely. Correct Answers
Ask the patient to describe feelings about having a
colostomy.
Rationale
Patients' reactions to colostomy surgery often
include fears about not being accepted by others,
grieving over disturbances in body image, and
concerns about sexuality; therefore, the nurse
should help the patient explore feelings about the
,colostomy. Reassuring the patient that the surgery
was successful and giving information about
support groups assumes that the patient is worried
about the cancer. Providing teaching about the
colostomy will be necessary for home management
but is not appropriate while the patient is
expressing feelings of grief.
p. 1134
A patient is admitted with peritonitis due to a
perforated appendix. Which intervention can be
delegated to unlicensed assistive personnel (UAP)?
Measuring intake and output
Assessing for signs of sepsis
Administering pain medication
Performing nasogastric tube suctioning Correct
Answers Measuring intake and output
Rationale
UAPs can measure intake and output.
Administering pain medication, performing
nasogastric tube suctioning, and assessing for
signs of sepsis would be beyond the scope of
practice for UAP and should be performed by a
registered nurse.
p. 1146
,A patient is receiving oxygen therapy. What are
potential sources of infection the nurse should
address? Select all that apply.
Oxygen tubing pulling on the airway
Use of nonpetroleum lotion for dry skin
Use of a heated humidifier or nebulizer
Use of an oral suction catheter in the endotracheal
tube
Rising white blood cell count noted on recent blood
work Correct Answers Use of a heated humidifier
or nebulizer
Use of an oral suction catheter in the endotracheal
tube
Rationale
Humidifiers and nebulizer containers can harbor
organisms, which can lead to infections in patients
receiving oxygen therapy. Organisms in the oral
cavity can cause respiratory infections when
transferred to the trachea via a suction catheter.
Although oxygen tubing tension on an airway can
cause pressure and potential breakdown, the more
immediate concerns are the heated fluid in the
, containers and transference via suction catheters.
The nonpetroleum lotions are preferred for dry skin
that can result from oxygen therapy. A rise in the
white blood cell count may indicate the presence of
an infection, but it is not a source of infection.
p. 531
A patient who is receiving long-term intravenous
therapy experiences edema around the
intravenous insertion site, along with fluid leakage
from the punctured site. The patient reports
blanching and skin tightness. The nurse should
perform what interventions? Select all that apply.
Apply a sterile dressing
Apply a cold compress
Clean the exit site with alcohol
Temporarily slow the infusion rate
Encourage the patient to elevate the extremity
Correct Answers Apply a sterile dressing
Apply a cold compress
Encourage the patient to elevate the extremity
Rationale
Edema around the intravenous insertion site,
leakage of fluid from the punctured site, and
