NSG 3130 EXAM 2 UPDATED ACTUAL
QUESTIONS AND VERIFIED ANSWERS
●● A 58-year-old man is admitted for a small-bowel obstruction late
Saturday night. The admitting orders include the need to place a
nasogastric (NG) tube to low intermittent suction. During the
assessment, the nurse determines that the patient does not speak English.
Which action should the nurse take first before placing the NG tube?
a. Use two additional staff members when placing the tube so the patient
can be restrained if needed.
b. Request an interpreter per facility protocol.
c. Do not place the NG tube because the physician would not want to
frighten the patient.
d. Document the inability to place the NG tube due to lack of ability to
communicate.
Answer: b. Request an interpreter per facility protocol.
An interpreter employed by the hospital would be the best choice so that
someone in the room can communicate and provide comfort for the
patient. Taking additional staff into the room may increase the patient's
anxiety, thereby decreasing his ability to comprehend the instructions.
Although the physician would not want to frighten the patient, the
physician ordered the nasogastric (NG) tube for the benefit of the
patient; therefore, it needs to be placed. Documenting the inability to
,place the NG tube due to lack of means of communication is not
acceptable and does not ensure that the patient gets the needed
treatment.
●● Which nursing diagnoses are used in developing a patient teaching
plan? (Select all that apply.)
a. Moral Distress
b. Lack of Knowledge
c. Difficulty Coping
d. Teaching about Disease
e. Anxiety
Answer: b
Lack of Knowledge and Literacy Problem are appropriate nursing
diagnoses for use in developing a patient teaching plan. Moral Distress
is a nursing diagnosis for those facing ethical decisions. Difficulty
Coping is not a nursing diagnosis used in developing a teaching plan, but
if a patient is not coping effectively, it may affect the ability to learn. A
nursing diagnosis of Anxiety may affect the patient's ability to learn but
is not directly related to developing a teaching plan. Teaching about
Disease is not a nursing diagnosis. It is an intervention performed by the
nurse.
,●● Which nursing diagnosis is appropriate if a patient expresses an
interest in learning?
a. Ready to Learn
b. Lack of Knowledge
c. Effective Information Processing
d. Health-Seeking Behaviors
Answer: a. Ready to Learn
A patient's expression of an interest in learning would indicate correct
use of the nursing diagnosis, Ready to Learn. Lack of Knowledge would
indicate the patient has a deficiency of knowledge on a particular
subject. Effective Information Processing is the patient's ability to
acquire useful information. Health-Seeking Behaviors is active seeking
by a person of ways to alter habits to enhance health.
●● A 61-year-old man is undergoing an emergency cardiac
catheterization. The nurse gives his wife the registration paperwork to
complete. Which observed actions may indicate a health literacy issue?
(Select all that apply.)
a. Putting on glasses before beginning the paperwork.
b. Asking someone in the waiting area to read the forms to her.
c. Waiting until her daughter arrives to begin the paperwork so that her
daughter can complete the forms.
, d. Setting the clipboard aside and staring tearfully out the window.
e. Returning the forms only partially filled out, with missing or
inaccurate information.
Answer: b, c, e
Asking someone else to read the form, waiting for help with the forms,
and partially or inaccurately filling out forms are behaviors indicative of
potential health literacy issues. Needing glasses does not correlate
directly with health literacy. A tearful spouse requires additional
assessment to see whether health literacy is a problem. The wife may be
overwhelmed and feel unable to complete the forms, or she may need to
collect her thoughts in the midst of a stressful time.
●● Teaching a patient to use an incentive spirometer by demonstration,
with a return demonstration by the patient, is an example of teaching
based on which domain of learning?
a. Psychomotor
b. Affective
c. Psychosocial
d. Cognitive
Answer: a. Psychomotor
Demonstration along with a return demonstration by the patient is an
example of psychomotor domain learning. Affective domain learning
QUESTIONS AND VERIFIED ANSWERS
●● A 58-year-old man is admitted for a small-bowel obstruction late
Saturday night. The admitting orders include the need to place a
nasogastric (NG) tube to low intermittent suction. During the
assessment, the nurse determines that the patient does not speak English.
Which action should the nurse take first before placing the NG tube?
a. Use two additional staff members when placing the tube so the patient
can be restrained if needed.
b. Request an interpreter per facility protocol.
c. Do not place the NG tube because the physician would not want to
frighten the patient.
d. Document the inability to place the NG tube due to lack of ability to
communicate.
Answer: b. Request an interpreter per facility protocol.
An interpreter employed by the hospital would be the best choice so that
someone in the room can communicate and provide comfort for the
patient. Taking additional staff into the room may increase the patient's
anxiety, thereby decreasing his ability to comprehend the instructions.
Although the physician would not want to frighten the patient, the
physician ordered the nasogastric (NG) tube for the benefit of the
patient; therefore, it needs to be placed. Documenting the inability to
,place the NG tube due to lack of means of communication is not
acceptable and does not ensure that the patient gets the needed
treatment.
●● Which nursing diagnoses are used in developing a patient teaching
plan? (Select all that apply.)
a. Moral Distress
b. Lack of Knowledge
c. Difficulty Coping
d. Teaching about Disease
e. Anxiety
Answer: b
Lack of Knowledge and Literacy Problem are appropriate nursing
diagnoses for use in developing a patient teaching plan. Moral Distress
is a nursing diagnosis for those facing ethical decisions. Difficulty
Coping is not a nursing diagnosis used in developing a teaching plan, but
if a patient is not coping effectively, it may affect the ability to learn. A
nursing diagnosis of Anxiety may affect the patient's ability to learn but
is not directly related to developing a teaching plan. Teaching about
Disease is not a nursing diagnosis. It is an intervention performed by the
nurse.
,●● Which nursing diagnosis is appropriate if a patient expresses an
interest in learning?
a. Ready to Learn
b. Lack of Knowledge
c. Effective Information Processing
d. Health-Seeking Behaviors
Answer: a. Ready to Learn
A patient's expression of an interest in learning would indicate correct
use of the nursing diagnosis, Ready to Learn. Lack of Knowledge would
indicate the patient has a deficiency of knowledge on a particular
subject. Effective Information Processing is the patient's ability to
acquire useful information. Health-Seeking Behaviors is active seeking
by a person of ways to alter habits to enhance health.
●● A 61-year-old man is undergoing an emergency cardiac
catheterization. The nurse gives his wife the registration paperwork to
complete. Which observed actions may indicate a health literacy issue?
(Select all that apply.)
a. Putting on glasses before beginning the paperwork.
b. Asking someone in the waiting area to read the forms to her.
c. Waiting until her daughter arrives to begin the paperwork so that her
daughter can complete the forms.
, d. Setting the clipboard aside and staring tearfully out the window.
e. Returning the forms only partially filled out, with missing or
inaccurate information.
Answer: b, c, e
Asking someone else to read the form, waiting for help with the forms,
and partially or inaccurately filling out forms are behaviors indicative of
potential health literacy issues. Needing glasses does not correlate
directly with health literacy. A tearful spouse requires additional
assessment to see whether health literacy is a problem. The wife may be
overwhelmed and feel unable to complete the forms, or she may need to
collect her thoughts in the midst of a stressful time.
●● Teaching a patient to use an incentive spirometer by demonstration,
with a return demonstration by the patient, is an example of teaching
based on which domain of learning?
a. Psychomotor
b. Affective
c. Psychosocial
d. Cognitive
Answer: a. Psychomotor
Demonstration along with a return demonstration by the patient is an
example of psychomotor domain learning. Affective domain learning
