NURS 226 Final Exam Questions and Answers

What is a primary prevention tool used for colon cancer screening? A. Abdominal x-rays B. Blood, urea, and nitrogen (BUN) testing C. Serum electrolytes D. Occult blood testing D. Occult blood testing Which of the following are safe practices to follow in the safe prepa- ration and storage of food? (Select all that apply.) A. Always use a single cutting board to prepare foods for cooking. B. Refrigerate leftovers as soon as possible. C. Always buy vegetables in packages marked "prewashed." D. Cook meats to the proper temperature. E. Wash hands thoroughly before food preparation. B, D, and E A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.) A. A current safety inspection sticker is on the IV fluids pump. B. A walker is positioned near the patient's bedside. C. The hospital bed is in the high position. D. There is no gait belt at the bedside. E. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed. C, D, and E A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.) A. Immediately phone in to the hospital alert system the exact loca- tion of the fire. B. Direct the nurse technician to place empty stretchers behind the fire doors. C. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. D. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. E. Close the room doors of patients who cannot get out of bed, and keep them in their rooms. A, C, and D A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? A. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. B. The second patient is very drowsy, loses attention span when the nurse asks questions, and mumbles when speaking. C. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume. D. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient. D. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient. A nurse working the night shift is assigned a patient who has a his- tory of having fallen in the hospital during a previous admission. The nurse wants to review the admission assessment completed by the nurse on the day shift. Which of the following sections in the assess- ment are most likely to provide information about the patient's cur- rent fall risks? (Select all that apply.) A. Allergy history B. Medication history C. Patient age D. Patient's occupation E. Physical exam of neuromuscular function B, C, and E Which of the following promotes child safety for preschoolers? A. Teach children proper bicycle and skate board safety. B. Teach children how to cross streets and walk in parking lot. C. Teach children proper techniques for specific sports. D. Teach children not to operate electric toothbrushes while unsupervised. D. Teach children not to operate electric toothbrushes while unsupervised. Which of the following promotes child safety for adolescents? A. Teach children proper techniques for specific sports. B. Teach children not to operate electric toothbrushes while unsupervised. C. Teach children not to talk to or go with a stranger. D. Teach children not to eat items found in the grass. A. Teach children proper techniques for specific sports. The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patients says she is looking for the bath- room. Which interventions are appropriate for this patient? (Select all that apply.) A. Ask the health care provider to order a restraint. B. Recommend insertion of a urinary catheter. C. Provide scheduled toileting rounds every 2 to 3 hours. D. Institute a routine exercise program for the patient. E. Keep the bed in high position with side rails down. F. Keep the pathway from the bed to the bathroom clear. C, D, and F Place the following steps for applying a wrist restraint in the correct order: A. Pad the skin overlying the wrist. B. Insert two fingers under the secured restraint to be sure that it is not too tight. C. Be sure that the patient is comfortable and in correct anatomical alignment. D. Secure restraint straps to bedframe with quick-release buckle. E. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly. C, A, E, B, D It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? A. Logging on to automated dispensing system (ADS) or unlock- ing medicine drawer or cart. B. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. C. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. D. Comparing MAR or computer printout with names of med- ications on medication labels and patient name at patient's bedside. B. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking ver- bal or telephone orders? (Select all that apply). A. Only authorized staff may receive and record verbal or tele- phone orders. The health care agency identifies in writing the staff who are authorized. B. Clearly identify patient's name, room number, and diagnosis. C. Read back all orders to health care provider. D. Use clarification questions to avoid misunderstandings. E. Write "VO" (verbal order) or "TO" (telephone order), includ- ing date and time, name of patient, and complete order; sign the name of the health care provider and nurse. A, B, C, D, and E A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment. A. Clean eye, washing from inner to outer canthus. B. Assess patient's level of consciousness and ability to follow instructions. C. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. D. Have patient close eye and rub lightly in a circular motion with a cotton ball. E. Ask patient to look at ceiling, and explain the steps to patient. B, A, E, C, D A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) A. Verifying tube placement after medications are given B. Mixing all medications together to give all at once C. Using an enteral tube syringe to administer medications D. Flushing tube with 30 to 60 mL of water after the last dose of medication E. Checking for gastric residual before giving the medications F. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given C, D, E, and F After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) A. Assess the injection site. B. Administer an oral medication for pain. C. Notify the patient's health care provider of assessment findings. D. Document assessment findings and related interventions in the patient's medical record. E. This is a normal finding, so nothing needs to be done. F. Apply ice to the site for relief of burning pain. A, C, and D The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) A. Heart disease B. Sepsis C. Hemorrhage D. Skin breakdown E. Diarrhea B, C, and D An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) A. Provide a dispensing system for each day of the week. B. Provide larger, easier-to-read labels. C. Tell the patient what is in each container. D. Have a family caregiver administer the medication. E. Use teach-back to ensure that the patient knows what medica- tion to take and when. A, B, and E The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) A. Serum total protein B. Potassium C. Lipids D. Albumin E. Serum BUN A and E The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? A. Suction her mouth and throat. B. Turn her on her side. C. Put on oxygen at 2 L nasal cannula. D. Stop feeding her. D. Stop feeding her. A client who is receiving parenteral nutrition (PN) through a cen- tral venous catheter (CVC) has an air embolus. What should be the nurse's priority action? A. Have the patient turn on the left side and perform a Valsalva maneuver. B. Clamp the intravenous (IV) tubing to prevent more air from entering the line. C. Have the patient take a deep breath and hold it. D. Notify the health care provider immediately. A. Have the patient turn on the left side and perform a Valsalva maneuver. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? A. When 25% of the patient's nutritional needs are met by the tube feedings B. When bowel sounds return C. When the central line has been in for 10 days D. When 75% of the patient's nutritional needs are met by the tube feedings D. When 75% of the patient's nutritional needs are met by the tube feedings A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? A. Assess bowel sounds. B. Raise the head of the bed to at least 45 degrees. C. Continue the feedings; this is normal gastric residual for this feeding. D. Hold the feeding until you talk to the primary care provider. C. Continue the feedings; this is normal gastric residual for this Which action can a nurse delegate to assistive personnel (AP)? A. Performing glucose monitoring every 6 hours on a patient B. Teaching the client about the need for enteral feeding C. Administering enteral feeding bolus after tube placement has been verified D. Evaluating the client's tolerance of the enteral feeding A. Performing glucose monitoring every 6 hours on a patient Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) A. Lift the patient's hips off the bed and slide the bedpan under the patient. B. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. C. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. D. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. E. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed. B and E Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) A. Increase fiber and fluids in the diet. B. Use a low-volume enema daily. C. Avoid gluten in the diet. D. Take laxatives twice a day. E. Exercise for 30 minutes every day. F. Schedule time to use the toilet at the same time every day. G. Take probiotics 5 times a week. A, E, and F Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) A. How to change the pouch B. How to empty the pouch C. How to open and close the pouch D. How to irrigate the colostomy E. How to determine whether the ostomy is healing appropriately A, B, C, and E Place the steps for an ileostomy pouch change in the correct order. 1 A. Close the end of the pouch. B. Measure the stoma. C. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. D. Press the pouch in place over the stoma. E. Remove the old pouch. F. Trace the correct measurement onto the back of the wafer. G. Assess the stoma and the skin around it. H. Cleanse and dry the peristomal skin. E, H, G, B, F, C, D, A Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) A. Change in bowel habits B. Blood in the stool C. A larger-than-normal bowel movement D. Fecal impaction E. Muscle aches F. Incomplete emptying of the colon G. Food particles in the stool H. Unexplained abdominal or back pain A, B, F, and G A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? A. Get three fecal smears from one bowel movement. B. Obtain one fecal smear from an early-morning bowel move- ment. C. Collect one fecal smear from three separate bowel movements. D. Get three fecal smears when you see blood in your bowel movement. C. Collect one fecal smear from three separate bowel movements. What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? A. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. B. Initiate bowel or habit training program to promote continence. C. Help the patient to toilet once every hour. D. Use sanitary pads in the patient's underwear. B. Initiate bowel or habit training program to promote continence. The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? A. A food allergy B. Irritable bowel syndrome C. Increased peristalsis D. Lactose intolerance D. Lactose intolerance A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? A. Have you eaten more high-fiber foods lately? B. Have you taken antibiotics recently? C. Do you have gluten intolerance? D. Have you experienced frequent, small liquid stools recently? D. Have you experienced frequent, small liquid stools recently? During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? A. Stop the instillation. B. Ask the patient to take deep breaths to decrease the pain. C. Tell the patient to bear down as he would when having a bowel movement. D. Continue the instillation; then administer a pain medication. A. Stop the instillation. Which statement made by the parents of a 2-month-old infant requires further education by the nurse? A. "I'll continue to use formula for the baby until he is at least a year old." B. "I'll make sure that I purchase iron-fortified formula." C. "I'll start feeding the baby cereal at 4 months." D. "I'm going to alternate formula with whole milk, starting next month." D. "I'm going to alternate formula with whole milk, starting next month."