RNSG 1216 Exam 1 Module Questions (Basic Skills, Mobility&Safety, Immunity&Safety) Solved 100%

A patient has been recently admitted to the hospital. What Infections, if observed, may suggest that the patient has dysphagia? - Answer 1. persistent drooling 2. change in voice after swallowing 3. Wet, gurgly voice In the change of shift report, the nurse was told a patient requires "minimal assistance with meals." What should the nurse expect to do for the patient at mealtime? - Answer packages and cartons. 2. assist the patient to an upright position 3. Ask the patient if he or she needs the nurse to cut up the food or butter the bread 4. document the intake A patient has sever rheumatoid arthritis affecting her hands. What measures can be taken to facilitate optimum nutrition? - Answer 1. determine the patients food preferences 2. provide adaptive utensils 3. attach a plate guard to the plate Which of the following are appropriate measure to help the patient with dysphagia to swallow and prevent aspiration? - Answer 1. add thickener to thin liquids 2. place the food on the unaffected side of the mouth 3. place the patient in high-Fowlers position 4. provide verbal coaching A hospitalized patient has repeatedly refused her meals. What should the nurse do? - Answer 1. determine the patients food preferences 2. determine whether the patient is in pain What are some examples of "verbal coaching" that can be used when feeding the adult dependent patient who has difficulty swallowing? - Answer 1. "open your mouth" 2. "raise your tongue to the roof of your mouth" 3. "Close your mouth and swallow" Where peristalsis moves food to the stomach - Answer Esophagus Receives enzymes from the gallbladder and pancreas to further break down chyme and absorbs nutrients - Answer Small intestine Secretes hydrochloric acid and pepsin; converts bolus of food to chyme - Answer stomach Absorbs, protects, secretes, eliminates - Answer colon Temporarily stores feces until elimination - Answer rectum If a patient had to have part of the colon removed, which of the following may result? - Answer The patient could experience an acid-base imbalance A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patients health history or admission assessment: - Answer 1. The patient is an elderly woman 2. the patient takes opioids for chronic back pain 3. the patient takes daily iron and calcium supplements A student nurse is studying Gi system in preparation for an exam. Which statement indicates correct understanding? - Answer "the ascending colon would be found in the right side of the patients abdomen" An increase in venous pressure caused by liver disease can result in the development of: - Answer Hemorrhoids A comatose patient in the ICU, who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect? - Answer Impaction The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe? - Answer A decrease in heart rate An adult patient is scheduled for an abdominal CT scan. Before the scan he must receive a cleansing tap water enema. The nurse should prepare: - Answer 1000 mL or less of tap water The HCP has ordered a Fleet enema for a patient experiencing constipation. Which of the following actions would require correction? - Answer The nurse squeezes and releases the bottle several times until all of the solution has entered the patient An adult patient complains of cramping during the admin. of an enema. What could be a possible cause? - Answer 1. the solution was instilled too rapidly 2. The enema solution was too cold Which of the following is the best example of documention of enema admin.? - Answer 0830 800 mL tap water enema administered. Return clear with no fecal material Bowel sounds present in all 4 quadrants pre and post procedure. Abdomen non-distended. Patient states "Im glad thats over." The nurse is observing the UAP admin. a soap suds enema to an adult patient. Which of the following actions, if made by the UAP, would require correction? - Answer The UAP inserts the rectal tube 5-7 inches after lubricating it A patient is to receive enemas "until clear." The nurse notes that stool remains in the fecal return after the second enema. What should the nurse do? - Answer Administer a third enema An infant is to have an enema. Which solution would the nurse anticipate using? - Answer Normal Saline The nurse is reviewing urinary catheter care with a newly UAP. Which statement made by the UAP indicates further instruction is needed? - Answer "The bedside drainage bag should only be emptied when it is full" The UAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the UAP did after application of clean gloves? - Answer stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? - Answer The patient's urine appears cloudy with a foul odor Identify the indicators of a UTI: - Answer fever, complaints of pain with urination, lower abdominal pain, cloudiness of the urine Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter? - Answer Gently aspirate the syringe plunger if water remains in the balloon. A patient had an indwelling catheter for 3 weeks. The patient had the catheters removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? - Answer "This is a normal occurrence after having a catheter in place for more than several days." If a patients indwelling catheter is removed at 0900, the patient should be due to void by: - Answer 1500 to 1700 (3:00 to 5:00 PM)