Nursing Exam 3 Questions and Answers (Latest Version) Guaranteed grade A.

Nursing Exam 3 Questions and Answers (Latest Version) Guaranteed grade A. The nurse is caring for a patient with pneumonia who has severe malnutrition. The nurse recognizes that, because of the nutritional status, the patient is at increased risk for: (Select all that apply.) 1. Heart disease 2. Sepsis 3. Pleural effusion 4. Cardiac arrhythmias 5. Diarrhea 2, 3, 4 The nurse evaluates which laboratory values to assess a patient's potential for wound healing? 1. Fluid status 2. Potassium 3. Lipids 4. Nitrogen balance 4 The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat 2. Turn her on her side 3. Put on oxygen at 2-L nasal cannula 4. Stop feeding her and place on NPO 4 A patient who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What would the nurse do first? 1. Have the patient perform a Valsalva maneuver 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line 3. Have the patient take a deep breath and hold it 4. Notify the health care provider immediately 1 A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request discontinuing parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings 4 The nurse is educating the patient and his family about the parenteral nutrition. Which aspect related to this form of nutrition would be appropriate to inculde? (Select all that apply.) 1. The purpose of the fat emulsion in parenteral nutrition is to prevent a deficiency in essential fatty acids 2. We can give you parenteral nutrition through your peripheral intravenous line to prevent further infection 3. The fat emulsion will help you control your hyperglycemia during periods of stress 4. The parenteral nutrition will help your wounds heal 5. Since we just started the parenteral nutrition, we will only infuse it at 50% of your daily needs for the next 6 hours 1, 3, 4 The nurse is inserting a small-bore nasoenteric tube before starting enteral feedings. Place the following steps in order to perform this procedure. 1. Place patient's head in high-Fowler's position 2. Have patient flex head towards chest 3. Assess patient's gag reflex 4. Determine length of the tube to be inserted 5. Obtain radiological confirmation of tube placement 6. Check pH of gastric aspirate for verifying placement 7. Identify patient with two identifiers 7, 1, 3, 4, 2, 5, 6 A patient's gastric residual volume was 250 mL at 0800 and 350 mL at 0900. What is the appropriate nursing action? 1. Assess bowel sounds 2. Raise the head of the bed to at least 45 degrees 3. Position the patient on his or her right side to promote stomach emptying 4. Do not reinstall aspirate and hold the feeding until you talk to the primary care provider 4 The nurse would delegate which of the following to nursing assistive personnel (NAP)? (Select all that apply.) 1. Repositioning and retaping a patient's nasogastric tube 2. Performing glucose monitoring every 6 hours on a patient 3. Documenting PO intake on a patient who is on a calorie count for 72 hours 4. Administering enteral feeding bolus after tube placement has been verified 5. Hanging a new bag of enteral feeding 2, 3 The patient's blood glucose level is 330 mg/dL. What is the priority nursing intervention? 1. Recheck by performing another blood glucose test 2. Call the primary health care provider 3. Check the medical record to see if there is a medication order for abnormal glucose levels 4. Monitor and recheck in 2 hours 3 Which statement made by a parent of a 2-month-old infant requires further education? 1. I'll continue to use formula for the baby until he is at least a year old 2. I'll make sure that I purchase iron-fortified formula 3. I'll start feeding the baby cereal at 4 months 4. I'm going to alternate formula with whole milk starting next month 4 The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) 1. Avoid grapefruit and grapefruit juice, which impair drug absorption 2. Increase the amount of carbohydrates for energy 3. Take a multivitamin that includes vitamin D for bone health 4. Cheese and eggs are good sources of protein 5. Limit fluids to decrease the risk of edema 1, 3, 4 The nurse sees the nursing assistive personnel (NAP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention? 1. Fastening tube to the gown with new tape 2. Placing the patient supine while giving a bath 3. Hanging a new container of enteral feeding 4. Ambulating patient with enteral feedings still infusing 2 A patient is receiving total parenteral nutrition (TPN). What is the primary intervention the nurse should follow to prevent a central line infection? 1. Institute isolation precautions 2. Clean the central line port through which the TPN is infusing with antiseptic 3. Change the TPN tubing ever 24 hours 4. Monitor glucose levels to watch and assess for glucose intolerance 2 Which patients are at a high risk for nutritional deficits? (Select all that apply.) 1. The divorced computer programmer who eats precooked food from the local restaurant 2. The middle-age female with celiac disease who does not follow her gluten-free diet 3. The 45-year-old patient with type II diabetes who monitors her carbohydrate intake and exercises regularly 4. The 25-year-old patient with Crohn's disease who follows a strict diet but does not take vitamins or iron supplements 5. The 65-year-old patient with gallbladder disease whose electrolyte, albumin, and protein levels are normal 2, 4 A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions 2. Instruct the patient that a full bladder is required for the test 3. Instruct the patient to save all urine in a special container 4. Ensure that informed consent has been obtained 5. Explain that the test includes instrumentation of the urinary tract 1, 4 When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine 2. Slightly cloudy urine 3. Light pink urine 4. Dark amber urine 3 What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline 2. Secure the catheter drainage tubing to the bed sheets 3. Advance the catheter to the bifurcation of the drainage and balloon ports 4. Advance the catheter until urine flows, then insert 1/4 inch more 3 Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube 2. Shaving the pubic area so hair does not adhere 3. Washing with soap and water before applying the condom-type catheter 4. Applying tape to the condom sheath to keep it securely in place 3 Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence 2. Expect patient complaints of suprapubic fullness and discomfort 3. Report the time and amount of first voiding 4. Instruct patient to stay in bed and use a urinal or bedpan 3 A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI 2. Assess the intake and output from system 3. Decrease the rate of the CBI 4. Assess vital signs 2 An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication 2. Start a scheduled toileting program 3. Recommend that she be evaluated for an indwelling catheter 4. Start a bladder-retraining program 2 What should the nurse teach a young woman with a history for urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular 2. Limit water intake to 1 to 2 glasses a day 3. Wear cotton underwear 4. Cleanse the perineum from front to back 5. Practice pelvic muscle exercise (Kegel) daily 1, 3, 4 Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine? 3 Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter 2. Lubricate catheter 3. Inflate catheter balloon 4. Cleanse urethral meatus with antiseptic solution 5. Drape patient with the sterile square and fenestrated drapes 6. When urine appears, advance another 2.5 to 5 cm 7. Prepare sterile field and supplies 8. Gently pull catheter until resistance is felt 9. Attach drainage tubing 5, 7, 2, 4, 1, 6, 3, 8, 9 The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? 1. Implement the "as-needed" order to irrigate the catheter 2. Assess the catheter and drainage tubing for obvious occlusion 3. Notify the health care provider immediately 4. Assess the vital signs and intake and output record 2 Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal 2, 3 What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding 2. Catheterize the patient 30 minutes after voiding 3. Bladder scan the patient when he or she reports a strong urge to void 4. Catheterize the patient with a 16 Fr/10 mL catheter 1 Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3.Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water 2 There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter 2. Leave the catheter there and start over with a new catheter 3. Pull the catheter back and reinsert at a different angle 4. Ask the patient to bear down and insert the catheter further 2 An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload 1, 2, 4 Which patients does a nurse plan to teach regarding water restriction? 1. A 23-year-old with extracellular fluid volume (ECV) deficit 2. A 34-year-old with hyponatremia 3. A 47-year-old with hypercalcemia 4. A 69-year-old with metabolic acidosis 2 A nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress 2. Monitor the patient's blood pressure 3. Aspirate the infusing fluid from the VAD 4. Stop the infusion and discontinue the intravenous infusion 4 When delegating input and output (I&O) measurement to nursing assistive personnel, a nurse instructs them to record what information for ice chips? 1. The total volume 2. Two-thirds of the volume 3. One-half of the volume 4. One-quarter of the volume 3 A nurse assesses four patients. Which patient has greatest risk for hypomagnesemia? 1. A 72-year-old with chronic alcoholism 2. A 79-year-old with bone cancer 3. A 41-year-old with hypernatremia 4. A 46-year-old with respiratory acidosis 1 Which assessment does a nurse interpret as a transfusion reaction? 1. Crackles in dependent lobes of the lungs 2. High fever, severe hypotension 3. Anxiety, itching, confusion 4. Chills, tachycardia, and flushing 4 What assessment does a nurse make before hanging an intravenous (IV) fluid that contains potassium? 1. Urine output 2. Arterial blood gas 3. Fullness of neck veins 4. Level of consciousness 1 The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does a nurse program into the infusion pump? 1. 125 mL/hr 2. 167 mL/hr 3. 200 mL/hr 4. 1000 mL/hr 1 An older-adult patient is receiving intravenous (IV) 0.9% NaCl. A nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider 2. Record in medical record 3. Decrease the IV flow rate 4. Discontinue the IV site 3 Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves 2. Explain procedure to patient 3. Remove IV site dressing and tape 4. Use two identifiers to ensure correct patient 5. Stop the infusion and clamp the tubing 6. Carefully check the health care provider's order 7. Clean the site, withdraw the catheter, and apply pressure 6, 4, 0, 2, 1, 5, 3, 7 A patient has severe hypercalcemia. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increases fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights 1, 3, 4 A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights 1, 4 A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH, 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3-, 24. The nurse interprets these laboratory values to indicate: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 3 What assessment does a nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Presence or absence of edema 3. Fullness of neck veins when supine 4. Fullness of veins when upright 3 A patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis 4 When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special be linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ishcemic episode 4 Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full-thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid. 1a, 2d, 3b, 4c We have an expert-written solution to this problem! When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound 4 After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the surgeon 2. Allow the area to be exposed to air until all drainage has stopped 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately 5. Cover the area with sterile gauze and apply an abdominal binder 1, 4 What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound 2. Attach 19-gauge angiocatheter to syringe 3. Fill syringe with irrigation fluid 4. Place waterproof bag near bed 5. Position angiocatheter over wound 4, 3, 2, 5, 1 For a patient who has a muscle sprain, localized hemmorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing 2 Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment 1, 4, 6 Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface 4 Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal would? (Select all that apply.) 1. Collection of would drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of stress on the abdominal when coughing or walking 4. Reduction of abdominal swelling 5. Reduction of stress on the abdominal incision 6. Stimulation of peristalsis (return of bowel function) from direct pressure 2, 4 When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect any bony prominences from pressure ulcers 5. To immobilize area 1, 3 What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization 1 Name the three important dimensions to consistently measure to determine wound healing. Width, length, and depth What does the Braden scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing 2 On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage II 2. Category/stage IV 3. Unstageable 4. Suspected deep-tissue damage 3 Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have a head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine 1, 3, 5