NUR 518 Clinical Essentials Exam Questions With
Correct Answers
1. When |caring |for |a |patient |receiving |oxygen |by |nasal |cannula, |which |of |the
|following |is |a |priority |to |help |maintain |good |skin |integrity?
A. Frequently |applying |moisturizing |lotion |to |facial |areas |that |come |into |contact
|with |the |cannula.
B. Removing |the |cannula |every |2 |hours |for |no |longer |than |10 |minutes.
C. Assessing |the |patient's |external |ears, |nares, |and |nasal |mucosa |for |breakdown |at
|least |once |per |shift.
D. Instructing |the |patient |to |inform |staff |of |any |problems |with |facial |dryness |or
|cracking. |- |ANSWER C. |Assessing |the |patient's |external |ears, |nares, |and |nasal
|mucosa |for |breakdown |at |least |once |per |shift.
Rationale: |Frequent |assessment |is |a |priority |and |will |help |the |nurse |identify |early
|signs |of |skin |breakdown. |Although |applying |lotion |is |appropriate, |this |option |is |not
|the |best |way |to |maintain |good |skin |integrity. |It |may |not |be |appropriate |to |remove
|the |cannula |in |a |patient |for |whom |oxygen |therapy |has |been |ordered. |The |patient
|may |be |unaware |of |facial |skin |areas |that |are |dry |or |cracking.
2. When |caring |for |a |patient |who |is |receiving |oxygen |by |simple |face |mask, |which
|action |ensures |that |the |rate |of |oxygen |being |delivered |is |appropriate?
A. Frequently |asking |the |patient |how |he |or |she |is |breathing.
B. Ensuring |that |the |oxygen |tubing |is |pulled |tight, |with |little |or |no |slack.
C. Securing |the |oxygen |tubing |to |the |patient's |clothing |to |prevent |tugging.
D. Assessing |for |proper |placement |of |the |mask |on |the |patient's |face. |- |ANSWER
D. |Assessing |for |proper |placement |of |the |mask |on |the |patient's |face.
Rationale: |Monitoring |placement |of |the |cannula |tips |helps |ensure |that |the |patient
|receives |the |oxygen |prescribed. |Asking |the |patient |if |he |or |she |is |having |trouble
|breathing |does |not |address |oxygen |delivery. |Oxygen |tubing |should |not |be |pulled
|tight. |There |should |be |enough |slack |in |the |tubing |to |allow |the |patient |to |turn |his |or
|her |head |comfortably. |Securing |the |oxygen |tubing |to |keep |the |patient |from |pulling
|out |the |cannula |does |not |address |oxygen |delivery.
When |caring |for |a |patient |for |whom |oxygen |by |nonrebreathing |mask |has |been
,ordered, |which |action |ensures |appropriate |oxygen |delivery?
A. |Looping |the |oxygen |tubing |around |the |side |rail |of |the |bed
B. |Assessing |breath |sounds |every |shift
C. |Securing |the |tubing |snugly |to |the |patient's |gown
D. |Assessing |that |the |reservoir |bag |stays |inflated |- |ANSWER D. |Assessing |that |the
|reservoir |bag |stays |inflated
Rationale: |A |mask |that |fits |properly |will |deliver |the |prescribed |amount |of |oxygen.
|The |oxygen |tubing |should |not |be |looped |around |the |side |rail |of |the |bed. |Assessing
|breath |sounds |does |not |ensure |that |the |oxygen |is |being |delivered |appropriately.
The |tubing |should |have |some |slack |so |that |the |patient |can |move |his |or |her |head.
When |caring |for |a |patient |who |is |receiving |supplemental |oxygen |by |face |tent, |which
|action |ensures |that |the |oxygen |is |flowing?
A. |Testing |the |closing |capacity |of |the |mask's |valves
B. |Routinely |monitoring |the |seal |over |the |patient's |mouth |and |nose
C. |Ensuring |that |a |mist |is |always |present
D. |Regularly |verifying |that |the |mask |is |positioned |loosely |- |ANSWER C. |Ensuring
|that |a |mist |is |always |present
Rationale: |It |is |appropriate |to |ensure |that |a |mist |is |always |present |when |oxygen |is
|delivered |by |face |tent. |Testing |the |closing |capacity |of |the |mask's |valves |is
|appropriate |only |for |a |nonrebreathing |mask. |Monitoring |the |seal |over |the |patient's
|mouth |and |nose |is |appropriate |only |for |a |nonrebreathing |mask. |Such |an |assessment
|is |appropriate, |but |correct |positioning |of |the |mask |does |not |indicate |that |oxygen |is
|flowing |from |it.
What |would |the |nurse |do |when |receiving |an |order |to |increase |the |delivery |rate |of |a
|patient's |oxygen |per |nasal |cannula |from |1 |L/min |to |3 |L/min?
A. |Encourage |the |patient |to |take |deeper |breaths |in |order |to |get |more |oxygen
B. |Change |the |device |from |nasal |cannula |to |simple |face |mask
,C. |Ensure |that |humidification |is |present
D. |Adjust |the |float |ball |on |the |flow |meter |to |3 |L/min |- |ANSWER D. |Adjust |the
|float |ball |on |the |flow |meter |to |3 |L/min
Rationale: |The |nurse |would |increase |the |flow |rate |by |moving |the |ball |on |the |oxygen
|delivery |system |from |1 |L/min |to |3 |L/min. |Taking |deeper |breaths |will |not |change |the
|flow |rate |from |1 |L/min |to |3 |L/min. |There |is |no |need |to |change |the |delivery |device.
|The |provider |has |ordered |oxygen |to |be |administered |per |nasal |cannula, |not |per
|simple |face |mask. |If |the |flow |rate |of |oxygen |is |4 |L/min |or |higher, |humidification |is
|added. |Oxygen |delivered |at |the |rate |of |3 |L/min |need |not |be |humidified.
A |patient |who |had |surgery |yesterday |has |the |initial |dressing |covering |the |surgical
|site. |What |is |the |nurse's |responsibility |in |assessing |this |patient's |wound?
A. |Remove |the |dressing, |inspect |the |wound, |and |reapply |a |new |dressing.
B. |Inspect |the |wound |and |reapply |the |surgical |dressing |every |2 |hours.
C. |Inspect |the |wound, |and |keep |the |dressing |off |until |the |health |care |provider
|arrives.
D. |Wait |until |the |health |care |provider |orders |the |removal |of |the |surgical |dressing. |-
|ANSWER D. |Wait |until |the |health |care |provider |orders |the |removal |of |the |surgical
|dressing.
Rationale: |The |nurse |would |want |to |wait |until |the |provider |orders |the |dressing |to |be
|removed |to |ensure |that |the |initial |dressing |is |ready |to |come |off. |The |nurse |would
|not |remove |an |initial |surgical |dressing |for |direct |wound |inspection |until |the |health
|care |provider |has |written |an |order |for |its |removal.
Which |wound |would |be |allowed |to |heal |by |secondary |intention?
A. |Cleft |lip |repair
B. |Infected |hysterectomy |incision
, C. |Exploratory |laparoscopy |incision
D. |Facial |laceration |caused |by |a |pocket |knife |- |ANSWER B. |Infected |hysterectomy
|incision
Rationale: |The |infected |hysterectomy |incision |would |heal |by |secondary |intention
|because |it |is |an |infected |surgical |wound. |The |cleft |lip |repair |and |the |exploratory
|laparoscopy |incision |would |heal |by |primary |intention |because |they |were |created
|during |a |surgical |procedure. |The |facial |laceration |caused |by |a |pocket |knife |would
|heal |by |primary |intention, |since |there |is |no |tissue |loss.
Before |performing |a |wound |assessment, |which |nursing |action |would |reduce |the
|patient's |risk |for |infection?
A. |Taking |the |patient's |temperature
B. |Applying |clean |gloves
C. |Assessing |the |wound |for |drainage
D. |Assessing |the |dressing |for |drainage |- |ANSWER B. |Applying |clean |gloves
Rationale: |Wearing |clean |gloves |would |reduce |the |risk |for |infection |when
|removing |an |old |dressing. |Measuring |the |patient's |temperature |could |identify |an
|infection |but |would |not |reduce |the |patient's |risk |for |infection. |Assessing |the
|wound |and |dressing |for |drainage |would |not |affect |the |patient's |risk |for |infection.
Which |intervention |can |the |nurse |delegate |to |nursing |assistive |personnel |(NAP) |in
|caring |for |a |patient |with |a |wound?
A. |Assessing |the |site |for |signs |of |redness |or |swelling
B. |Reporting |the |presence |of |wound |odor
C. |Removing |a |soiled |outer |dressing
D. |Opening |sterile |dressings |during |the |dressing |change |- |ANSWER B. |Reporting
|the |presence |of |wound |odor
Rationale: |The |task |of |reporting |the |presence |of |odor |in |the |area |of |the |wound |may |be
|delegated |to |NAP. |Wound |assessment |may |not |be |delegated |to |NAP. |NAP |are |not
|permitted |to |remove |a |wound |dressing |or |to |participate |in |setting |up |a |sterile
Correct Answers
1. When |caring |for |a |patient |receiving |oxygen |by |nasal |cannula, |which |of |the
|following |is |a |priority |to |help |maintain |good |skin |integrity?
A. Frequently |applying |moisturizing |lotion |to |facial |areas |that |come |into |contact
|with |the |cannula.
B. Removing |the |cannula |every |2 |hours |for |no |longer |than |10 |minutes.
C. Assessing |the |patient's |external |ears, |nares, |and |nasal |mucosa |for |breakdown |at
|least |once |per |shift.
D. Instructing |the |patient |to |inform |staff |of |any |problems |with |facial |dryness |or
|cracking. |- |ANSWER C. |Assessing |the |patient's |external |ears, |nares, |and |nasal
|mucosa |for |breakdown |at |least |once |per |shift.
Rationale: |Frequent |assessment |is |a |priority |and |will |help |the |nurse |identify |early
|signs |of |skin |breakdown. |Although |applying |lotion |is |appropriate, |this |option |is |not
|the |best |way |to |maintain |good |skin |integrity. |It |may |not |be |appropriate |to |remove
|the |cannula |in |a |patient |for |whom |oxygen |therapy |has |been |ordered. |The |patient
|may |be |unaware |of |facial |skin |areas |that |are |dry |or |cracking.
2. When |caring |for |a |patient |who |is |receiving |oxygen |by |simple |face |mask, |which
|action |ensures |that |the |rate |of |oxygen |being |delivered |is |appropriate?
A. Frequently |asking |the |patient |how |he |or |she |is |breathing.
B. Ensuring |that |the |oxygen |tubing |is |pulled |tight, |with |little |or |no |slack.
C. Securing |the |oxygen |tubing |to |the |patient's |clothing |to |prevent |tugging.
D. Assessing |for |proper |placement |of |the |mask |on |the |patient's |face. |- |ANSWER
D. |Assessing |for |proper |placement |of |the |mask |on |the |patient's |face.
Rationale: |Monitoring |placement |of |the |cannula |tips |helps |ensure |that |the |patient
|receives |the |oxygen |prescribed. |Asking |the |patient |if |he |or |she |is |having |trouble
|breathing |does |not |address |oxygen |delivery. |Oxygen |tubing |should |not |be |pulled
|tight. |There |should |be |enough |slack |in |the |tubing |to |allow |the |patient |to |turn |his |or
|her |head |comfortably. |Securing |the |oxygen |tubing |to |keep |the |patient |from |pulling
|out |the |cannula |does |not |address |oxygen |delivery.
When |caring |for |a |patient |for |whom |oxygen |by |nonrebreathing |mask |has |been
,ordered, |which |action |ensures |appropriate |oxygen |delivery?
A. |Looping |the |oxygen |tubing |around |the |side |rail |of |the |bed
B. |Assessing |breath |sounds |every |shift
C. |Securing |the |tubing |snugly |to |the |patient's |gown
D. |Assessing |that |the |reservoir |bag |stays |inflated |- |ANSWER D. |Assessing |that |the
|reservoir |bag |stays |inflated
Rationale: |A |mask |that |fits |properly |will |deliver |the |prescribed |amount |of |oxygen.
|The |oxygen |tubing |should |not |be |looped |around |the |side |rail |of |the |bed. |Assessing
|breath |sounds |does |not |ensure |that |the |oxygen |is |being |delivered |appropriately.
The |tubing |should |have |some |slack |so |that |the |patient |can |move |his |or |her |head.
When |caring |for |a |patient |who |is |receiving |supplemental |oxygen |by |face |tent, |which
|action |ensures |that |the |oxygen |is |flowing?
A. |Testing |the |closing |capacity |of |the |mask's |valves
B. |Routinely |monitoring |the |seal |over |the |patient's |mouth |and |nose
C. |Ensuring |that |a |mist |is |always |present
D. |Regularly |verifying |that |the |mask |is |positioned |loosely |- |ANSWER C. |Ensuring
|that |a |mist |is |always |present
Rationale: |It |is |appropriate |to |ensure |that |a |mist |is |always |present |when |oxygen |is
|delivered |by |face |tent. |Testing |the |closing |capacity |of |the |mask's |valves |is
|appropriate |only |for |a |nonrebreathing |mask. |Monitoring |the |seal |over |the |patient's
|mouth |and |nose |is |appropriate |only |for |a |nonrebreathing |mask. |Such |an |assessment
|is |appropriate, |but |correct |positioning |of |the |mask |does |not |indicate |that |oxygen |is
|flowing |from |it.
What |would |the |nurse |do |when |receiving |an |order |to |increase |the |delivery |rate |of |a
|patient's |oxygen |per |nasal |cannula |from |1 |L/min |to |3 |L/min?
A. |Encourage |the |patient |to |take |deeper |breaths |in |order |to |get |more |oxygen
B. |Change |the |device |from |nasal |cannula |to |simple |face |mask
,C. |Ensure |that |humidification |is |present
D. |Adjust |the |float |ball |on |the |flow |meter |to |3 |L/min |- |ANSWER D. |Adjust |the
|float |ball |on |the |flow |meter |to |3 |L/min
Rationale: |The |nurse |would |increase |the |flow |rate |by |moving |the |ball |on |the |oxygen
|delivery |system |from |1 |L/min |to |3 |L/min. |Taking |deeper |breaths |will |not |change |the
|flow |rate |from |1 |L/min |to |3 |L/min. |There |is |no |need |to |change |the |delivery |device.
|The |provider |has |ordered |oxygen |to |be |administered |per |nasal |cannula, |not |per
|simple |face |mask. |If |the |flow |rate |of |oxygen |is |4 |L/min |or |higher, |humidification |is
|added. |Oxygen |delivered |at |the |rate |of |3 |L/min |need |not |be |humidified.
A |patient |who |had |surgery |yesterday |has |the |initial |dressing |covering |the |surgical
|site. |What |is |the |nurse's |responsibility |in |assessing |this |patient's |wound?
A. |Remove |the |dressing, |inspect |the |wound, |and |reapply |a |new |dressing.
B. |Inspect |the |wound |and |reapply |the |surgical |dressing |every |2 |hours.
C. |Inspect |the |wound, |and |keep |the |dressing |off |until |the |health |care |provider
|arrives.
D. |Wait |until |the |health |care |provider |orders |the |removal |of |the |surgical |dressing. |-
|ANSWER D. |Wait |until |the |health |care |provider |orders |the |removal |of |the |surgical
|dressing.
Rationale: |The |nurse |would |want |to |wait |until |the |provider |orders |the |dressing |to |be
|removed |to |ensure |that |the |initial |dressing |is |ready |to |come |off. |The |nurse |would
|not |remove |an |initial |surgical |dressing |for |direct |wound |inspection |until |the |health
|care |provider |has |written |an |order |for |its |removal.
Which |wound |would |be |allowed |to |heal |by |secondary |intention?
A. |Cleft |lip |repair
B. |Infected |hysterectomy |incision
, C. |Exploratory |laparoscopy |incision
D. |Facial |laceration |caused |by |a |pocket |knife |- |ANSWER B. |Infected |hysterectomy
|incision
Rationale: |The |infected |hysterectomy |incision |would |heal |by |secondary |intention
|because |it |is |an |infected |surgical |wound. |The |cleft |lip |repair |and |the |exploratory
|laparoscopy |incision |would |heal |by |primary |intention |because |they |were |created
|during |a |surgical |procedure. |The |facial |laceration |caused |by |a |pocket |knife |would
|heal |by |primary |intention, |since |there |is |no |tissue |loss.
Before |performing |a |wound |assessment, |which |nursing |action |would |reduce |the
|patient's |risk |for |infection?
A. |Taking |the |patient's |temperature
B. |Applying |clean |gloves
C. |Assessing |the |wound |for |drainage
D. |Assessing |the |dressing |for |drainage |- |ANSWER B. |Applying |clean |gloves
Rationale: |Wearing |clean |gloves |would |reduce |the |risk |for |infection |when
|removing |an |old |dressing. |Measuring |the |patient's |temperature |could |identify |an
|infection |but |would |not |reduce |the |patient's |risk |for |infection. |Assessing |the
|wound |and |dressing |for |drainage |would |not |affect |the |patient's |risk |for |infection.
Which |intervention |can |the |nurse |delegate |to |nursing |assistive |personnel |(NAP) |in
|caring |for |a |patient |with |a |wound?
A. |Assessing |the |site |for |signs |of |redness |or |swelling
B. |Reporting |the |presence |of |wound |odor
C. |Removing |a |soiled |outer |dressing
D. |Opening |sterile |dressings |during |the |dressing |change |- |ANSWER B. |Reporting
|the |presence |of |wound |odor
Rationale: |The |task |of |reporting |the |presence |of |odor |in |the |area |of |the |wound |may |be
|delegated |to |NAP. |Wound |assessment |may |not |be |delegated |to |NAP. |NAP |are |not
|permitted |to |remove |a |wound |dressing |or |to |participate |in |setting |up |a |sterile
