FOUNDATIONS AND ADULT HEALTH NURSING

MULTIPLE CHOICE 1. The nurse cautions a patient with a pancreatic disorder that the disorder will interfere with the digestion of fats and may lead to a clotting disorder. What is the cause of these potential problems? a. Inability to use vitamin B b. Inability to use vitamin C c. Inability to use vitamin D d. Inability to use vitamin K ANS: D Vitamins A, D, E, and K are fat-soluble. Difficulty with fat metabolism will result in the inability to use fat-soluble vitamins. Vitamin K p...

MULTIPLE CHOICE 1. During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis ANS: B Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. DIF: Cognitive Level: Knowledge REF: p. 314 OBJ: 13 TOP: Assessment KEY: Nursing Process Step: Assessment MS...

MULTIPLE CHOICE 1. A farm worker who has been kicked in the stomach by a mule passes a foul, black, tarry stool. What is this called? a. Loose stool b. Melena c. Hematuria d. Hemoptysis ANS: B When internal bleeding occurs, the patient may demonstrate hemoptysis (bloody sputum), hematemesis (bloody vomit), melena (foul black tarry stool), or hematuria (bloody urine). DIF: Cognitive Level: Knowledge REF: p. 406 OBJ: 2 TOP: Melena KEY: Nursing Process Step: Assessment MSC: NC...

MULTIPLE CHOICE 1. During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse? a. Withdraw the catheter. b. Ask the patient to bear down. c. Continue to inflate the balloon. d. Advance the catheter into the bladder. ANS: D Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation. DIF: Cognitive Level: Application ...

MULTIPLE CHOICE 1. The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff? a. Prevent regurgitation after meals. b. Hold the trachea open until it is completely healed. c. Dilate the tracheal opening for passage of secretions. d. Prevent aspiration when eating. ANS: D The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube. DIF: Cognitive Level: Analysis REF: ...

MULTIPLE CHOICE 1. How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter? a. At least once a day b. At least twice a day c. At bedtime d. Each shift ANS: B Catheter care should be performed at least two times daily. DIF: Cognitive Level: Comprehension REF: p. 214 OBJ: 8 TOP: Catheter care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to perform perineal care for...

MULTIPLE CHOICE 1. What site should be selected if a peripheral pulse needs to be assessed quickly? a. Radial pulse b. Brachial pulse c. Carotid pulse d. Pedal pulse ANS: C The carotid site is the best for finding a pulse quickly. DIF: Cognitive Level: Application REF: p. 293 OBJ: 5 TOP: Carotid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level...

MULTIPLE CHOICE 1. Upon admission, the nurse notes that a patient without family members present has a billfold filled with cash. Where can the nurse suggest the money be placed? a. In a sealed envelope in the bedside table b. In the care of hospital security c. Locked in the narcotic cupboard d. In the hospital safe ANS: D Valuables should be locked in the hospital safe. DIF: Cognitive Level: Application REF: p. 263 OBJ: 6 TOP: Care of valuables KEY: Nursing Process Step:...

MULTIPLE CHOICE 1. What should the nurse do when offering a cup of hot coffee to a frail, older adult patient? a. Give the patient a straw. b. Dilute the coffee with cold water. c. Fill the cup half full. d. Offer a bib or an apron. ANS: C Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron. DIF: Cognitive Level: Application REF: p. 236 | p. 237 | p. 241 OBJ: 2 ...

MULTIPLE CHOICE 1. What assists the nurse in the identification of patient problems? a. Objective data b. Subjective data c. Data clustering d. Validated data ANS: C Data clustering assists the nurse in determining patient problems. DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 4 TOP: Patient problem KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 2. What organized approach might the nurse use when performing a complete physical examination? a. Maslow’s h...