FUNDAMENTAL CONCEPTS AND SKILLS FOR NURSING

MULTIPLE CHOICE 1. The nurse is aware that for a drug to be effectively eliminated from the body, the patient must have a fluid intake of 50 mL/kg/day. The nurse would provide for a patient who weighs 125 pounds ______ mL of water per day. a. 1560 b. 899.2 c. 2840.9 d. 3039.1 ANS: C The patient’s weight is 125 pounds/2.2 pounds = 56.8 kg 50 mL = 2840.9 mL. DIF: Cognitive Level: Analysis REF: p. 627 OBJ: Theory #3 TOP: Distribution of Drugs KEY: Nursing Process Step: Pl...

MULTIPLE CHOICE 1. The nurse who is preparing to give a feeding per a nasogastric (NG) tube tests the placement of the tube most safely by: a. checking the lungs for rhonchi. b. instilling 10 mL of sterile water and checking for cough. c. aspirating stomach contents. d. injecting 20 mL of air and listen at the tip of the xiphoid. ANS: C The safest and most assured method to test for NG tube placement is to aspirate stomach contents and check fluid for pH. Using the air method is not...

MULTIPLE CHOICE 1. The mother of a 4-month old infant asks what type of cereal is most appropriate to feed the infant as a first solid food. The best response from the nurse is to suggest a. wheat. b. barley. c. corn. d. rice. ANS: D A cereal such as rice is the best initial choice, because it is easily tolerated, provides additional calories and iron, and is least likely to be allergenic. DIF: Cognitive Level: Comprehension REF: p. 474 OBJ: Theory #8 TOP: Nutritional Needs...

MULTIPLE CHOICE 1. An ambulatory clinic patient telephones to report diarrhea and to ask for advice on medication to manage it. The best response by the nurse is, “Do not use antidiarrheal medication for longer than: a. 24 hours without calling back for an appointment.” b. 48 hours without calling back for an appointment.” c. 72 hours without calling back for an appointment.” d. 96 hours without calling back for an appointment.” ANS: B Antidiarrheal medication should not ...

MULTIPLE CHOICE 1. A nurse is cleansing the perineal area of a female patient who is having a urinary catheter inserted. The nurse should use the last povidone iodine–soaked cotton ball to cleanse downward over the: a. urinary meatus. b. left labia. c. right labia. d. perirectal area. ANS: A The urinary meatus is cleansed after the labia on each side are cleansed. DIF: Cognitive Level: Comprehension REF: p. 557|Skill 29-3 OBJ: Clinical Practice #5 TOP: Catheterizing the Fem...

MULTIPLE CHOICE 1. A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should: a. apply suction while advancing the catheter into the airway. b. suction the nasotracheal passage after suctioning the mouth. c. hold the catheter with the dominant hand after donning sterile gloves. d. insert the nonlubricated catheter into the nasal passage. ANS: C The suction catheter should be held with the dominant hand after donning sterile...

MULTIPLE CHOICE 1. A patient who has questions about the availability of home health services after hospital discharge should be referred to the: a. primary care provider. b. registered nurse. c. occupational therapist. d. medical social worker (MSW). ANS: D An MSW can provide information about long-term planning, financial assistance, and community services available after discharge. DIF: Cognitive Level: Application REF: p. 404 OBJ: Clinical Practice #5 TOP: Discharge KEY...

MULTIPLE CHOICE 1. The nurse who is assessing the patient with the Glasgow Coma Scale finds a patient who can open his eyes spontaneously, obeys all commands, and is oriented. The nurse documents a score of: a. 7. b. 10. c. 12. d. 15. ANS: D The Glasgow Coma Scale is used for the evaluation of neurologically impaired patients: spontaneous eye opening = 4, obeying commands = 6, orientation = 5. This is the highest possible score of 15. DIF: Cognitive Level: Analysis REF: p. 396|...

MULTIPLE CHOICE 1. An older adult patient has a tympanic temperature of 96.2° F (35.7° C). What nursing intervention would best meet this patient’s need? a. Take the patient’s vital signs every 4 hours, including temperature. b. Provide fluids to increase circulation. c. Increase room temperature to 72° F (22.2° C) and add blankets to the bed. d. Check the temperature orally to confirm the accuracy of the reading. ANS: C Nursing interventions for treating hypothermia should...

MULTIPLE CHOICE 1. An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to: a. sit up. b. lie down. c. breathe through a re-breather mask. d. pant with mouth open. ANS: C Anxiety can lead to hyperventilation, causing respiratory alkalosis; the treatment is to have the patient breathe through a re-breather mask. In the home setting, the patient can be asked to breathe into a...