1. Which intervention is appropriate for a patient with an indwelling (Foley) catheter?

    D) Maintain a closed drainage system.
  2. The nurse provides discharge teaching for a patient who is going home with a new colostomy.  The patient asks the nurse how to clean the ostomy.  Which instruction is appropriate?

    A) Clean with a washcloth and warm tap water.
  3. Which fluid should the nurse use to administer an enema to an infant?

    A) normal saline
  4. The nurse should expect to test the urine of a patient with uncontrolled diabetes mellitus for which product?

    C) ketone bodies
  5. The RN is observing a new graduate nurse applying an external catheter to a male patient.  Which action indicates that the graduate nurse is performing the procedure incorrectly?

    B) applies the external catheter directly over the tip of the penis.
  6. A patient with impaired kidney function should avoid which type of cathartic?

    C) saline
  7. An appropriate nursing intervention for a patient experiencing flatulence is to have the patient restrict which activity?

    B) drinking through straws
  8. Which statement from a patient's history represents an increased risk for constipation?

    A) "I drink two glasses of water a day."
  9. When performing a digital removal of fecal impaction, the nurse should periodically assess the patient for which response?

    C) change in pulse rate
  10. A nurse identifies the nursing diagnosis "altered patterns of urinary elimination: frequency related to UTI" as being appropriate for the client who was diagnosed with a UTI. Which client outcome would demonstrate that this problem has been resolved?

    C) normal voiding pattern
  11. A patient complains of nausea, has a distended abdomen, is passing liquid stool, but has had no formed bowel movement in three days.  The nurse should assess the patient for which problem?

    C) fecal impaction
  12. What altered elimination pattern is most likely affecting a patient who experiences a  small loss of urine upon coughing, sneezing, or laughing?

    C) stress incontinence
  13. A patient complains of feeling bloated.  The nursing assessment reveals that the patient last had a small, formed stool four days ago.  The patient reports normally having a soft, formed bowel movement each morning. Based on this data, which nursing diagnosis is most appropriate?

    C) constipation
  14. Which food should the nurse include when selection a menu for a school age child who is at risk for constipation?

    A) popcorn
  15. Which diagnostic study is used to determine the  presence of occult blood in a patient's stool?

    D) guaiac
  16. Which question by the nurse should most effectively elicit information about the quality of a patient's sleep?

    D) "Do you feel rested today?"
  17. Which is characteristic of rapid eye movement (REM) sleep?

    C) depressed muscle tone
  18. Which is a clinical manifestation of sleep deprivation?

    D) excitability
  19. When implementing a discharge plan for a patient with insomnia, the nurse should discourage the patient from which practice?

    A) drinking several glasses of wine before going to bed.
  20. The nurse employs measures at bedtime to induce sleep in a patient who is experiencing a sleep pattern disturbance.  Under what circumstances should the nurse modify the plan of care?

    C) The patient awakens in the morning complaining of fatigue.
  21. Which observation indicates that a patient is responding positively to oxygen therapy?

    D) eupnea
  22. Which instruction should the nurse include when teaching a patient pursed-lip breathing?

    D) Inhale through the nose and exhale through pursed lips.
  23. What changes related to the respiratory system should the nurse anticipate in the older adult?

    D) decreased mucociliary clearance
  24. Which statement by the LPN/LVN indicates the need for in-service education about oxygen delivery?

    A) "A simple face mask should be used to deliver oxygen to 2 to 3 L/min.
  25. The nurse is performing postural drainage on a patient who is confused and has difficulty hearing.  The patient does not cough when instructed to cough.  Which action should the nurse implement next?

    C) Perform nasal tracheal suctioning.
  26. Which early sign should the nurse expect to assess in a client experiencing hypoxia?

    B) confusion
  27. Which person will have the lowest respiratory rate?

    C) the person who is waiting in the cold for a bus.
  28. Which laboratory finding should the nurse expect for a patient who develops polycythemia secondary to chronic hypoxia?

    D) increased hematocrit
  29. Which type of respiration accompanies metabolic acidosis?

    C) Kussmaul's
Card Set
Excelsior N105 Form B