EXN105B

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  1. Which intervention is appropriate for a patient with an indwelling (Foley) catheter?
    A) Use Betadine antiseptic for routine catheter care.
    B) Place the drainage bag at the level of the bladder.
    C) Empty the drainage bag once every 24 hours.
    D) Maintain a closed drainage system.
    D) Maintain a closed drainage system.
    (this multiple choice question has been scrambled)
  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 sterile gauze and betadine.
    B) Clean with a washcloth and warm tap water.
    C) Scrub with a washcloth and deodorant soap.
    D) Scrub with gauze and hydrogen peroxide.
    B) Clean with a washcloth and warm tap water.
    (this multiple choice question has been scrambled)
  3. Which fluid should the nurse use to administer an enema to an infant?
    A) normal saline
    B) tap water
    C) mineral oil
    D) castile soap
    A) normal saline
    (this multiple choice question has been scrambled)
  4. The nurse should expect to test the urine of a patient with uncontrolled diabetes mellitus for which product?
    A) occult blood
    B) ketone bodies
    C) specific gravity
    D) urinary pH
    B) ketone bodies
    (this multiple choice question has been scrambled)
  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?
    A) thoroughly washes and dries the genital area.
    B) applies the external catheter directly over the tip of the penis.
    C) attaches the urinary drainage bag to the leg.
    D) positions the patient in a bed-sitting position.
    B) applies the external catheter directly over the tip of the penis.
    (this multiple choice question has been scrambled)
  6. A patient with impaired kidney function should avoid which type of cathartic?
    A) stimulant
    B) emollient
    C) saline
    D) bulk-forming
    C) saline
    (this multiple choice question has been scrambled)
  7. An appropriate nursing intervention for a patient experiencing flatulence is to have the patient restrict which activity?
    A) drinking through straws
    B) consuming hot tea
    C) sucking hard candies
    D) eating spicy foods
    A) drinking through straws
    (this multiple choice question has been scrambled)
  8. Which statement from the patient's history represents an increased risk for constipation?
    A) "I drink two glasses of water a day."
    B) "I walk on mile three times a week."
    C) "I eat fruits but don't like vegetables."
    D) "I have a bowel movement every two or three days."
    A) "I drink two glasses of water a day."
    (this multiple choice question has been scrambled)
  9. When performing a digital removal of fecal impaction, the nurse should periodically assess the patient for which response?
    A) complaints of rectal discomfort
    B) complaints of flatulence
    C) change in pulse rate
    D) blood in the feces
    C) change in pulse rate
    (this multiple choice question has been scrambled)
  10. A nurse identifies the nursing diagnosis "altered pattern 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?
    A) absence of edema
    B) normal voiding pattern
    C) normal temperature
    D) absence of pain
    B) normal voiding pattern
    (this multiple choice question has been scrambled)
  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?
    A) constipation
    B) fecal incontinence
    C) fecal impaction
    D) diarrhea
    C) fecal impaction
    (this multiple choice question has been scrambled)
  12. What altered elimination pattern is most likely affecting a patient who experiences a small loss of urine upon coughing, sneezing, or laughing?
    A) urge incontinence
    B) functional incontinence
    C) stress incontinence
    D) reflex incontinence
    C) stress incontinence
    (this multiple choice question has been scrambled)
  13. A patient complains of feeling bloated. The nurse 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?
    A) self-care deficit, toileting
    B) pain
    C) constipation
    D) perceived constipation
    C) constipation
    (this multiple choice question has been scrambled)
  14. Which food should the nurse include when selecting a menu for a school age child who is at risk for constipation?
    A) cheese
    B) popcorn
    C) bananas
    D) rice
    B) popcorn
    (this multiple choice question has been scrambled)
  15. Which diagnostic study is used to determine the presence of occult blood in a patient's stool?
    A) bilirubin test
    B) colonoscopy
    C) checking the melena
    D) guaiac
    D) guaiac
    (this multiple choice question has been scrambled)
  16. Which question by the nurse should most effectively elicit information about the quality of a patient's sleep?
    A) "Do you take a nap often?"
    B) "Do you have trouble getting to sleep?"
    C) "Do you dream a lot?"
    D) "Do you feel rested today?"
    D) "Do you feel rested today?"
    (this multiple choice question has been scrambled)
  17. Which is characteristic of rapid eye movement (REM) sleep?
    A) slow, regular respirations
    B) depressed muscle tone
    C) decreased brain metabolism
    D) dilated peripheral blood vessels
    B) depressed muscle tone
    (this multiple choice question has been scrambled)
  18. Which is a clinical manifestation of sleep deprivation?
    A) precise speech
    B) intense concentration
    C) excitability
    D) animated facial expression
    C) excitability
    (this multiple choice question has been scrambled)
  19. When implementing a discharge plan for a patient with insomnia, the nurse should discourage the patient from which practice?
    A) taking a warm bath before going to bed.
    B) drinking several glasses of wine before going to bed.
    C) exercising one or two hours before going to bed.
    D) eating a light bedtime snack of cheese, crackers, and milk
    B) drinking several glasses of wine before going to bed.
    (this multiple choice question has been scrambled)
  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?
    A) The patient awakens feeling rested, but requires a nap in the day.
    B) The patient experiences pain on awakening in the morning.
    C) The patient awakens in the morning complaining of fatigue.
    D) The patient awakens after having slept eight hours.
    C) The patient awakens in the morning complaining of fatigue.
    (this multiple choice question has been scrambled)
  21. Which observation indicates that a patient is responding positively to oxygen therapy?
    A) dyspnea
    B) orthopnea
    C) eupnea
    D) hyperpnea
    C) eupnea
    (this multiple choice question has been scrambled)
  22. Which instruction should the nurse include when teaching a patient pursed-lip breathing?
    A) Inhale through the nose, keeping the lips pursed.
    B) Inhale through the nose and exhale through pursed lips
    C) Inhale and exhale through pursed lips.
    D) Inhale through the mouth and exhale through pursed lips.
    B) Inhale through the nose and exhale through pursed lips.
    (this multiple choice question has been scrambled)
  23. What changes related to the respiratory system should the nurse anticipate in the older adult?
    A) increased elastic recoil
    B) decreased size of alveoli
    C) increased chest wall compliance
    D) decreased mucociliary clearance
    D) decreased mucociliary clearance
    (this multiple choice question has been scrambled)
  24. Which statement by the LPN/LVN indicates the need for in-service education about oxygen delivery?
    A) "The non-rebreather mask is contraindicated in patient with chronic airway obstruction."
    B) "Oxygen delivered by nasal cannula at 5 to 6 L/min should be humidified."
    C) "The non-rebreather mask bag should be kept inflated at all times when in use."
    D) "A simple face mask should be used to deliver oxygen at 2 to 3 L/min."
    D) "A simple face mask should be used to deliver oxygen at 2 to 3 L/min."
    (this multiple choice question has been scrambled)
  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?
    A) Administer an expectorant from a prn order.
    B) Offer the patient a large glass of water.
    C) Perform nasal tracheal suctioning.
    D) Provide oxygen at 2 L/min via nasal cannula.
    C) Perform nasal tracheal suctioning.
    (this multiple choice question has been scrambled)
  26. Which early sign should the nurse expect to assess in a client experiencing hypoxia?
    A) constricted pupils
    B) enlarged liver
    C) cyanosis
    D) confusion
    D) confusion
    (this multiple choice question has been scrambled)
  27. Which person will have the lowest respiratory rate?
    A) the person who is resting on the top of a mountain
    B) the person who is sunbathing at the beach
    C) the person who is waiting in the cold for a bus
    D) the person who is sitting is a poorly ventilated area
    C) the person who is waiting in the cold for a bus
    (this multiple choice question has been scrambled)
  28. Which laboratory finding should the nurse expect for a patient who develops polycythemia secondary to chronic hypoxia?
    A) increased hematocrit
    B) decreased platelets
    C) increased white blood cells
    D) decreased blood urea nitrogen
    A) increased hematocrit
    (this multiple choice question has been scrambled)
  29. Which type of respiration accompanies metabolic acidosis?
    A) apneustic
    B) Kussmaul's
    C) Biot's
    D) Cheyne-Stokes
    B) Kussmaul's
    (this multiple choice question has been scrambled)
  30. From which area should a specimen for a throat culture be obtained?
    A) upper palate
    B) gingiva
    C) pharynx
    D) buccal mucosa
    C) pharynx
    (this multiple choice question has been scrambled)
  31. Hypercapnia describes the elevation of which substance?
    A) sodium bicarbonate
    B) serum calcium
    C) oxygen
    D) carbon dioxide
    D) carbon dioxide
    (this multiple choice question has been scrambled)
  32. Which instruction should the community health nurse give to the patient who is prescribed oxygen therapy?
    A) cotton blankets
    B) electronic equipment
    C) fingernail polish
    D) a room humidifier
    C) fingernail polish
    (this multiple choice question has been scrambled)
  33. What is the primary purpose of assessing a patient's oxygenation status using a pulse oximeter?
    A) to measure lung volume
    B) to identify breath sounds
    C) to detect presence of hypoxemia
    D) to determine pulse rate
    C) to detect presence of hypoxemia
    (this multiple choice question has been scrambled)
  34. Which best describes tidal volume?
    A) the volume of air (mL) left in the lungs after maximal exhalation
    B) the volume of air (mL) in the lungs following a maximal inhalation
    C) the volume of air (mL) inhaled and exhaled per breath
    D) the volume of air (mL) exhaled after a maximum inhalation
    C) the volume of air (mL) inhaled and exhaled per breath
    (this multiple choice question has been scrambled)
  35. Prior to suctioning the nasopharyngeal cavity of a patient who is unconscious, the nurse should place the patient in which position?
    A) lateral
    B) semi-Fowler's
    C) supine
    D) high-Fowler's
    A) lateral
    (this multiple choice question has been scrambled)
  36. What is the physiological response to living at a high altitude?
    A) increased oxygen saturation
    B) increased hematocrit levels
    C) decreased respiratory excursion
    D) decreased blood pressure
    B) increased hematocrit levels
    (this multiple choice question has been scrambled)
  37. The nurse is assessing the patient's pulse and notes a pulse rate of 50 beats/min. Which term describes this clinical finding?
    A) bradycardia
    B) tachycardia
    C) bradypnea
    D) tachypnea
    A) bradycardia
    (this multiple choice question has been scrambled)
  38. Which type of mask delivers the highest possible oxygen concentration?
    A) simple face
    B) partial rebreather
    C) non-rebreather
    D) Venturi
    C) non-rebreather
    (this multiple choice question has been scrambled)
  39. A client admitted with chronic obstructive pulmonary disease (COPD) is in respiratory failure. Which arterial blood gas results should the nurse expect for this client?
    A) pH 7.48, pCO2 31, HCO3 20
    B) pH 7.40, pCO2 41, HCO3 24
    C) pH 7.45, pCO2 37, HCO3 22
    D) pH 7.33, pCO2 55, HCO3 29
    D) pH 7.33, pCO2 55, HCO3 29
    (this multiple choice question has been scrambled)
  40. Which finding should the nurse expect to observe in a patient with Kussmaul's respiration?
    A) increasing inspiratory time with short grunting
    B) tachypnea and deep respirations
    C) apnea and shallow respirations
    D) respiratory rate less than 12/min
    B) tachypnea and deep respirations
    (this multiple choice question has been scrambled)
  41. Which clinical manifestation is indicative of thrombophlebitis in the lower leg of a light skinned patient?
    A) pain on dorsiflexion of the foot
    B) loss of function in the foot
    C) blanching of the leg
    D) bluish discoloration of the leg
    A) pain on dorsiflexion of the foot
    (this multiple choice question has been scrambled)
  42. Which safety instruction should the nurse include in the teaching plan for a patient who is learning to use a cane?
    A) Move the cane and the stronger leg together.
    B) Wear rubber-soled shoes or slippers.
    C) Hold the cane away from the body.
    D) Be sure the body weight is on both legs at all times.
    B) Wear rubber-soled shoes or slippers
    (this multiple choice question has been scrambled)
  43. Which instruction will help minimize the effect of orthostatic hypotension in a patient when helping the patient get out of bed?
    A) Take a deep breath before transfer.
    B) Create a wider base of support.
    C) Get out of bed after eating.
    D) Sit up in bed before getting out of bed.
    D) Sit up in bed before getting out of bed.
    (this multiple choice question has been scrambled)
  44. Which intervention is a priority when assisting a hospitalized ten year old in traction to deal with the monotony of immobilization?
    A) Urge the parents to feed and bathe their child.
    B) Request that the parents urge their child's friends to call or visit.
    C) Encourage the patient to wear personal clothing from home.
    D) Assist the patient to change positions frequently.
    B) Request that the parents urge their child's friends to call or visit.
    (this multiple choice question has been scrambled)
  45. Which physiological change that is associated with aging makes older adults particularly susceptible to fractures?
    A) bone demineralization
    B) loss of cartilage
    C) loss of muscle tone
    D) vitamin D deficiency
    A) bone demineralization
    (this multiple choice question has been scrambled)
  46. Which motor skill would a six month old infant usually be striving to accomplish?
    A) picking up tiny objects
    B) pulling self to a standing position
    C) sitting steadily without support
    D) achieving head control
    C) sitting steadily without support
    (this multiple choice question has been scrambled)
  47. What is the rationale for encouraging a patient who is immobile to perform leg exercises?
    A) to increase the cardiac workload
    B) to promote full long expansion
    C) to prevent orthostatic hypotension
    D) to prevent thrombus formation
    D) to prevent thrombus formation
    (this multiple choice question has been scrambled)
  48. A patient who is immobile has a nursing diagnosis of risk for impaired skin integrity related to sensory deficit. To prevent injury to the patient, the nurse should include which action in the plan of care?
    A) Position the patient in a dorsal recumbent position.
    B) Place heel protectors on the patient's feet.
    C) Place trochanter rolls lateral to the femur.
    D) Keep the patient's siderails padded at all times.
    B) Place heel protectors on the patient's feet.
    (this multiple choice question has been scrambled)
  49. The nurse places a patient in right Sim's position. Which observation would indicate proper body alignment?
    A) The patient's neck is flexed at a 90 degree angle.
    B) The patient's knees are flexed equally.
    C) Pillows are placed under the head, left arm, and left leg.
    D) a trochanter roll is placed at the right thigh.
    C) Pillows are placed under the head, left arm, and left leg.
    (this multiple choice question has been scrambled)
  50. Which intervention will best prevent contractures in a patient who is confined to bed?
    A) Have the patient perform range of motion exercises.
    B) Turn the patient every two hours.
    C) Keep the patient's joints in a brace.
    D) Keep the patient's joints warm.
    A) Have the patient perform range of motion exercises.
    (this multiple choice question has been scrambled)
Author
ID
299093
Card Set
EXN105B
Description
Excelsior N105 Form B
Updated
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