30. A T-tube was inserted and the physician ordered, “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures can the nurse perform without the doctor’s order?

30. A T-tube was inserted and the physician ordered, “Monitor
the amount, color, consistency and odor of drainage.” Which
of the following procedures can the nurse perform without
the doctor’s order?
by

1 Answer

Answer :

D. Emptying the drainage
by

Related questions

To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 – 2 cm and inflammation. The nurse would prepare the client for which specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography

The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

Description : The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described ... of tissue due to insufficient blood supply and may be associated with steroid use.

Last Answer : a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

Description : When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in ... residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely.

Last Answer : a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

The most controversial way of communicating doctor’s orders is by phone. It becomes valid and legal only when A. Countersigned by the receiving RN B. Signed by the physician who gave the order C. Signed by the resident physician on duty D. Countersigned by the medical doctor

Description : The most controversial way of communicating doctor’s orders is by phone. It becomes valid and legal only when A. Countersigned by the receiving RN B. Signed by the physician who gave the order C. Signed by the resident physician on duty D. Countersigned by the medical doctor

Last Answer : B. Encourage the client to discuss feelings/pain or discomfort openly

Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts. b) Requires a physician’s order. Teaching, as a function of nursing, is included in all state nurse practice acts. c) Must be approved by the physician. Health education is a primary responsibility of the nursing profession. d) Must focus on wellness issues. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Description : Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state ... restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Last Answer : a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts.

The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

Description : The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent ... is noted. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

Last Answer : a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

In general, chest drainage tubes are not used for the patient undergoing a) Pneumonectomy Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemithorax prevents mediastinal shift. b) Lobectomy With lobectomy, two chest tubes are usually inserted for drainage, the upper for air and the lower for fluid c) Wedge resection With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak d) Segmentectomy With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

Description : In general, chest drainage tubes are not used for the patient undergoing a) Pneumonectomy Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty ... With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

Last Answer : a) Pneumonectomy Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemithorax prevents mediastinal shift.

67. The physician ordered bilateral lower extremities Doppler ultrasound. Which of the following is the physician interested to find out through this diagnostic test?

Description : 67. The physician ordered bilateral lower extremities Doppler ultrasound. Which of the following is the physician interested to find out through this diagnostic test?

Last Answer : C. Occlusion of large vessels and arterioles

Ductal lavage is used for a) women at higher risk for benign proliferative breast disease. Performed in the doctor’s office, a microcatheter is inserted through the nipple while instilling saline and retrieving the fluid for analysis. It has been shown to identify atypical cells in this population and has been found to be adept at detecting cellular changes within the breast tissue.

Description : Ductal lavage is used for a) women at higher risk for benign proliferative breast disease. Performed in the doctor's office, a microcatheter is inserted through the nipple while instilling saline ... risk for benign proliferative breast disease; it is not specific for women with breast implants.

Last Answer : a) women at higher risk for benign proliferative breast disease. Performed in the doctor's office, a microcatheter is inserted through the nipple while instilling saline and retrieving the fluid ... population and has been found to be adept at detecting cellular changes within the breast tissue.

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Description : Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or ... for short periods of time. Difficulty in waking the patient should be reported or treated immediately.

Last Answer : a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

The basic difference between nursing diagnoses and collaborative problems is that a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic complications that nurses monitor to detect onset or changes and manage through the use of physician-prescribed and nursing-prescribed interventions to minimize the complications of events.

Description : The basic difference between nursing diagnoses and collaborative problems is that a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic ... or potential health problems that can be managed by independent nursing interventions.

Last Answer : a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic complications that nurses monitor to detect onset or changes and manage ... physician-prescribed and nursing-prescribed interventions to minimize the complications of events.

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for redness and palpated for hardening. b) drainage. Drainage at the site does not indicate a reaction to the tubercle bacillus. c) tissue sloughing. Sloughing of tissue at the site of injection does not indicate a reaction to the tubercle bacillus. d) bruising. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Description : When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for ... site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Last Answer : a) redness and induration. The site is inspected for redness and palpated for hardening.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled. b) clean. Clean cases are those with no apparent source of potential infection. c) contaminated. Contaminated cases are those that contain an open and obvious source of potential infection. d) dirty. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Description : When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean contaminated. Clean-contaminated cases are those with a potential, limited ... with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Last Answer : a) clean contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled.

40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time the medication was ordered 4. Dosage, route, frequency and strength 5. Physician’s signature and specialty 6. Physician’s signature and PRC license number

Description : 40. The nurse should ensure that all components of medications are documented. Identify all these components. 1. Dosage, route and frequency 2. Name of client and medication 3. Date and time ... and strength 5. Physician's signature and specialty 6. Physician's signature and PRC license number

Last Answer : C. All except 5 and 6

The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, “I will A. Call you when the return flow is clear” B. Stop the enema only if the return flow is without formed fecal material” C. Need 1 liter of tap water to have clear return flow” D. Put the client in left Sim’s position to achieve the desired return flow.”

Description : The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, I will A. Call you when the return flow is ... flow D. Put the client in left Sim's position to achieve the desired return flow.

Last Answer : A. Call you when the return flow is clear”

Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures. b) Neurogenic Neurogenic shock is associated with spinal cord injury and anesthesia. c) Cardiogenic Cardiogenic shock is associated with disease of the heart. d) Anaphylactic Anaphylactic shock is associated with hypersensitivity reactions.

Description : The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Septic Septic shock is associated with immunosuppression, extremes of age, ... disease of the heart. d) Anaphylactic Anaphylactic shock is associated with hypersensitivity reactions.

Last Answer : a) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures.

75. At the start of thyroid replacement post-total thyroidectomy, the nurse must monitor for side effects. Which side effects would the nurse expect to assess? 1. Hypertension 2. Tremors 3. Hirsutism 4. Insomnia 5. Tachycardia 6. Hyperglycemia

Description : 75. At the start of thyroid replacement post-total thyroidectomy, the nurse must monitor for side effects. Which side effects would the nurse expect to assess? 1. Hypertension 2. Tremors 3. Hirsutism 4. Insomnia 5. Tachycardia 6. Hyperglycemia

Last Answer : A. 3, 4, 5, and 6

57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Description : 57. The client was prescribed Ocreotide acetate (Sandostatin). Nurse Carla would monitor for which of the following side effects?

Last Answer : A. Abdominal pain

As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the top dressing B. Continue to monitor the vital signs C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

After admitting the patient to the PACU, the first action of the nurse would be to A. Assess patency of the airway B. Check the rate of the IV infusion C. Monitor the vital signs D. Assess the clients pain

Description : After admitting the patient to the PACU, the first action of the nurse would be to A. Assess patency of the airway B. Check the rate of the IV infusion C. Monitor the vital signs D. Assess the clients pain

Last Answer : A. Assess patency of the airway

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

Description : The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed ... retention before their menstrual period, BSE is best performed when the time for menses is taken into account.

Last Answer : a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

81. The scrub and circulating nurse should perform sponge count during which phases of an abdominal hysterectomy procedure? 1. Before the procedure 2. Before closing the endometrium 3. Before closing the peritoneum 4. At the skin closure 5. When the scrub nurse goes for a lunch break

Description : 81. The scrub and circulating nurse should perform sponge count during which phases of an abdominal hysterectomy procedure? 1. Before the procedure 2. Before closing the endometrium 3. Before closing the peritoneum 4. At the skin closure 5. When the scrub nurse goes for a lunch break

Last Answer : A. All except 5

When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient’s serum electrolytes anticipating which abnormality? a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). b) Hypercalcemia Hypercalcemia would likely be demonstrated by asystole. c) Hypomagnesemia Hypomagenesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. d) Hyponatremia Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).

Which of the following terms is used to describe hemorrhage from the nose? a) Epistaxis Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose. b) Xerostomia Xerostomia refers to dryness of the mouth. c) Rhinorrhea Rhinorrhea refers to drainage of a large amount of fluid from the nose. d) Dysphagia Dysphagia refers to difficulties in swallowing.

Description : Which of the following terms is used to describe hemorrhage from the nose? a) Epistaxis Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose. b ... of a large amount of fluid from the nose. d) Dysphagia Dysphagia refers to difficulties in swallowing.

Last Answer : a) Epistaxis Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose.

39. In case of telephone orders, the concerned physician needs to countersign the order within

Description : 39. In case of telephone orders, the concerned physician needs to countersign the order within

Last Answer : C. A time frame according to hospital policy

37. When do you carry out the order of the physician?

Description : 37. When do you carry out the order of the physician?

Last Answer : B. When the physician has signed the order

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

Description : When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a ... saline q8h as ordered The nurse may irrigate a nephrostomy tube with specific orders to do so.

Last Answer : a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. b) every hour. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. c) every 24 hours. Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. d) when a tube feeding is continuous, it is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. b) interruption of GI integrity Tube feedings preserve GI integrity by intraluminal delivery of nutrients. c) disturbance in the sequence of intestinal and hepatic metabolism Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. d) interruption in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

Description : The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of ... in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

Last Answer : a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, “How old is the client?” Holding the fallopian tube, the surgeon asks for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said, “Doctor there is no signed consent for tubal ligation.” The nurse just demonstrated which of the following?

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to Fowler’s B. Reassure the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Description : In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to ... the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Last Answer : Which of the following expected outcomes for the patient is most relevant for the nursing diagnosis “At risk for imbalanced nutrition related to impaired swallowing”? A. Appropriate body weight maintained B. Fear of choking relieved C. Oral intake increased D. Swallowing of soft foods facilitated

Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration. b) 10-15 mm Hg water pressure. A measure of 10–15 mm Hg water pressure would indicate that the cuff is underinflated. c) 30-35 mm Hg water pressure. A measure of 30–35 mm Hg water pressure would indicate that the cuff is overinflated. d) 0-5 mm Hg water pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Description : Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 20-25 mm Hg water pressure. Usually the ... pressure A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.

Last Answer : a) 20-25 mm Hg water pressure. Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B may cause fever, chills and body aches. The administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Description : A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of ... and cerebral spinal fluid (CSF) cultures. Blood and CSF cultures help diagnosis fungal encephalitis.

Last Answer : a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B ... 30 minutes prior to the administration of amphotericin B may prevent these side effects.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. b) 30-35 seconds Applying suction for 30-35 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.

Description : When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general ... suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

Last Answer : a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Description : 62. A 30-year-old client had cholesterol blood test before admission to the hospital. The nurse in charge would teach the family and significant others that the client should exercise to help keep the total cholesterol to a desired level of

Last Answer : A. 140 mg/dl

Which of the following statements defines laparoscopic myomectomy—an alternative to hysterectomy for the treatment of excessive bleeding due to fibroids? a) Removal of fibroids through a laparoscope inserted through a small abdominal incision. Laparoscopic myomectomy is the removal of fibroids through a laparoscope inserted through a small abdominal incision.

Description : Which of the following statements defines laparoscopic myomectomy-an alternative to hysterectomy for the treatment of excessive bleeding due to fibroids? a) Removal of fibroids through a laparoscope inserted ... through a hyserscope passed through the cervix; no incision or overnight stay is needed.

Last Answer : a) Removal of fibroids through a laparoscope inserted through a small abdominal incision. Laparoscopic myomectomy is the removal of fibroids through a laparoscope inserted through a small abdominal incision.

What must you be good at in order to be a nurse?

Description : What must you be good at in order to be a nurse?

Last Answer : Drawing blood without digging a hole in the patient’s arm.

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

90. When a telephone order is made, it should be documented by the nurse who is receiving the order. The following should be included in the order to be executed except

Description : 90. When a telephone order is made, it should be documented by the nurse who is receiving the order. The following should be included in the order to be executed except

Last Answer : A. Time the call was made and its duration