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.

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.
by

1 Answer

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.
by

Related questions

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.

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 charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

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.

A 17-year-old patient involved in an automobile accident is paralyzed with multiple peripheral extremity injuries. Nutritional support is instituted with a transnasal feeding catheter. Which of the following statement(s) is/are true concerning the patient’s management? a. Feeding into the stomach results in stimulation of the biliary/pancreatic axis which is probably trophic for small bowel b. Gastric secretions will dilute the feedings increasing the risk of diarrhea c. The major risk in this patient is tracheobronchial aspiration d. Placement of the feeding catheter through the pylorus into the first portion of the duodenum reduces the risk of regurgitation and aspiration

Description : A 17-year-old patient involved in an automobile accident is paralyzed with multiple peripheral extremity injuries. Nutritional support is instituted with a transnasal feeding catheter. Which of the ... pylorus into the first portion of the duodenum reduces the risk of regurgitation and aspiration

Last Answer : Answer: a, c, d The use of transnasal feeding catheters for intragastric feeding or for duodenal intubation are popular adjuncts for providing nutritional support by the enteral route. The ... the fourth portion of the duodenum reduces the risk of regurgitation and aspiration of feeding formulas

Medium -length nasoenteric tubes are used for: a) Feeding Placement of the tube must be verified prior to any feeding. b) Decompression A gastric sump and nasoenteric tube are used for gastrointestinal decompression. c) Aspiration Nasoenteric tubes are used for gastrointestinal aspiration. d) Emptying Gastric sump tubes are used to decompress the stomach and keep it empty.

Description : Medium -length nasoenteric tubes are used for: a) Feeding Placement of the tube must be verified prior to any feeding. b) Decompression A gastric sump and nasoenteric tube are used for ... aspiration. d) Emptying Gastric sump tubes are used to decompress the stomach and keep it empty.

Last Answer : a) Feeding Placement of the tube must be verified prior to any feeding.

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.

While making your PM shift endorsement, you saw the nursing attendant receiving a package from a patient’s watcher. Your appropriate action would be A. Reprimand the nursing attendant right away B. Remind the patient that gift giving to any hospital staff is not allowed C. Review with the nursing attendant the hospital policy D. Endorse to the incoming shift for proper action

Description : While making your PM shift endorsement, you saw the nursing attendant receiving a package from a patient's watcher. Your appropriate action would be A. Reprimand the nursing attendant right away ... with the nursing attendant the hospital policy D. Endorse to the incoming shift for proper action

Last Answer : D. Endorse to the incoming shift for proper action

Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes. b) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. c) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger. d) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Description : Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to ... the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Last Answer : a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes.

Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. b) Peroneal The peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes. c) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. d) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Description : Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation ... The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Last Answer : a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve.

Mercury is typically used in the placement of which of the following tubes? a) Miller-Abbott Most nasoenteric tubes use mercury to carry the tube by gravity to its desired location. b) Gastric sump A gastric sump is used to decompress and empty the stomach. c) Dobbhoff Dobbhoff tubes are used for enteric feeding. d) EnterafloW Enteraflow tubes are used for enteric feeding

Description : Mercury is typically used in the placement of which of the following tubes? a) Miller-Abbott Most nasoenteric tubes use mercury to carry the tube by gravity to its desired location. b) ... Dobbhoff tubes are used for enteric feeding. d) EnterafloW Enteraflow tubes are used for enteric feeding

Last Answer : a) Miller-Abbott Most nasoenteric tubes use mercury to carry the tube by gravity to its desired location.

When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Description : When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the ... are removed routinely. Traction must be continuous to be effective in reducing and immobilizing fractures.

Last Answer : a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for shortcourse (e.g. 3-day) therapy? a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

Description : When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for ... to be significantly more effective than TMP-SMX in community-based patients and in nursing home residents.

Last Answer : a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

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.

Which of the following methods is the best method for determining nasogastric tube placement in the stomach? a) X-ray Radiologic identification of tube placement in the stomach is most reliable. b) Observation of gastric aspirate Gastric fluid may be grassy green, brown, clear, or odorless while an aspirate from the lungs may be off-white or tan. Hence, checking aspirate is not the best method of determining nasogastric tube placement in the stomach.

Description : Which of the following methods is the best method for determining nasogastric tube placement in the stomach? a) X-ray Radiologic identification of tube placement in the stomach is most reliable. ... for air bubbles is not a reliable method for determining nasogastric tube placement in the stomach.

Last Answer : a) X-ray Radiologic identification of tube placement in the stomach is most reliable.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Description : What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the ... oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

Last Answer : a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen ... literally be pulled away with such great force that they can fly like projectiles towards the magnet.

For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless. b) Increased wakefulness As the body weakens, the patient will sleep more and begin to detach from the environment. c) Increased eating For many patients, refusal of food is an indication that they are ready to die. d) Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Description : For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the ... Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Last Answer : a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless.

A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke? a) Reversible ischemic neurologic deficit With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.

Description : A patient has had neurologic deficits lasting for more than 24 hours, and now the symptoms are resolving. The nurse concludes that the patient has had which type of stroke? a) Reversible ... and symptoms have stabilized with no indication of further progression of the hypoxic insult to the brain.

Last Answer : a) Reversible ischemic neurologic deficit With a reversible ischemic neurologic deficit, the patient has more pronounced signs and symptoms that last more than 24 hours; symptoms resolve in a matter of days without any permanent neurologic deficit.

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.

The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

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.

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Description : 88. When the nurse ensures that the client has plan for continuous care after leaving the health care facility and assists from the transition from one environment to another, she is doing a

Last Answer : A. Discharge plan

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 advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. b) Minimize intake of caffeine, ****, milk, and foods containing peppermint and spearmint. The patient should be instructed to avoid the listed foods and food components. c) Elevate the foot of the bed on 6- to 8-inch blocks The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

Description : When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision a) sees an object from 20 feet away that a person ... 20/20 line, the person of normal vision will be standing at a distance of 20 feet from the chart.

Last Answer : a) sees an object from 20 feet away that a person with normal vision sees from 200 feet away. The fraction 20/20 is considered the standard of normal vision.

When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Description : When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the ... or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Last Answer : a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a vial that is almost empty. She was able to aspirate 60 mg only. Nurse Kristine decided to inject it instead of making the client wait until the next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Description : 77. Nurse Kristine is to inject Demerol 75 mg to a post-TURP (transurethral resection of the prostate) client who is in pain. When she checked the narcotic cabinet, she found out a ... next Demerol vial is available. The action of the nurse violates which of the following ethical principles?

Last Answer : A. Justice

69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Description : 69. When Marina checked the capillary blood glucose of the client at 6 PM before meals as instructed by the senior nurse, the result showed 65 mg/dl. Which of the following will Marina do first?

Last Answer : C. Check the physician’s order in case CBG is below 70 mg/dl

Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Description : Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. ... rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

Last Answer : a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS) is closely monitored for a) leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

Description : The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS) is closely monitored for a) leukopenia and cardiac toxicity. Mitoxantrone is an ... d) hypoxia. Patients receiving mitoxantrone are closely monitored for leukopenia and cardiac toxicity.

Last Answer : a) leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have ... ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

Description : The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin ... A broken cast should be reported to the physician; the patient should not attempt to fix it.

Last Answer : a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

During which step of the nursing process does the nurse analyze data related to the patient’s health status? a) Assessment Analysis of data is included as part of the assessment. b) Implementation Implementation is the actualization of the plan of care through nursing interventions. c) Diagnosis Diagnosis is the identification of patient problems. d) Evaluation Evaluation is the determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved.

Description : During which step of the nursing process does the nurse analyze data related to the patient's health status? a) Assessment Analysis of data is included as part of the assessment. b) ... patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Last Answer : a) Assessment Analysis of data is included as part of the assessment.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

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.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

The Code of Ethics states that the nurse’s primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical principle called justice? A. The nurse providing care on a “first come – first served” basis B. Referring the client for evaluation to the social worker on duty regarding her socio-economic status C. The client’s preference is least considered D. The nurse’s providing care to maximize health according to available resources

Description : The Code of Ethics states that the nurse's primary commitment is to the client whether an individual of family, group or community. Which nursing activity would best demonstrate the ethical ... is least considered D. The nurse's providing care to maximize health according to available resources

Last Answer : A. The nurse providing care on a “first come – first served” basis

Which stage of anesthesia is termed surgical anesthesia? a) III With proper administration of the anesthetic, this stage may be maintained for hours. b) I Stage I is beginning anesthesia, as the patient breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. c) II Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. d) IV Stage IV is a stage of medullary depression and is reached when too much anesthesia has been administered.

Description : Which stage of anesthesia is termed surgical anesthesia? a) III With proper administration of the anesthetic, this stage may be maintained for hours. b) I Stage I is beginning anesthesia, as the ... IV is a stage of medullary depression and is reached when too much anesthesia has been administered.

Last Answer : a) III With proper administration of the anesthetic, this stage may be maintained for hours.

Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling catheter, the patient is placed on a timed voiding schedule, usually two to three hours. At the given time interval, the patient is instructed to void. a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

Description : Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling ... in the bladder after voiding, straight catheterization may be performed for complete bladder emptying.

Last Answer : a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Description : 54. Albert is prescribed NSAID every four hours to relieve, fever, inflammation, and pericardial pain. To maximize the effect of the drug, the nurse would administer it

Last Answer : C. Round the clock on a consistent basis

The nurse auscultates the apex beat at which of the following anatomical locations? a) Fifth intercostal space, midclavicular line The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space. b) Mid-sternum The right ventricle lies anteriorly, just beneath the sternum. c) 2” to the left of the lower end of the sternum Use of inches to identify the location of the apex beat is inappropriate based upon variations in human anatomy. d) 1” to the left of the xiphoid process Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.

Description : The nurse auscultates the apex beat at which of the following anatomical locations? a) Fifth intercostal space, midclavicular line The left ventricle is responsible for the apex beat or the point of ... of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.

Last Answer : a) Fifth intercostal space, midclavicular line The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space.