Test 2, TB questions, prep u, and questions we know will be on the test from ppt , questions from ppt made by chat

A nurse reads the laboratory report and notes that the client has hyponatremia. What
physical assessment should be made?
A) Observe Skin color and texture
B) Auscultate bowel sounds.
C) Percuss lung density.
D) Monitor for GI symptoms.

By what route do oxygen and carbon dioxide exchange in the lung?
a. osmosis
b. filtration
c. diffusion
d. active transport

A nurse measures a client’s 24-hour fluid intake and documents the findings. To be an
accurate indicator of fluid status,
10. what must the nurse also do with the information? A) Compare the client’s intake with the normal range of adult fluid intake.
B) Report the exact milliliter of intake to the physician’s office nurse.
C) Compare the total intake and output of fluids for the 24 hours.
D) Ensure that the information is included in the verbal end-of-shift report.

A physician writes an order to “force fluids.” What will be the first action the nurse will take in implementing this order?
A) Explain to the client why this is needed.
B) Tell the client and family to increase oral intake.
C) Decide how much fluid to increase each eight hours.
D) Divide the intake so the largest amount is at night.

Which client would be the most likely candidate for the administration of total parenteral nutrition?
A) A client with severe pancreatitis
B) A client with a myocardial infarction
C) A client with hepatitis B
D) A client with mild malnutrition

Cross-matching of blood is ordered for a client before major surgery. What does this process do?
A) Determines compatibility between blood specimens
B) Determines a person’s blood type
C) Predicts the amount of needed blood replacement
D) Specifies the donor and the recipient of the blood

A nurse is initiating a peripheral venous access IV infusion ordered for a client
presurgically. In what position would the 22. nurse place the client to perform this skill?
A) High-Fowler’s
B) Low-Fowler’s
C) Sims’
D) Dorsal recumbent

When do you raise the clients arm, and when do you stop the IV.

Which of the following descriptions best summarizes fluid homeostasis?
a. Almost every body organ and system helps maintain homeostasis.
b. The cardiovascular and renal systems primarily maintain homeostasis.
c. Homeostasis is maintained by the arterioles, capillaries, and venules.
d. Homeostasis is maintained by the arterioles, capillaries, and venules.

A nurse reads the laboratory report for a patient and notes that the patient has hyponatremia. What physical assessment would be made?
a. Observe skin color and texture.
b. Auscultate bowel sounds.
c. Percuss lung density.
d. Palpate skin of sternum

A patient has metabolic (nonrespiratory) acidosis. What type of respirations would be assessed?
a. periods of apnea
b. decreased depth and rate
c. increased depth and rate
d. alternating fast and slow

A nurse reads a complete blood count report for a patient who has been admitted to the hospital with fluid overload from late-stage kidney disease. What abnormal result would the nurse expect to find?
a. increased white blood cells
b. increased platelets
c. decreased hematocrit
d. increased hematocrit

The student nurse studying fluid and electrolyte balance learns that which of the following is a function of water? (Select all that apply).
a. provide a medium for transporting wastes to cells and nutrients from cells
b. provide a medium for transporting substances throughout the body
c. facilitate cellular metabolism and proper cellular chemical functioning
d. act as a buffer for electrolytes and nonelectrolytes
e. help maintain normal body temperature
f. facilitate digestion and promote elimination

A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which of the following statements accurately describe this process? (Select all that apply).
a. The kidneys selectively retain electrolytes and water and excrete wastes and
excesses according to the bodys needs.
b. The cardiovascular system is responsible for pumping and carrying nutrients and
water throughout the body.
c. The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the
body conserve sodium, helps save chloride and water, and causes potassium to be
excreted.
Test Bank - Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Edition (Taylor, 2023)
d. The lungs regulate oxygen and carbon dioxide levels of the blood, which is
WWW.TBSM.WS
especially crucial in maintaining acidbase balance.
e. Thyroxine, released by the adrenal glands, increases blood flow in the body,
leading to increased renal circulation and resulting in increased glomerular
filtration and urinary output.
f. The parathyroid glands secrete parathyroid hormone, which regulates the level of
calcium and phosphorus.

Red ____
Yellow ____
Black___. (wound colors, what do we do for each?)

what color surrounds venous ulcers?

when you have tight hairless skin, reddish, yellowish, black, brownish, red when dangling and pallor when feet are up, what kinda ulcer is it

How does heat therapy cause the body to lose heat?

Why should you watch for hypovolemic shock during heat therapy?

What does the body do to keep warm during cold therapy?

Name two systemic reactions to cold.

What happens at the local level when you apply heat?

How does cold therapy help with swelling and spasms? (green highlight)

How long should you apply heat or cold?

Why use cold therapy after surgery?

Why might you alternate heat with cold?

What happens to thermal skin receptors when they are first exposed to a temperature change?

What's the maximum time heat should be applied before it starts to cause negative effects?

What should you do after applying heat or cold for the recommended time?

When does the body start to counteract the effects of cold therapy?

Why is it important to stop heat or cold therapy before the rebound effect?

What are the key uses for heat therapy?

What conditions is cold therapy good for?

When should you not use cold therapy?

When is heat therapy not recommended?

What should you assess before starting heat or cold therapy?

What must you have before applying heat or cold therapies?

What should you always check before applying heat or cold therapy?

What should you place between a heating pad and the patient's skin?

How should a heating pad be positioned?

What's important about the patient's role during heat or cold therapy?

What should you not do with towels or medical products for heat therapy?

What safety measure should you take with a heating pad's temperature control?

How should you monitor a patient during heat or cold therapy?

What are two types of dry heat therapy?

How should you adjust the temperature when using a hypothermia blanket?

What's a key safety tip for applying cold therapy?

Upon assessment of a client’s wound, the nurse notes the formation of granulation tissue. The
tissue easily bleeds when
1. the nurse performs wound care. What is the phase of wound healing characterized by the
nurse’s assessment?
A) Proliferation phase
B) Hemostasis
C) Inflammatory phase
D) Maturation phase

The nurse would recognize which of these devices as an open drainage system?
A) Penrose drain
B) Jackson-Pratt drain
C) Hemovac
D) Negative pressure dressing

A nurse is caring for a client who is two days postoperative after abdominal surgery. What
nursing intervention would be important to promote wound healing at this time?
A) Administer pain medications on a p.r.n. and regular basis.
B) Assist in moving to prevent strain on the suture line.
C) Tell the client that a mild fever is a normal response.
D) If a scar forms over a joint, it may limit movement.

A nurse assessing a client’s wound documents the finding of purulent drainage. What is the
composition of this type of 16. drainage?
A) Clear, watery blood
B) Large numbers of red blood cells
C) Mixture of serum and red blood cells
D) White blood cells, debris, bacteria

A nurse caring for a female client notes a number of laceration wounds around the cervix of
the uterus due to childbirth. How could the nurse describe the laceration wound in the client’s medical record?
A) A clean separation of skin and tissue with a smooth, even edge
B) A separation of skin and tissue in which the edges are torn and irregular
C) A wound in which the surface layers of skin are scraped away
D) A shallow crater in which skin or mucous membrane is missing

A nurse caring for a post-operative client observes the drainage in the client’s closed wound
drainage system. The
23. drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of
the following?
A) Serous
B) Sanguineous
C) Serosanguineous
D) Purulent

An older adult client has edema of the right lower extremity with redness and clear drainage.
This is most likely related 24. to what?
A) Beta-hemolytic streptococcus
B) Age
C) Venous insufficiency
D) Hemangioma

Which of the following clients would be considered at risk for skin alterations? Select all that apply.
A) A teenager with multiple body piercings
B) A homosexual in a monogamous relationship
C) A client receiving radiation therapy
D) A client undergoing cardiac monitoring
E) client with diabetes

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the
following is an effect of cold 26. therapy? Select all that apply.
A) Constricts peripheral blood vessels
B) Reduces muscle spasms
C) Increases blood flow to tissues
D) Increases the local release of pain-producing substances
E) Reduces the formation of edema and inflammation

Which of the following is an accurate step when applying a saline-moistened dressing on a client’s wound?
A) Do not use irrigation to clean the wound before changing the dressing.
B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it.
C) Exert light pressure to pack the wound tightly with moistened dressing.
D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What
would be the best type of 32. dressing for this wound?
A) Saline-moistened dressing
B) Dressing secured with Montgomery straps
C) Hydrocolloid dressing
D) Foam dressing

A student has been assigned to provide morning care to a client. The plan of care includes the
information that the client
34. requires partial care. What will the student do?
A) Provide total physical hygiene, including perineal care.
B) Provide total physical hygiene, excluding hair care.
C) Provide supplies and orient to the bathroom.
D) Provide supplies and assist with hard-to-reach areas.

When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?
a. friction
b. necrosis of tissue
c. ischemia
d. shearing force

A nurse assesses an area of pale white skin over a patients coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?
a. Immediately report to the physician that the patient has a pressure ulcer.
b. Recognize that this is ischemia, followed by reactive hyperemia.
c. Document the presence of a pressure ulcer and develop a care plan.
d. Implement nursing interventions for Altered Skin Integrity.

A nurse is assessing wound drainage during the immediate postoperative period for a patient who has had a breast removed. In addition to assessing the dressing, where would the nurse also check for drainage?
a. under the skin
b. under the patient
c. on the output sheet
d. in the axilla

Heat applications are often used to promote tissue healing. What is the rationale for this type of treatment?
a. Physiologic effects of heat accelerate the inflammatory response.
b. Local heat increases cardiac output and pulse rate.
c. Heat reduces blood flow to tissues resulting in decreased edema.
d. Heat reduces muscle tension to promote relaxation.

Which of the following considerations should be made when assessing a patient for the application of cold or heat therapy?
a. prolonged exposure decreases tolerance
b. the neck and perineum are less sensitive to thermal change
c. open tissue or abraded skin is less sensitive to thermal changes
d. applications of heat or cold to large areas of the body cause systemic responses

A nurse assessing the skin of patients knows that the following are health states that may predispose patients to skin alterations. (Select all that apply).
a. obesity
b. excessive perspiration
c. cataracts
d. hypertension
e. low BMI
f. Jaundice

A nurse is applying cold therapy to a patient with a contusion of the arm. Which of the following is an effect of cold therapy? (Select all that apply).
a. constricts peripheral blood vessels
b. reduces muscle spasms
Test Bank - Fundamentals of Nursing: The Art and Science of Person-Centered Care, 10th Edition (Taylor, 2023)
c. increases blood flow to tissues
d. increases the local release of pain-producing substances
e. reduces the formation of edema and inflammation.
f. alters tissue sensitivity (producing numbness)

Define Primary Intention Healing.

Define Secondary Intention Healing.

Define Tertiary Intention Healing.

When does a sterile object remain sterile?

Where can sterile objects be placed?

What contaminates a sterile object or field?
Define Secondary Intention Healing.

How should you handle sterile objects?

Key behaviors to maintain surgical asepsis?

How to manage sterile solutions and packages?

The nurse is aware that an antiviral medication is most effective when given during which
phase of the infectious process?
A) Prodromal stage
B) Incubation period
C) Full stage of illness
D) Convalescent period

Which of the following most accurately defines an infection?
A) An illness resulting from living in an unclean environment
B) The result of lack of knowledge about food preparation
C) A disease resulting from pathogens in or on the body
D) An acute or chronic illness resulting from traumatic injury

A college-aged student has influenza. At what stage of the infection is the student most infectious?
A) Incubation period
B) Prodromal stage
C) Full stage of illness
D) Convalescent period

A nurse is caring for a client with a serious bacterial infection. The client is dehydrated.
Knowledge of the physical effects of the infection would support which of the following nursing diagnoses?
A) High Risk for Infection
B) Excess Fluid Volume
C) Risk for Imbalanced Body Temperature
D) Risk for Latex Allergy Response

A nurse is required to clean the open wounds of a client who has been involved in an
automobile accident. What
30. intervention would the nurse need to perform when cleaning open wounds to protect himself
from infection?
A) Wash hands with alcohol-based hand wash.
B) Wear a pair of sterile latex gloves.
C) Use sterilizing acid to clean the injury.
D) Use sterile solutions such as normal saline.
mani

Which of the following are characteristics of the stage of infection known as full stage of illness? Select all that apply.
A) It is the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection.
B) Specific signs and symptoms are present.
C) The organisms are growing and multiplying.
D) The signs and symptoms disappear, and the person returns to a healthy state.
E) Early signs and symptoms of disease are present, but these are often vague and nonspecific.

Which of the following are characteristics of the stage of infection known as full stage of illness? (Select all that apply).
a. It is the interval between the pathogens invasion of the body and the appearance of
symptoms of infection .
b. The presence of specific signs and symptoms indicates the full stage of illness.
c. During the full stage of illness, the organisms are growing and multiplying.
d. The signs and symptoms disappear, and the person returns to a healthy state.
e. Early signs and symptoms of disease are present, but these are often vague and
nonspecific.
f. The type of infection determines the length of the illness and the severity of the
manifest

A nurse is positioning a sterile drape to extend the working area when performing a urinary
catheterization. Which of the following is an appropriate technique for this procedure?
A) Use sterile gloves to handle the entire drape surface.
B) Fold the lower edges of the drape over the sterile-gloved hands.
C) Touch only the outer two inches of the drape when not wearing sterile gloves.
D) When reaching over the drape do not allow clothing to touch the drape.

the interval between the pathogen’s invasion of the body and the appearance of symptoms of infection

recovery period from the infection; the signs and symptoms disappear, and the person returns to a healthy state

A person is most infectious during the ___________, in which early signs and symptoms of disease are present, but are often vague and nonspecific (ranging from fatigue and malaise to a low- grade fever).

Which of the following statements accurately describe a component of the inflammatory response? (Select all that apply).
a. The inflammatory response is a protective mechanism that eliminates the invading
pathogen and allows for tissue repair to occur.
b. Inflammation helps the body to neutralize, control, or eliminate the offending
agent and to prepare the site for repair.
c. The inflammatory response involves specific body responses to an invading
foreign protein, such as bacteria, or in some cases, to the bodys own proteins.
d. The antigenantibody reaction, also known as humoral immunity, is one component
of the overall inflammatory response.
e. The vascular and cellular stages are the main components of the inflammatory
process and these physiological processes are responsible for the appearance of the
cardinal signs.
f. One of the first lines of defense against infection is the inflammatory response,
which helps to keep potentially harmful bacteria from invading the body.

left __, right ___

What does the cardiopulmonary system do?

Explain the path of blood in the cardiopulmonary system.

what is stroke volume?

in s1 what 2 valves close

in s2 what 2 valves close

CO (amoint of blood plumbed from left ventricle per minute)=

preload

after load

what kind of waves will you see with high potassium

What happens in impaired valvular function? (just read)

What is myocardial ischemia, and what can it lead to? (read)

what can happen if the epiglottis is not working properly

conducts food and air

connects the pharynx and the trachea; made of
cartilage; contains vocal cords.

- contraction & descent draws air into lungs
• 75% of normal air movement

assist inhalation – lift ribs up & out
• 25% of normal air movement

sternocleidomastoids, trapezius, scalenes, abdominals
• Used during inspiration – assist in elevating ribs
• Quantifies the “work of breathing”

Exchange of respiratory gases in the alveoli and capillaries

The process by which oxygenated capillary blood passes through the body tissues

The effort required to expand and contract the lungs. depending on , rate and depth, compliance, difficulty breathing, and airway resistance

Chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing; Decreased surfactant from disease can develop atelectasis

Collapse of the alveoli that prevents the normal exchange of oxygen and carbon dioxide.

Movement of resp. gases from area of high concentration to area of low concentration u Occurs at alveolar capillary membrane
u O2 diffuses into capillary, CO2 diffuses into alveolus
u The thickness of the alveolar capillary membrane affects the rate of

late sign of hypoxia

Front: What can decrease oxygen-carrying capacity in the blood? (read)

What is hypovolemia, and what can cause it?(r)

What can lead to a decrease in inspired oxygen concentration? (r)

factors that increase metabolic rate? (r)

How can conditions affecting chest wall movement impact cardiopulmonary functioning? (r)

if slough is draining ________ it is an improvement (on test)

what are infants and toddlers at risk for when it comes to factors effecting cardiopulmany funnction and oxygenation?

medications such as _____ effect cardiopulmany function and oxygenation

causes of hypoventilation (on test)

signs and symptoms of hypoventilation (on test)

PaCO2 level elevated =

PaCO2 levels decreased =

breathing exercise for dyspnea managament include deep breathing and cough and specifically for copd (test question)

arms on pillow or overhead table or side lying affected side raised above shoulder, big needle to remove fluid

Nasotracheal tube is always before or after oral?

which is sterile and which is clean between naso and oral

A firm plastic tube placed through thorax to remove air & fluids from pleural space, to prevent air from re-entering, & to re-establish intrapleural and intrapulmonic pressures, thereby re-expanding the lung

What is the primary purpose of administering oxygen therapy? r

What must a provider's order for oxygen include? r

How is the effectiveness of oxygen therapy assessed? r

Name two safety precautions that should be taken when using oxygen therapy.

must be added if flow rate is greater than 4 L/min (Oxygenation)

what kind of oxygen delivery do you give for copd

o2 must be (r)

indications for home oxygen systems include: arterial partial pressure (PaO2) at ____ or less

indications for home oxygen systems include: arterial oxygen saturation (SaO2) at ____ or less on room air at rest, on exertion, or with exercise

What are the methods of administering home oxygen therapy? r

Who benefits from home oxygen systems? r

most serious artificial airway complication?

perform ____ suctioning before _____ suctioning

suctioning elevates ____ pressure, so be careful when suctioning patients with head injuries

The nurse caring for a client with emphysema has determined that a priority nursing
diagnosis for this client is “Imbalanced Nutrition: Less Than Body Requirements
related to difficulty breathing while eating.” Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the
client’s care plan?
A) Provide six small meals daily.
B) Provide three large meals daily.
C) Encourage the client to eat immediately before breathing treatments.
D) Encourage the client to alternate eating and using a nebulizer during meal time.

The nurse is developing a plan of care for a client admitted with pneumonia. The
nurse has determined that apriority nursing diagnosis for this client is “Ineffective
Airway Clearance related to copious and tenacious secretions.” Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the
client’s care plan?
A) Encouraging the client to consume two to three quarts of clear fluids daily
B) Creating an environment that is likely to reduce anxiety
C) Positioning the client supine
D) Encouraging the client to decrease the number of cigarettes smoked daily

While the nurse is providing morning hygiene for a client who has a chest tube, the client
has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first
respond to this event?
A) Submerge the end of the tube in sterile water.
B) Clamp the tube near the end and also near the insertion point.
C) Place the end of the tube on a sterile surface and seek help promptly.
D) Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit.

A client has had a head injury affecting the brain stem. What is located in the brain stem
that may affect respiratory 4. function?
A) Chemoreceptors
B) Stretch receptors
C) Respiratory center
D) Oxygen center

Which of the following diseases may result in decreased lung compliance?
A) Emphysema
B) Appendicitis
C) Acne
D) chronic diarrhea

A nurse is caring for a client with pneumonia. The client’s oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?
A) changes in the alveolar-capillary membrane and diffusion
B) alterations in the structures of the ribs and diaphragm
C) rapid decreases in atmospheric and intrapulmonic pressures
D) lower-than-normal concentrations of environmental oxygen

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur?
A) Inspiration and expiration
B) Only on inspiration
C) Only on expiration
D) When coughing

A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?
A) Anxiety
B) Nausea
C) Pain
D) Hypothermia

A nurse is educating a preoperative client on how to effectively deep breathe. Which of
the following would be included?
A) “Make each breath deep enough to move the bottom ribs.”
B) “Breathe through the mouth when you inhale and exhale.”
C) “Breathe in through the mouth and out through the nose.”
D) “Practice deep breathing at least once each week.”

A nurse is explaining a chest tube to family members who do not understand where it is
placed. What would the nurse tell them?
A) “It is inserted into the space between the lining of the lungs and the ribs.”
B) “I don’t exactly know, but I will make sure the doctor comes to explain.”
C) “It is inserted directly into the lung itself, connecting to a lung airway.”
D) “It is inserted into the peritoneal space and drains into the lungs.”

What prevents air from re-entering the pleural space when chest tubes are inserted?
A) The location of the tube insertion
B) The sutures that hold in the tube
C) A closed water-seal drainage system
D) Respiratory inspiration and expiration

A physician prescribes the use of water-seal chest tube drainage for a client at a health
care facility. What should the nurse ensure when using the water-seal chest tube drainage?
A) Filters need to be cleaned regularly to avoid unpleasant taste or smell.
B) The chest tube should not be separated from the drainage system unless clamped.
C) A nasal cannula should be used to administer oxygen when cleaning the opening.
D) A secondary source of oxygen should be available in case of power failure.

A nurse is conducting a health promotion program for adolescents to educate them about
the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse
most likely include?
A) Decreased production of mucus
B) Inhibition of mucus removal
C) Increase in the mucous escalator
D) Inhibition of bacterial colonization

The nurse is caring for a postoperative adult client who has developed pneumonia. The
nurse should assess the client 28. frequently for symptoms of
A) Atelectasis
B) Bronchospasm
C) Croup
D) Epiglottitis

A nurse is caring for an older adult client who is to be discharged from the health care
facility. The client has been prescribed the use of a liquid oxygen unit at home to
continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply.
A) Liquid oxygen may leak during warm weather.
B) The unit may give off a bad smell if not cleaned regularly.
C) The unit’s outlet may become occluded because of frozen moisture.
D) Portable liquid oxygen is more expensive.
E) The unit may require a secondary source of oxygen.

A nurse is educating a postoperative client on how to use an incentive spirometer. Which
of the following is an accurate
31. step that should be included in the teaching plan?
A) Instruct the client to inhale normally and then place the lips securely around the mouthpiece.
B) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose.
C) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10.
D) Encourage the client to perform incentive spirometry two to three times every one to two hours, if possible.

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure?
A) Adjust the mask so it fits tightly around the face.
B) For a mask with a reservoir, fill the reservoir half-full of oxygen.
C) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously.
D) If the client is experiencing redness around the mask, remove and apply powder to the mask.

A physician is choosing a chest drainage system for a client who is ambulating daily.
Which of the following systems would be the best choice for this client?
A) Traditional water seal
B) Wet suction
C) Dry suction water seal
D) Dry suction/one-way valve system

A client visits the health care facility for a scheduled physical assessment. What should
the nurse do when physically
34. assessing the quality of the client’s oxygenation? Select all that apply.
A) Monitor the client’s respiratory rate.
B) Note the amount of oxygen administered.
C) Check the symmetry of the client’s chest.
D) Observe the breathing pattern and effort.
E) Check the devices used to deliver oxygen.

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the 35. developmental level of this client?
A) 15 to 25 breaths/minute
B) 16 to 20 breaths/minute
C) 20 to 44 breaths/minute
D) 30 to 55 breaths/minute

While reading a physicians progress notes, a student notes that an assigned patient is having hypoxia. What abnormal assessments would the student expect to find?
a. abdominal pain, hyperthermia, dry skin
b. diarrhea, flatulence, decreased skin turgor
c. hypotension, reddened skin, edema
d. dyspnea, tachycardia, cyanosis

What is the action of codeine when used to treat a cough? a. antisuppressant
b. suppressant c. antihistamine d. expectorant

What can a nurse ask a patient to do before suctioning to prevent hypoxemia (an abnormally low concentration of oxygen in the blood)?
a. Sit in an upright position and cough.
b. Breathe normally for at least 5 minutes.
c. Lie flat in bed and practice relaxation.
d. Take several deep breaths.

A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?
a. obturator
b. outer cannula
c. inner cannula
d. cuff

What is the rationale for placing a writing board in the room of a patient who has had surgery to insert a tracheostomy tube?
a. The patient is not able to speak.
b. Verbal communication will be too tiring.
c. It will occupy the patients time.
d. Voice rest will decrease pain levels.

A student observes a nurse instilling a small amount of saline into a tracheostomy tube before suctioning. What should the student discuss with the nurse?
a. a description of how the nurse is carrying out the skill
b. saline is no longer recommended for routine suctioning c. nothing; the nurse has been doing this for years
d. compliments for carrying out the procedure skillfully

A nurse is caring for older adults in a nursing home. Which of the following age-related changes may affect the respiratory functioning of the patients living there? (Select all that apply).
a. increased elastic recoil of the lungs
b. less fibrous tissue in alveoli
c. increase in vital capacity and residual volume
d. less air exchange, more secretions in lungs
e. greater risk for aspiration due to slower gastric motility
f. impaired mobility and inactivity, effects of medication

Which of the following statements accurately describe a step for inserting an oropharyngeal airway? (Select all that apply).
a. Use an airway that is the correct size (size 90 mm is appropriate for the average
adult).
b. Airway should reach from opening of mouth to the back angle of the jaw.
c. Position patient on his or her stomach with neck hyperextended (unless this is
inappropriate).
d. Open patients mouth by using your thumb and index finger to gently pry teeth
apart.
e. Insert the airway with the curved tip pointing up toward the roof of the mouth.
f. Rotate the airway 360 degrees as it passes the uvula.

factors which increase bmr (test question)

factors which decrease bmr (test question)

bmi ranges:

bad waist circumfrences, risk for type 2 diabetes, dyslipidemia, hypertension and cardiac disease

what is something you want to keep in mind when it comes to stimulating appetite for everyone

when it comes to assisting with eating, what should you not use with patients who have dysphagia (difficulty swallowing)

test question. eggs are a good source of

short term enteral tube

long term enteral feeding tubes

what is something we don't do anymore with pegs

is ng tube clean or sterile? Why

how do u measure length of tube to be inserted for ng tube tip of nose to ear to mid umbilicus
most reliable wau to confirm placement of tubes

if co2 is present when testing tube placement what is going on

PPN can go through

TPN has to go through ___ no matter what

tpn is a very _____ solution (test)

tpn has a lot of ____, why can this be a problem

peripheral parenteral nutrition (ppn) is a ____ solution (test)

When administering TPN, why must you always use a pump?

What is the time limit for hanging lipids with TPN, and what's crucial if you observe oil droplets or a creamy layer?

How do you manage TPN administration for a patient with an egg allergy?

Why should you never add meds to TPN solutions?

What should be monitored every 6 hours for a patient on TPN?

Describe the process of weaning a patient off TPN.

is tpn sterile or clean?

what happens if u abruptly stop tpn

symptoms of hypoglycemia

symptoms of hyperglycemia

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During
the in-service, she informs the group that there are six classes of nutrients, and three
supply the body with energy. What are the three sources of energy?
A) Carbohydrates, protein, and lipids
B) Vitamins, minerals, and water
C) Carbohydrates, protein, and water
D) Lipids, vitamins, and minerals

A patient is discussing weight loss with a nurse. The patient says, I will not eat for 2 weeks, then I will lose at least 10 pounds. What should the nurse tell the patient?
a. What a good idea. Go ahead. That will jump start your weight loss!
b. Many people find that to be an ideal way to lose weight quickly and easily.
c. That will increase your metabolic rate and help you lose weight.
d. That will decrease your metabolic rate and make weight loss more difficult.

In planning to meet the nutritional needs of a critically ill client in the intensive care unit,
which factor will increase the client’s basal metabolic rate?
A) Infection
B) Advanced age
C) Prolonged fasting
D) Long periods of sleep

A client is interested in losing 15 pounds, and she informs the nurse she is counting
her calorie intake each day. The client has a goal of losing one pound a week until
she reaches her goal. The client asks the nurse how many calories she
should decrease daily to lose a pound a week. What is the nurse’s best response? A) 500 calories/day
B) 200 calories/day
C) 300 calories/day
D) 400 calories/day

A nurse is establishing an ideal body weight for a 5’9 healthy female. Based on the rule-of-thumb method, what would be this patients ideal weight?
a. 130 lb
b. 135 lb
c. 140 lb
d. 145 lb

A nurse performing a nutritional assessment determines BMI of a 5-foot 11-inch male patient who weighs 180 pounds. What would be the BMI for this patient? A. 25.1 B. 18.5 C) 20.3 D) 28.6

What health problem may occur in a person who is on a low-carbohydrate diet for a long period of time?
a. obesity
b. fatigue
c. ketosis d. Infection

A hospitalized patient has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition?
a. fever, joint pain, dehydration
b. poor wound healing, apathy, edema
c. sleep disturbances, anger, increased output
d. weight gain, visual deficits, erythema of skin

At what percent of weight over ideal weight is a person considered obese? a. 20%
b. 40% c. 60% d. 100%

What information do anthropometric measurements provide in adults?
A) Indirect measure of protein and fat stores
B) Direct measure of degree of obesity
C) Indication of degree of growth rate
D) Reflection of social interaction with others

A healthy, active 72-year-old woman asks a nurse if it is safe to take dietary supplements and, if so, what should be taken? What would the nurse tell her?
a. Yes, take calcium, vitamin D, and vitamin B12.
b. Yes, take iron, folic acid, and iodine.
c. No, instead increase intake of carbohydrates.
d. No, increase fat intake for fat-soluble vitamins.

A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment?
a. Why dont you eat more meat? You need protein.
b. When did you first notice that you had this sore on your heel?
c. What kinds of foods did you prepare when your husband was alive?
d. What prescribed and over-the-counter medicines do you take?

What independent nursing intervention can be implemented to stimulate appetite?
A) Administer prescribed medications.
B) Recommend dietary supplements.
C) Encourage or provide oral care.
D) Assess manifestations of malnutrition.
100% test question.

A client has been prescribed a clear liquid diet. What food or fluids will be served?
A) Milk, frozen dessert, egg substitutes
B) High-calorie, high-protein supplements
C) Hot cereals, ice cream, chocolate milk
D) Jell-O, carbonated beverages, apple juice
test question.

19. What is the route of administration for TPN? A) Oral B) Subcutaneous
C) Intramuscular
D) Intravenous

A nurse is caring for a client with a history of cardiac and vascular disease. Which of the
following fats should the nurse allow in the client’s diet for his condition?
A) Unsaturated fats
B) Trans fats
C) Saturated fats
D) Hydrogenated fats

A nurse is caring for a young adult female client who has a folic acid defiency. When teaching
the client about this condition, the nurse would include a discussion about the client’s increased risk for which of the following?
A) Neural tube deficits in the fetus
B) Inadequate absorption of calcium and phosphorus
C) Hemolysis of red blood cells
D) Impaired neuromuscular functioning

After the administration of a nasointestinal feeding tube, a patient complains of gas, abdominal pain, and dizziness. What do these symptoms indicate?
a. aspiration of the feeding solution
b. lack of intestinal tone and constipation
c. a type of dumping syndrome
d. an infection of the gastrointestinal system

(TEST QUESTION) A student is following current recommendations for assessing tube placement. A staff nurse says, Oh, just insert air and listen for a whoosh sound. How would the student respond?
a. Thank you. That would be much easier for me to do.
b. That procedure has been found to be unreliable.
c. My instructor told me to do it this way, so I will.
d. I appreciate your advice. Let me ask the patient.

what are the 6 nutrients

which 3 nutrients provide energy

which 3 nutrients are needed to regulate body processes

Which of the following factors increase BMR? Select all that apply.
A) Growth
B)Infections
C)Fever
D)Emotional tension
E) Aging

A nurse has assessed the residual amount before beginning a nasogastric tube feeding and has found 100 mL. What will the nurse do next?
a. Nothing; this amount is within normal limits.
b. Report the finding to the physician.
c. Omit the feeding and document the reason.
d. Rinse the tube and repeat the assessment.

Which laboratory test is the best indicator of a patient in need of TPN?
a. hemoglobin
b. hematocrit
c. serum albumin
d. Creatinine

Which of the following are signs and symptoms of poor nutritional status?
A) Flaky facial skin, facial edema, pale skin color
B) Tongue is a deep red in color with surface papillae present.
C) Firm, pink nailbeds
D) Firm hair that is resistant to plucking

Which of the following laboratory results indicates the presence of malnutrition?
A) Serum albumin 2.8 g/dL
B) Hemoglobin (Hgb) 11.3 g/dL
C) Creatinine 1.9 mg/dL
D) Hematocrit (Hct) 56%

A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a
carbohydrate that should be included to help improve glucose tolerance?
A) Milk
B) Eggs
C) Oatmeal
D) Nuts

A nurse calculates the BMI of a client during a general survey as 26. Under which of the
following categories would this 30. client fall?
A) Underweight
B) Normal
C) Overweight
D) Obesity Class I

A nurse is caring for a client with complaints of chest pain. Which of the following test results
would indicate whether the client is at risk for cardiac disease?
A) Test results of levels of unsaturated fats
B) Test results for dyslipidemia
C) Test results of levels of balanced proteins
D) Test results of levels of calories in each food intake

The nurse prepares to administer an intermittent feeding to a client who has a nasogastric feeding tube. Arrange the following steps in the correct order
1. Verify correct tube placement.
2. Position client with head of bed elevated 30 to 45° degrees 3. Aspirate all gastric contents.
4. Flush tube with 30 mL water.
5. Verify that residual volume is less than 400 mL.
6. Administer feeding.
A) 1,2,3,4,5,6
B) 2,1,3,5,4,6
C) 2,3,1,4,6,5
D) 1,3,2,4,5,6
E) 1,4,2,3,5,6

A nurse researching a diet for a client with diabetes includes foods that supply energy to the
body. Which of the following are classes of nutrients that supply this energy? Select all that apply.
A) Vitamins
B) Proteins
C) Fats
D) Minerals
E) Carbohydrates