Nursing 230 Exam 1 Questions With Complete Solutions
24 hour urine Correct Answers -discard the first void and save
all urine after
-make sure entire healthcare team knows its being collected
-end time have patient void final time and add it to collection
-refrigerate and document
5 moments of hand hygiene Correct Answers -before touching
the patient
-before clean/aseptic procedure
-after body fluid exposure
-after touching patient
-after touching patient surroundings
administering enema Correct Answers Verify orders, Prepare
supplies, Hand hygiene
ID patient
Assess patient, explain procedure, provide privacy
Don PPE, Pad Bed
Position patient in left lateral Sims
Insert tube 3-4 inches
Instruct patient to try to retain
Control flow with clamp or by gravity
Assist patient to commode
Clean patient and bed
Perform hand hygiene
Document
administering tube feedings Correct Answers -bolus vs
continuous
,-gravity vs pump
-confirm placement (x-ray, length of tube, auscultation, pH)
-treat like medical
-medical asepsis
-asses bowel sounds, residual, tolerance
-aspiration risk (HOC at 30 degrees at least)
-flush tube & crushed meds (making sure that nothing is stuck to
it causing clog)
-free water
-changing tubing, syringes ever 24 hours or per policy
adolescent Correct Answers developmental considerations;
increased need for calories, protein and calcium
airborne precautions Correct Answers -used for patients that
have infection that is spread through air
-ex) tuberculosis, varicella, measles, SARS
-patient is placed in negative pressure room
-keep door closed
-gown, gloves, respirator/mask (must be fit tested)
alcohol based Correct Answers use recommended amount (3-
5mL) and rub vigorously covering all surfaces until hands are
completely dry
anuria Correct Answers decreased urine output; less than 100
mL
-this is normal in dialysis
aspiration Correct Answers when oral secretions/content or
gastric contents go into the larynx or respiratory tract
,Signs:
-sudden severe coughing, choking, difficulty breathing/cyanosis,
voice change, gurgling after swallowing, frequent throat clearing
after meals
assessing urinary system Correct Answers History:
-past problems and surgeries (UTI, stones, prostate probs,
incontinence, renal insufficiency), voiding pattern, medication
Current symtptoms:
-COLDSPA, frequency, urgency, and differences
assessment Correct Answers -collection, validation, and
communication of patient data
-make a judgement about the patients health status, ability to
manage his or her own care, and need for nursing assistance
-information to develop individualized care based on patient
strengths and changes to patient's conditions
assisting with eating/feeding Correct Answers loss of
independence can be challenging to patients to cope with
-help maintain dignity: involve patient as much as possible,
engage in conversation, sit eye level and make eye contact, open
containers, cut meat, and apply condiments only if patient
wishes
at risk for infection Correct Answers immunocompromised,
recent surgery, indwelling devices, wound/break in skin,
impaired circulation, chronic or acute diseases, living in
crowded environment, IV drug users, unprotected sex, stress
, bacteria Correct Answers Gram positive/negative, shape (rods,
spheres), aerobic/anaerobic
Barium Enema Correct Answers Examine the large intestine (x
ray done after rectal instillation of barium sulfate)
bladder distention Correct Answers between symphysis pubis
and umbilicus
bladder scanner Correct Answers Tells you how much is left in
the bladder. We move around the wand until bladder is directly
in the cross hair of it.
Only goes up until 999 mL anything greater than that's really
bad.
If bladder is really full and distended youll feel it right below
belly button
bland diet Correct Answers low in spices, fat, and Fiber
blood glucose testing Correct Answers store supplies
appropriately, normal readings are 70 and 105 mg/d,
BMI Correct Answers weight in kg/height in meters squared
- < 18.5 underweight
- 18.5-24.9 normal
- 25.-29.9 overweight
- >30 obese
- >40 extremely obese
BMR Correct Answers energy requirements of body at rest
24 hour urine Correct Answers -discard the first void and save
all urine after
-make sure entire healthcare team knows its being collected
-end time have patient void final time and add it to collection
-refrigerate and document
5 moments of hand hygiene Correct Answers -before touching
the patient
-before clean/aseptic procedure
-after body fluid exposure
-after touching patient
-after touching patient surroundings
administering enema Correct Answers Verify orders, Prepare
supplies, Hand hygiene
ID patient
Assess patient, explain procedure, provide privacy
Don PPE, Pad Bed
Position patient in left lateral Sims
Insert tube 3-4 inches
Instruct patient to try to retain
Control flow with clamp or by gravity
Assist patient to commode
Clean patient and bed
Perform hand hygiene
Document
administering tube feedings Correct Answers -bolus vs
continuous
,-gravity vs pump
-confirm placement (x-ray, length of tube, auscultation, pH)
-treat like medical
-medical asepsis
-asses bowel sounds, residual, tolerance
-aspiration risk (HOC at 30 degrees at least)
-flush tube & crushed meds (making sure that nothing is stuck to
it causing clog)
-free water
-changing tubing, syringes ever 24 hours or per policy
adolescent Correct Answers developmental considerations;
increased need for calories, protein and calcium
airborne precautions Correct Answers -used for patients that
have infection that is spread through air
-ex) tuberculosis, varicella, measles, SARS
-patient is placed in negative pressure room
-keep door closed
-gown, gloves, respirator/mask (must be fit tested)
alcohol based Correct Answers use recommended amount (3-
5mL) and rub vigorously covering all surfaces until hands are
completely dry
anuria Correct Answers decreased urine output; less than 100
mL
-this is normal in dialysis
aspiration Correct Answers when oral secretions/content or
gastric contents go into the larynx or respiratory tract
,Signs:
-sudden severe coughing, choking, difficulty breathing/cyanosis,
voice change, gurgling after swallowing, frequent throat clearing
after meals
assessing urinary system Correct Answers History:
-past problems and surgeries (UTI, stones, prostate probs,
incontinence, renal insufficiency), voiding pattern, medication
Current symtptoms:
-COLDSPA, frequency, urgency, and differences
assessment Correct Answers -collection, validation, and
communication of patient data
-make a judgement about the patients health status, ability to
manage his or her own care, and need for nursing assistance
-information to develop individualized care based on patient
strengths and changes to patient's conditions
assisting with eating/feeding Correct Answers loss of
independence can be challenging to patients to cope with
-help maintain dignity: involve patient as much as possible,
engage in conversation, sit eye level and make eye contact, open
containers, cut meat, and apply condiments only if patient
wishes
at risk for infection Correct Answers immunocompromised,
recent surgery, indwelling devices, wound/break in skin,
impaired circulation, chronic or acute diseases, living in
crowded environment, IV drug users, unprotected sex, stress
, bacteria Correct Answers Gram positive/negative, shape (rods,
spheres), aerobic/anaerobic
Barium Enema Correct Answers Examine the large intestine (x
ray done after rectal instillation of barium sulfate)
bladder distention Correct Answers between symphysis pubis
and umbilicus
bladder scanner Correct Answers Tells you how much is left in
the bladder. We move around the wand until bladder is directly
in the cross hair of it.
Only goes up until 999 mL anything greater than that's really
bad.
If bladder is really full and distended youll feel it right below
belly button
bland diet Correct Answers low in spices, fat, and Fiber
blood glucose testing Correct Answers store supplies
appropriately, normal readings are 70 and 105 mg/d,
BMI Correct Answers weight in kg/height in meters squared
- < 18.5 underweight
- 18.5-24.9 normal
- 25.-29.9 overweight
- >30 obese
- >40 extremely obese
BMR Correct Answers energy requirements of body at rest
