What is the removal of devitalized tissue from a wound called?
a. debridement
b. pressure reduction
c. negative pressure wound therapy
d. sanitization - ANSWER a. debridement
Which of the following skills can the nurse delegate to nursing assistive personnel? Select all
that apply.
a. nasotracheal suctioning
b. oropharyngeal suctioning of a stable patient
c. suctioning a new artificial airway
d. permanent tracheostomy tube suctioning
e. care of an endotracheal tube - ANSWER b. oropharyngeal suctioning of a stable patient
d. permanent tracheostomy tube suctioning
Place the following in correct sequence for suctioning a patient.
1. open kit and basin
2. apply gloves
3. lubricate catheter
4. verify functioning of suction device and pressure
5. connect suction tubing to suction catheter
6. increased supplemental oxygen
7. reapply oxygen
8. suction airway - ANSWER 4. verify functioning of suction device and pressure
6. increased supplemental oxygen
1
,1. open kit and basin
3. lubricate catheter
2. apply gloves
5. connect suction tubing to suction catheter
8. suction airway
7. reapply oxygen
A patient was admitted following a motor vehicle accident with multiple fractured ribs. Res-
piratory assessment includes signs/symptoms of secondary pneumothorax. Which are the
most common assessment findings associated with a pneumothorax? Select all that apply.
a. sharp pleuritic pain that worsens on inspiration
b. crackles over lung bases of affected lung
c. tracheal deviation toward the affected lung
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side - ANSWER a. sharp pleuritic pain
that worsens on inspiration
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple
and cost-effective method for reducing the risks of pulmonary complication?
a. antibiotics
b. frequent change of position
c. oxygen humidification
d. chest physiotherapy - ANSWER B (Frequent change of position)
(Movement not only mobilizes secretions but helps strengthen respiratory muscles by im-
pacting the effectiveness of gas exchange processes.)
2
,A nurse in a provider's office is evaluating a client who reports losing control of urine when-
ever she coughs, laughs, or sneezes. THe client relates a history of three vaginal births, but
no serious accidents or illnesses. Which of the following interventions should the nurse sug-
gest for helping to control or eliminate the client's incontinence? Select all that apply.
A. limit total daily fluid intake
B. decrease or avoid caffeine
C. take calcium supplements
D. avoid drinking alcohol
E. use the Crede maneuver. - ANSWER B. Decrease or avoid caffeine
D. Avoid drinking alcohol
A client who has an indwelling catheter reports a need to urinate. which of the following ac-
tions should the nurse take?
a) check to see whether to catheter is patent
b) reassure the client that it is not possible for her to urinate
c) recatheterize the bladder with a larger-gauge catheter
d) collect a urine specimen for analysis - ANSWER A. Check to see whether the catheter is
patent.
A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the
following actions should the nurse take?
A. discard the first voiding.
B. keep the urine in a single container at room temperature.
C. ask the client to urinate and pour the urine into a specimen container.
D. ask the client to urinate into the toilet, stop midstream, and finish urinating into the speci-
men container. - ANSWER A. discard the first voiding.
A nurse is reviewing factors that increase the risk of urinary tract infections with a client who
has recurrent UTIs. Which of the following factors should the nurse include? Select all that
apply.
3
, A. frequent sexual intercourse.
B. lowering of testosterone levels.
C. wiping from front to back.
D. location of urethra in relation to the anus.
E. frequent catheterization. - ANSWER A. frequent sexual intercourse
D. location of the urethra in relation to the anus.
E. frequent catheterization
A nurse is preparing to initiate a bladder-retraining program for a client who has inconti-
nence. Which for the following actions should the nurse take? Select all that apply.
A. Establish a schedule of urinating prior to meal times.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time.
E. provide a sterile container for urine. - ANSWER B. have the client record urination
times.
C. gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time.
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for
hypoxemia. Which of the following findings are early indications that should alert the nurse
that the client is developing hypoxemia? Select all that apply.
A. restlessness
B. tachypnea
C. bradycardia
D. confusion
E. pallor - ANSWER A. restlessness
B. tachypnea
D. confusion
4
a. debridement
b. pressure reduction
c. negative pressure wound therapy
d. sanitization - ANSWER a. debridement
Which of the following skills can the nurse delegate to nursing assistive personnel? Select all
that apply.
a. nasotracheal suctioning
b. oropharyngeal suctioning of a stable patient
c. suctioning a new artificial airway
d. permanent tracheostomy tube suctioning
e. care of an endotracheal tube - ANSWER b. oropharyngeal suctioning of a stable patient
d. permanent tracheostomy tube suctioning
Place the following in correct sequence for suctioning a patient.
1. open kit and basin
2. apply gloves
3. lubricate catheter
4. verify functioning of suction device and pressure
5. connect suction tubing to suction catheter
6. increased supplemental oxygen
7. reapply oxygen
8. suction airway - ANSWER 4. verify functioning of suction device and pressure
6. increased supplemental oxygen
1
,1. open kit and basin
3. lubricate catheter
2. apply gloves
5. connect suction tubing to suction catheter
8. suction airway
7. reapply oxygen
A patient was admitted following a motor vehicle accident with multiple fractured ribs. Res-
piratory assessment includes signs/symptoms of secondary pneumothorax. Which are the
most common assessment findings associated with a pneumothorax? Select all that apply.
a. sharp pleuritic pain that worsens on inspiration
b. crackles over lung bases of affected lung
c. tracheal deviation toward the affected lung
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side - ANSWER a. sharp pleuritic pain
that worsens on inspiration
d. worsening dyspnea
e. absent lung sounds to auscultation on affected side
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple
and cost-effective method for reducing the risks of pulmonary complication?
a. antibiotics
b. frequent change of position
c. oxygen humidification
d. chest physiotherapy - ANSWER B (Frequent change of position)
(Movement not only mobilizes secretions but helps strengthen respiratory muscles by im-
pacting the effectiveness of gas exchange processes.)
2
,A nurse in a provider's office is evaluating a client who reports losing control of urine when-
ever she coughs, laughs, or sneezes. THe client relates a history of three vaginal births, but
no serious accidents or illnesses. Which of the following interventions should the nurse sug-
gest for helping to control or eliminate the client's incontinence? Select all that apply.
A. limit total daily fluid intake
B. decrease or avoid caffeine
C. take calcium supplements
D. avoid drinking alcohol
E. use the Crede maneuver. - ANSWER B. Decrease or avoid caffeine
D. Avoid drinking alcohol
A client who has an indwelling catheter reports a need to urinate. which of the following ac-
tions should the nurse take?
a) check to see whether to catheter is patent
b) reassure the client that it is not possible for her to urinate
c) recatheterize the bladder with a larger-gauge catheter
d) collect a urine specimen for analysis - ANSWER A. Check to see whether the catheter is
patent.
A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the
following actions should the nurse take?
A. discard the first voiding.
B. keep the urine in a single container at room temperature.
C. ask the client to urinate and pour the urine into a specimen container.
D. ask the client to urinate into the toilet, stop midstream, and finish urinating into the speci-
men container. - ANSWER A. discard the first voiding.
A nurse is reviewing factors that increase the risk of urinary tract infections with a client who
has recurrent UTIs. Which of the following factors should the nurse include? Select all that
apply.
3
, A. frequent sexual intercourse.
B. lowering of testosterone levels.
C. wiping from front to back.
D. location of urethra in relation to the anus.
E. frequent catheterization. - ANSWER A. frequent sexual intercourse
D. location of the urethra in relation to the anus.
E. frequent catheterization
A nurse is preparing to initiate a bladder-retraining program for a client who has inconti-
nence. Which for the following actions should the nurse take? Select all that apply.
A. Establish a schedule of urinating prior to meal times.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time.
E. provide a sterile container for urine. - ANSWER B. have the client record urination
times.
C. gradually increase the urination intervals.
D. remind the client to hold urine until the next scheduled urination time.
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for
hypoxemia. Which of the following findings are early indications that should alert the nurse
that the client is developing hypoxemia? Select all that apply.
A. restlessness
B. tachypnea
C. bradycardia
D. confusion
E. pallor - ANSWER A. restlessness
B. tachypnea
D. confusion
4
