Answers
1. What is the greatest risk for a pre-op patient who has had an NGT
to decom- press the stomach for 3 days?
A. Physical Injury
B. Ineffective social interaction
C. Decreased nutritional intake
D. Altered oral mucous membranes
Answer C. Decreased nutritional intake
2. Which is the first assessment that should be performed by the
nurse before planning to meet the hygiene needs of a pt?
A. Recognize the patient's developmental stage
B. Collect the patient's toiletries needed for the bath
C. Indentify the patient's ability to assist in hygiene activities
D. Determine the patient's preferences
Answer C. Determine the patient's preferences about hygiene practices.
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, 3. Nurses should monitor for which systemic responses in
immobilized pa- tients?
Select all that apply.
A. Pressure ulcer
B. Dependent edema
C. Pneumonia
D. Plantar flexion contrature
Answer Pneumonia, Dependent edema
4. What is the primary rationale for a 2 hour turning and
positioning routine for an immobilized bed-bound patient
A. Facilitates respiratory
B. supports comfort
C. promotes elimination
D. Maintains tissue integrity
Answer D. Maintains tissue integrity
5. What diet should be ordered for an older adult with no teeth
and reports of difficulty eating?
A. Liquid diet
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