Exam 2 |Highly Rated| Questions and Answers| Rasmussen
College
1. The nurse has assessed that a patient's stool has changed from brown to dark black and
sticky. The nurse suspects:
- Presence of occult blood.
2. The nurse in a long-term care facility understands that the 86-year-old resident's frequent
complains about "heartburn" are most likely due to the age-related decreased:
- Sphincter tone.
3. The nurse informs the patient who is to have an electroencephalogram (EEG) that the
technician will try to stimulate seizure activity by asking the patient to: (Select all that
apply)
- -hyperventilate.
- -breathe in a rapid shallow fashion.
- -hold a flashing light over his face.
4. The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing
intervention in the care of such patient would be to:
- Place a sieve over the commode.
,5. The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour
ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse
should:
- outline the area of drainage with a pen and mark it with the date and time.
6. The nurse assisting with an admission assessment of a patient with hypertension. While
the nurse is preparing to weigh the patient, the patient states, "it is not necessary to weigh
me, because I weighed 130 pounds last week." What would be the nurse's best response?
- "It is important to get a more recent weight."
7. The nurse is aware that one of the time-flexible tasks to be accomplished would be:
- taking the patient's vital signs once a day.
8. The nurse is aware that patients who are admitted to the hospital as a routine admission
under a managed care plan must:
- Be pre-approved.
9. The nurse is caring for an anxious patient who is scheduled for surgery for colostomy
placement. While the nurse is talking to the patient, the patient states, "I am so scared."
The nurse's most supportive response would be:
- "What about your colostomy scares you?."
, 10. The nurse is performing an initial assessment on a patient with respiratory difficulty. The
nurse would anticipate documenting signs and symptoms such as:
- Use of accessory muscles
11. The nurse monitoring patients eating in the dining room of a skilled nursing facility notes
that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver,
the fist should be positioned:
- halfway between the xiphoid process and the umbilicus
12. The nurse obtaining a wound culture would:
- place the swab in the culture tube without touching the sides
13. The nurse performing a focused assessment on pain will assess: (Select all that apply)
- -verbal indicators.
- -contributing factors.
- -phycological factors.
- -history of pain.
14. The nurse performing tracheotomy care will:
- suction tracheotomy before beginning care.