6001 FINAL PRACTICE QUESTIONS
1. A nurse caring for a patient with chronic obstructive pulmonary disease (COPD)
knows that hypoxia may occur in patients with respiratory problems. What are signs of
this serious condition?
Select all answers that apply.
A. Dyspnea
B .Hypotension
C. Small pulse pressure
D. Decreased respiratory rate
E. Pallor
F. Increased pulse rate - ANS - 1. a, c, e, f. If a problem exists in ventilation,
respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an
inadequate amount of oxygen is available to cells. The most common symptoms of
hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small
pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
1. A nurse is caring for an older patient with type II diabetes who is living in a long-term
care facility. The nurse determines that the patient's fluid intake and output is
approximately 1200 mL daily. What patient teaching would the nurse provide for this
patient? Select all that apply.
A. "Try to drink at least six to eight glasses of water each day."
B. "Try to limit your fluid intake to one quart of water daily."
C. "Limit sugar, salt, and alcohol in your diet."
D. "Report side effects of medications you are taking, especially diarrhea."
E. "Temporarily increase foods containing caffeine for their diuretic effect."
F. "Weigh yourself daily and report any changes in your weight." - ANS - A, C, D, F
Generally, fluid intake and output averages 2,600 mL per day. This patient is
experiencing dehydration and should be encouraged to drink more water, maintain
normal body weight, avoid consuming excess amounts of products high in salt, sugar,
and caffeine, limit alcohol intake, and monitor side effects of medications, especially
diarrhea and water loss from diuretics.
,1. Thirty-six hours after having surgery, a patient has a slightly elevated body
temperature and generalized malaise, as well as pain and redness at the surgical site.
Which intervention is most important to include in this patient's nursing care plan?
A. Document the findings and continue to monitor the patient.
B. Administer antipyretics, as ordered.
C. Increase the frequency of assessment to every hour and notify the patient's primary
care provider.
D. Increase the frequency of wound care and contact the primary care provider for an
antibiotic order - ANS - A.
The assessment findings are normal for this stage of healing following surgery. The
patient is in the inflammatory phase of the healing process, which involves a response
by the immune system. This acute inflammation is characterized by pain, heat, redness,
and swelling at the site of the injury (surgery, in this case). The patient also has a
generalized body response, including a mildly elevated temperature, leukocytosis, and
generalized malaise.
10. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to
abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to
a house diet as tolerated. Which assessments would indicate to the nurse that the
patient's diet should not be advanced?
A. The patient consumed 75% of the liquids on her breakfast tray.
B. The patient tells you she is hungry.
C. The patient's abdomen is soft, nondistended, with bowel sounds.
D. The patient reports fullness and diarrhea after breakfast. - ANS - D
10. A nurse is explaining to a patient the anticipated effect of the application of cold to
an injured area. What response indicates that the patient understands the explanation?
A. "I can expect to have more discomfort in the area where the cold is applied."
B. "I should expect more drainage from the incision after the ice has been in place."
C. "I should see less swelling and redness with the cold treatment."
D. "My incision may bleed more when the ice is first applied." - ANS - C
10. A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing
intervention would be appropriate for this patient?
A. Encourage foods and fluids with high sodium content.
B. Administer oral K supplements as ordered.
,C. Caution the patient about eating foods high in potassium content.
D. Discuss calcium-losing aspects of nicotine and alcohol use. - ANS - B
Nursing interventions for a patient with hypokalemia include encouraging foods high in
potassium and administering oral K as ordered.
Encouraging foods with high sodium content is appropriate for a patient with
hyponatremia.
Cautioning the patient about foods high in potassium is appropriate for a patient with
hyperkalemia,
and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for
a patient with hypocalcemia.
10. When planning care for a patient with chronic lung disease who is receiving oxygen
through a nasal cannula, what does the nurse expect?
A. The oxygen must be humidified.
B. The rate will be no more than 2 to 3 L/min or less.
C. Arterial blood gases will be drawn every 4 hours to assess flow rate.
D. The rate will be 6 L/min or more. - ANS - b. A rate higher than 3 L/min may destroy
the hypoxic drive that stimulates respirations in the medulla in a patient with chronic
lung disease. Oxygen delivered at low rates does not necessarily have to be humidified,
and arterial blood gases are not required at regular intervals to determine the flow rate.
11. A nurse is administering 500 mL of saline solution to a patient over 10 hours. The
administration set delivers 60 gtts/min. Determine the infusion rate to administer via
gravity infusion.
Place your answer on the line provided below. - ANS - Ans: 50 gtts/min. When
administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the
nurse would use the following formula:
gtt/min= 500x60/600= 50gtt/min
11. A nurse is providing patient teaching regarding the use of negative-pressure wound
therapy. Which explanation provides the most accurate information to the patient?
A. The therapy is used to collect excess blood loss and prevent the formation of a scab.
B. The therapy will prevent infection, ensuring that the wound heals with less scar
tissue.
C. The therapy provides a moist environment and stimulates blood flow to the wound.
, D. The therapy irrigates the wound to keep it free from debris and excess wound fluid. -
ANS - c. Negative-pressure wound therapy (or topical negative pressure [TNP])
promotes wound healing and wound closure through the application of uniform negative
pressure on the wound bed, reduction in bacteria in the wound, and the removal of
excess wound fluid, while providing a moist wound healing environment.
The negative pressure results in mechanical tension on the wound tissues, stimulating
cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used
to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds
failing to heal, or healing slowly.
11. A nurse is securing a patient's endotracheal tube with tape and observes that the
tube depth changed during the retaping. Which action would be appropriate related to
this incident?
A. Instruct assistant to notify the primary care provider.
B. Assess the patient's vital signs.
C. Remove the tape, adjust the depth to ordered depth and reapply the tape.
D. No action is required as depth will adjust automatically - ANS - c. The tube depth
should be maintained at the same level unless otherwise ordered by the physician. If
the depth changes, the nurse should remove the tape, adjust the tube to ordered depth,
and reapply the tape
11. A patient who is moved to a hospital bed following throat surgery is ordered to
receive continuous tube feedings through a small-bore nasogastric tube. Following
placement of the tube, which nursing action would the nurse initiate to ensure correct
placement of the tube?
A. Auscultate the bowel sounds.
B. Measure the gastric aspirate pH.
C. Measure the amount of residual in the tube.
D. Order radiographic examination of the tube. - ANS - D
12. A nurse is initiating a peripheral venous access IV infusion for a patient. Following
the procedure, the nurse observes that the fluid does not flow easily into the vein and
the skin around the insertion site is edematous and cool to the touch. What would be
the nurse's next action related to these findings?
A. Reposition the extremity and raise the height of the IV pole.
B. Apply pressure to the dressing on the IV.
C. Pull the catheter out slightly and reinsert it.
D. Put on gloves; remove the catheter; apply pressure with a sterile pad. - ANS - D
1. A nurse caring for a patient with chronic obstructive pulmonary disease (COPD)
knows that hypoxia may occur in patients with respiratory problems. What are signs of
this serious condition?
Select all answers that apply.
A. Dyspnea
B .Hypotension
C. Small pulse pressure
D. Decreased respiratory rate
E. Pallor
F. Increased pulse rate - ANS - 1. a, c, e, f. If a problem exists in ventilation,
respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an
inadequate amount of oxygen is available to cells. The most common symptoms of
hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small
pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
1. A nurse is caring for an older patient with type II diabetes who is living in a long-term
care facility. The nurse determines that the patient's fluid intake and output is
approximately 1200 mL daily. What patient teaching would the nurse provide for this
patient? Select all that apply.
A. "Try to drink at least six to eight glasses of water each day."
B. "Try to limit your fluid intake to one quart of water daily."
C. "Limit sugar, salt, and alcohol in your diet."
D. "Report side effects of medications you are taking, especially diarrhea."
E. "Temporarily increase foods containing caffeine for their diuretic effect."
F. "Weigh yourself daily and report any changes in your weight." - ANS - A, C, D, F
Generally, fluid intake and output averages 2,600 mL per day. This patient is
experiencing dehydration and should be encouraged to drink more water, maintain
normal body weight, avoid consuming excess amounts of products high in salt, sugar,
and caffeine, limit alcohol intake, and monitor side effects of medications, especially
diarrhea and water loss from diuretics.
,1. Thirty-six hours after having surgery, a patient has a slightly elevated body
temperature and generalized malaise, as well as pain and redness at the surgical site.
Which intervention is most important to include in this patient's nursing care plan?
A. Document the findings and continue to monitor the patient.
B. Administer antipyretics, as ordered.
C. Increase the frequency of assessment to every hour and notify the patient's primary
care provider.
D. Increase the frequency of wound care and contact the primary care provider for an
antibiotic order - ANS - A.
The assessment findings are normal for this stage of healing following surgery. The
patient is in the inflammatory phase of the healing process, which involves a response
by the immune system. This acute inflammation is characterized by pain, heat, redness,
and swelling at the site of the injury (surgery, in this case). The patient also has a
generalized body response, including a mildly elevated temperature, leukocytosis, and
generalized malaise.
10. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to
abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to
a house diet as tolerated. Which assessments would indicate to the nurse that the
patient's diet should not be advanced?
A. The patient consumed 75% of the liquids on her breakfast tray.
B. The patient tells you she is hungry.
C. The patient's abdomen is soft, nondistended, with bowel sounds.
D. The patient reports fullness and diarrhea after breakfast. - ANS - D
10. A nurse is explaining to a patient the anticipated effect of the application of cold to
an injured area. What response indicates that the patient understands the explanation?
A. "I can expect to have more discomfort in the area where the cold is applied."
B. "I should expect more drainage from the incision after the ice has been in place."
C. "I should see less swelling and redness with the cold treatment."
D. "My incision may bleed more when the ice is first applied." - ANS - C
10. A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing
intervention would be appropriate for this patient?
A. Encourage foods and fluids with high sodium content.
B. Administer oral K supplements as ordered.
,C. Caution the patient about eating foods high in potassium content.
D. Discuss calcium-losing aspects of nicotine and alcohol use. - ANS - B
Nursing interventions for a patient with hypokalemia include encouraging foods high in
potassium and administering oral K as ordered.
Encouraging foods with high sodium content is appropriate for a patient with
hyponatremia.
Cautioning the patient about foods high in potassium is appropriate for a patient with
hyperkalemia,
and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for
a patient with hypocalcemia.
10. When planning care for a patient with chronic lung disease who is receiving oxygen
through a nasal cannula, what does the nurse expect?
A. The oxygen must be humidified.
B. The rate will be no more than 2 to 3 L/min or less.
C. Arterial blood gases will be drawn every 4 hours to assess flow rate.
D. The rate will be 6 L/min or more. - ANS - b. A rate higher than 3 L/min may destroy
the hypoxic drive that stimulates respirations in the medulla in a patient with chronic
lung disease. Oxygen delivered at low rates does not necessarily have to be humidified,
and arterial blood gases are not required at regular intervals to determine the flow rate.
11. A nurse is administering 500 mL of saline solution to a patient over 10 hours. The
administration set delivers 60 gtts/min. Determine the infusion rate to administer via
gravity infusion.
Place your answer on the line provided below. - ANS - Ans: 50 gtts/min. When
administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the
nurse would use the following formula:
gtt/min= 500x60/600= 50gtt/min
11. A nurse is providing patient teaching regarding the use of negative-pressure wound
therapy. Which explanation provides the most accurate information to the patient?
A. The therapy is used to collect excess blood loss and prevent the formation of a scab.
B. The therapy will prevent infection, ensuring that the wound heals with less scar
tissue.
C. The therapy provides a moist environment and stimulates blood flow to the wound.
, D. The therapy irrigates the wound to keep it free from debris and excess wound fluid. -
ANS - c. Negative-pressure wound therapy (or topical negative pressure [TNP])
promotes wound healing and wound closure through the application of uniform negative
pressure on the wound bed, reduction in bacteria in the wound, and the removal of
excess wound fluid, while providing a moist wound healing environment.
The negative pressure results in mechanical tension on the wound tissues, stimulating
cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used
to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds
failing to heal, or healing slowly.
11. A nurse is securing a patient's endotracheal tube with tape and observes that the
tube depth changed during the retaping. Which action would be appropriate related to
this incident?
A. Instruct assistant to notify the primary care provider.
B. Assess the patient's vital signs.
C. Remove the tape, adjust the depth to ordered depth and reapply the tape.
D. No action is required as depth will adjust automatically - ANS - c. The tube depth
should be maintained at the same level unless otherwise ordered by the physician. If
the depth changes, the nurse should remove the tape, adjust the tube to ordered depth,
and reapply the tape
11. A patient who is moved to a hospital bed following throat surgery is ordered to
receive continuous tube feedings through a small-bore nasogastric tube. Following
placement of the tube, which nursing action would the nurse initiate to ensure correct
placement of the tube?
A. Auscultate the bowel sounds.
B. Measure the gastric aspirate pH.
C. Measure the amount of residual in the tube.
D. Order radiographic examination of the tube. - ANS - D
12. A nurse is initiating a peripheral venous access IV infusion for a patient. Following
the procedure, the nurse observes that the fluid does not flow easily into the vein and
the skin around the insertion site is edematous and cool to the touch. What would be
the nurse's next action related to these findings?
A. Reposition the extremity and raise the height of the IV pole.
B. Apply pressure to the dressing on the IV.
C. Pull the catheter out slightly and reinsert it.
D. Put on gloves; remove the catheter; apply pressure with a sterile pad. - ANS - D
