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1. While working on a long term care unit, health care aid (HCA) asks the nurse if
they could chart the bowel care that the HCA did earlier this morning. Which of
the following in true concerning charting?
a. As a team leader the nurse should take this opportunity to provide education to
the HCA on the importance of charting
b. It is acceptable for the nurse to chart in this instance because the HCA is. to
regulated
c. The nurse is required to report the HCA to the manager as the HCAs conduct is
unprofessional
d. The nurse should refuse the request and tell the HCA to chart whenever they
have time - ANSWER a. As a team leader the nurse should take this
opportunity to provide education to the HCA on the importance of charting
2. A patient expresses fear of going home and being alone. Her vital sigma are
stable and her incision is nearly completely healed. What can the nurse infer from
the subjective data?
a. The patient can begin retaking all her previous medications
b. The patient can now perform the dressing change herself
c. The patient is apprehensive about discharge
d. The wound is healing as expected and the surgery was a success - ANSWER
c. The patient is apprehensive about discharge
,A blowing sound osculated over the carotid artery is know as bruit
3. Which nursing intervention is most effective in promoting normal defencies for
a patient who has muscle weakness in the legs that prevents ambulation?
a. Give the patient a pillow to brace against the abdomen while bearing dowm
b. Elevate the head of the bed 45 degrees 60 minutes after breakfast
c. Uses a mobility device to replace a patient on a bedside commode
d. Administer a soup suds enema every 2 hours - ANSWER c. Uses a mobility
device to replace a patient on a bedside commode
11. The patient has just been started on an internal feeding and has developed
diarrhea after being on the feeding for 2 hours. What is the most likely cause of
diarrhea
a. Bacterial contamination
b. Clostridium difficile
c. Formula intolerance
d. Antibiotic therapy - ANSWER c. Formula intolerance
12. The nurse is concerned about pulmonary aspiration when providing her
patient with tube feedings. How should the nurse proceed?
a.Add blue food colouring to the enteral formula
b. Run the formula over 12 hours to decrease volume
c. verify tube placement before feeding
,d. lower the head of the bed to a supine position - ANSWER c. verify tube
placement before feeding
13. When performing an abdominal assessment on a resident, you would carry
out:
a. Visual inspection of abdomen
b. Auscultation of bowel sounds in all four quadrants
c. Palpation of abdomen for masses & pain
d. All of the above - ANSWER d. All of the above
14. Injuries among older adults resulting from falls in the home are due to
intrinsic and extrinsic factors. Which one of the following is an example of an
extrinsic factor?
a. Illness
b. Environmental obstacles
c. Drug therapy
d. Alcohol use - ANSWER b. Environmental obstacles
15. When performing a physical musculoskeletal assessment, an LPN would
include:
a. Palpation of muscle mass
b. Inspection of posture
c. Observe of gait
, d. All of the above - ANSWER d. All of the above
16. Which of the following is the most accurate way to determine the correct
placement of a newly inserted tube feed?
a. Patient description of placement
b. X-ray
c. ph of aspirated contents
d. Surgical report from physcian - ANSWER b. X-ray
17. true or false - ANSWER true
A patient with a Glasgow coma scale score of 15 would be considered to be in a
coma
18. true or false - ANSWER false
Certain medications, like chemotherapeutics or steroids may impede wound
healing.
19. true or false - ANSWER
When administering a fleet, the patient should be lying on their right side.
20. true or false - ANSWER false