PN 2006 PRE
LEC/QUIZZES/MIDTERM REVIEW
QUESTIONS AND CORRECT
ANSWERS
An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's
disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
1. Confusion
2. Impaired judgment
3. Sensory deficits
4. History of falls ANSW✅✅4. History of falls
A 79 year old resident in a long term care facility is known to "wander" at night and has fallen in the
past. Which of the following nursing interventions is the most appropriate for this client?
a. The client should be checked frequently during the night
b. An abdominal restraint should be placed on the client during sleeping hours
c. The client should be placed in a room away from the acidity of the nursing station
d. A radio should be left playing at the bedside to assist in reality orientation ANSW✅✅a. The
client should be checked frequently during the night
Application of cold will cause vasodilation and will therefore help to relive pain
true or false ANSW✅✅false
While caring for a patient, the nurse determines that he has a rating of 6 on the Glasgow coma scale.
The nurse understands that:
,a. He has received the highest possible score
b. His is not in a coma
c. He is in a coma
d. He has received the lowest possible score ANSW✅✅c. He is in a coma
A patient has no bowel sounds in his upper left quadrant. After listening carefully for 10 seconds,
you believe that:
a. The patient may have a bowel obstruction
b. You need to listen longer in all quadrants
c. This is a medical emergency
d. The patient may have an ileus ANSW✅✅b. You need to listen longer in all quadrants
A patient's tube feed has finished running through. Which of the following nursing measures would
be helpful in preventing clogging in the tubing?
a. remove feeding tube from the patient's abdomen
b. flush with 20-30 ml of water after feed
c. ascertain that feeding tube is in correct position by sending the patient for an x-ray
d. leave the patient in left lateral sim's position ANSW✅✅b. flush with 20-30 ml of water after
feed
Assisting with oral care will help to enhance a patient sense of taste.
true or false ANSW✅✅true
Abnormal gait in a patient, might include, staggering, foot scarping, or high stepping
true or false ANSW✅✅true
,Prior to commencing a patient's tube feed, it is important to remember to position the patient in
supine position
true or false ANSW✅✅false
Which of the following should be completed with a patient sustains an un-witnessed fall?
a. a neurological system assessment
b. a muscular system assessment
c. a skeletal system assessment
d. all of the above ANSW✅✅d. all of the above
Which of the following is not part of a neurological assessment?
a. level of consciousness
b. muscle strength
c. orientation
d. dietary changes ANSW✅✅d. dietary changes
The nurse is listening to the patient's lungs. Which information should the nurse use to document
normal patient lung sounds?
a. inspiratory wheezing in the upper lobes
b. no adventitious breath sounds
c. rales in the right lower lobe
d. pleural friction rub in the left lung ANSW✅✅b. no adventitious breath sounds
the patient is being assessed for a possible respiratory problem. In which position should the patient
be placed to facilitate chest expansion during a thoracic assessment ?
a. high fowlers
b. Doral recumbent
, c. side-lying
d. prone ANSW✅✅a. high fowlers
an oxygen saturation of level of 85%-95% would be considered normal
true or false ANSW✅✅false
Wheezes can be described as high-pitched musical sounds that are heard on inspiration and
expiration
true or false ANSW✅✅true
The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction by the
nurse has been effective if the patient breathes in which manner?
a. takes a deep breath and holds it
b. breathes with the mouth open
c. coughs and then takes a deep breath
d. takes rapid shallow breaths ANSW✅✅b. breathes with the mouth open
A home care patient receives oxygen by nonbreather (NRB) mask. Which does the nurse include
when teaching the caregiver about the oxygen delivery system?
a. Keep the plastic bag at the end of the mask inflated
b. offer fluids frequently and apply moisturizer to prevent dry skin
c. Remove the elastic head strap to prevent skin breakdown at the ears
d. Adjust the oxygen flow rate whenever the patient feels like the need more oxygen ANSW✅✅a.
Keep the plastic bag at the end of the mask inflated
The nurse teaches the patient controlled coughing. Which action should the nurse include in patient
teaching effective coughing?
LEC/QUIZZES/MIDTERM REVIEW
QUESTIONS AND CORRECT
ANSWERS
An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's
disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
1. Confusion
2. Impaired judgment
3. Sensory deficits
4. History of falls ANSW✅✅4. History of falls
A 79 year old resident in a long term care facility is known to "wander" at night and has fallen in the
past. Which of the following nursing interventions is the most appropriate for this client?
a. The client should be checked frequently during the night
b. An abdominal restraint should be placed on the client during sleeping hours
c. The client should be placed in a room away from the acidity of the nursing station
d. A radio should be left playing at the bedside to assist in reality orientation ANSW✅✅a. The
client should be checked frequently during the night
Application of cold will cause vasodilation and will therefore help to relive pain
true or false ANSW✅✅false
While caring for a patient, the nurse determines that he has a rating of 6 on the Glasgow coma scale.
The nurse understands that:
,a. He has received the highest possible score
b. His is not in a coma
c. He is in a coma
d. He has received the lowest possible score ANSW✅✅c. He is in a coma
A patient has no bowel sounds in his upper left quadrant. After listening carefully for 10 seconds,
you believe that:
a. The patient may have a bowel obstruction
b. You need to listen longer in all quadrants
c. This is a medical emergency
d. The patient may have an ileus ANSW✅✅b. You need to listen longer in all quadrants
A patient's tube feed has finished running through. Which of the following nursing measures would
be helpful in preventing clogging in the tubing?
a. remove feeding tube from the patient's abdomen
b. flush with 20-30 ml of water after feed
c. ascertain that feeding tube is in correct position by sending the patient for an x-ray
d. leave the patient in left lateral sim's position ANSW✅✅b. flush with 20-30 ml of water after
feed
Assisting with oral care will help to enhance a patient sense of taste.
true or false ANSW✅✅true
Abnormal gait in a patient, might include, staggering, foot scarping, or high stepping
true or false ANSW✅✅true
,Prior to commencing a patient's tube feed, it is important to remember to position the patient in
supine position
true or false ANSW✅✅false
Which of the following should be completed with a patient sustains an un-witnessed fall?
a. a neurological system assessment
b. a muscular system assessment
c. a skeletal system assessment
d. all of the above ANSW✅✅d. all of the above
Which of the following is not part of a neurological assessment?
a. level of consciousness
b. muscle strength
c. orientation
d. dietary changes ANSW✅✅d. dietary changes
The nurse is listening to the patient's lungs. Which information should the nurse use to document
normal patient lung sounds?
a. inspiratory wheezing in the upper lobes
b. no adventitious breath sounds
c. rales in the right lower lobe
d. pleural friction rub in the left lung ANSW✅✅b. no adventitious breath sounds
the patient is being assessed for a possible respiratory problem. In which position should the patient
be placed to facilitate chest expansion during a thoracic assessment ?
a. high fowlers
b. Doral recumbent
, c. side-lying
d. prone ANSW✅✅a. high fowlers
an oxygen saturation of level of 85%-95% would be considered normal
true or false ANSW✅✅false
Wheezes can be described as high-pitched musical sounds that are heard on inspiration and
expiration
true or false ANSW✅✅true
The nurse is instructing a patient how to breathe during auscultation of the lungs. Instruction by the
nurse has been effective if the patient breathes in which manner?
a. takes a deep breath and holds it
b. breathes with the mouth open
c. coughs and then takes a deep breath
d. takes rapid shallow breaths ANSW✅✅b. breathes with the mouth open
A home care patient receives oxygen by nonbreather (NRB) mask. Which does the nurse include
when teaching the caregiver about the oxygen delivery system?
a. Keep the plastic bag at the end of the mask inflated
b. offer fluids frequently and apply moisturizer to prevent dry skin
c. Remove the elastic head strap to prevent skin breakdown at the ears
d. Adjust the oxygen flow rate whenever the patient feels like the need more oxygen ANSW✅✅a.
Keep the plastic bag at the end of the mask inflated
The nurse teaches the patient controlled coughing. Which action should the nurse include in patient
teaching effective coughing?
