FOUNDATIONS AND ADULT HEALTH NURSING

MULTIPLE CHOICE 1. The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff? a. Prevent regurgitation after meals. b. Hold the trachea open until it is completely healed. c. Dilate the tracheal opening for passage of secretions. d. Prevent aspiration when eating. ANS: D The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube. DIF: Cognitive Level: Analysis REF: ...

MULTIPLE CHOICE 1. How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter? a. At least once a day b. At least twice a day c. At bedtime d. Each shift ANS: B Catheter care should be performed at least two times daily. DIF: Cognitive Level: Comprehension REF: p. 214 OBJ: 8 TOP: Catheter care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is preparing to perform perineal care for...

MULTIPLE CHOICE 1. What site should be selected if a peripheral pulse needs to be assessed quickly? a. Radial pulse b. Brachial pulse c. Carotid pulse d. Pedal pulse ANS: C The carotid site is the best for finding a pulse quickly. DIF: Cognitive Level: Application REF: p. 293 OBJ: 5 TOP: Carotid KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level...

MULTIPLE CHOICE 1. Upon admission, the nurse notes that a patient without family members present has a billfold filled with cash. Where can the nurse suggest the money be placed? a. In a sealed envelope in the bedside table b. In the care of hospital security c. Locked in the narcotic cupboard d. In the hospital safe ANS: D Valuables should be locked in the hospital safe. DIF: Cognitive Level: Application REF: p. 263 OBJ: 6 TOP: Care of valuables KEY: Nursing Process Step:...

MULTIPLE CHOICE 1. What should the nurse do when offering a cup of hot coffee to a frail, older adult patient? a. Give the patient a straw. b. Dilute the coffee with cold water. c. Fill the cup half full. d. Offer a bib or an apron. ANS: C Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron. DIF: Cognitive Level: Application REF: p. 236 | p. 237 | p. 241 OBJ: 2 ...

MULTIPLE CHOICE 1. What assists the nurse in the identification of patient problems? a. Objective data b. Subjective data c. Data clustering d. Validated data ANS: C Data clustering assists the nurse in determining patient problems. DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 4 TOP: Patient problem KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 2. What organized approach might the nurse use when performing a complete physical examination? a. Maslow’s h...

MULTIPLE CHOICE 1. How should the nurse assist the patient with moving when pain is anticipated? a. Be supportive. b. Apply heat before moving them. c. Administer medication before ambulation. d. Obtain assistance if the patient is heavy. ANS: C The nurse may want to administer medication before an activity that may be painful. DIF: Cognitive Level: Application REF: p. 180 OBJ: 6 TOP: Body mechanics KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Inte...

MULTIPLE CHOICE 1. A major threat to health care workers is blood-contaminated sharps. What should the nurse use to discard the used syringe? a. Wastebasket b. Sink c. Puncture-proof container d. Disinfecting soap ANS: C All patient care areas where sharps are used require puncture-proof containers. DIF: Cognitive Level: Comprehension REF: p. 122 | p. 136 OBJ: 8 TOP: Sharps KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 2. The nur...

MULTIPLE CHOICE 1. A nurse is caring for an Orthodox Jewish patient. What is the most appropriate dietary requirement for the nurse to implement? a. Mixing of milk and meat at a meal b. Use of separate cooking utensils for meat and milk products c. Use of one set of cooking utensils for meat and milk products d. Consumption of food not slaughtered in accordance with Jewish law ANS: B For observant Jews, Kosher dietary laws include the following: no mixing of milk and meat at a meal;...

MULTIPLE CHOICE 1. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information? a. Nurse practice act b. Standards of care c. Scope of nursing practice d. Professional organizations ANS: B Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not...