Examsrevision

MULTIPLE CHOICE 1. A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the: a. right side and raise the head of the bed. b. right side and lower the head of the bed. c. left side and raise the head of the bed. d. left side and lower the head of the bed. ANS: D To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should turn the patient onto the left side and lower the h...

MULTIPLE CHOICE 1. The nurse adds to the plan of care for a cognitively impaired resident who has begun to wander night and day throughout the long-term care facility. An appropriate intervention to add to the plan of care for the resident with wandering behavior would be to: a. place the resident on a locked unit to prevent long-range wandering. b. obtain an order for wrist restraints or a vest restraint. c. apply a bracelet that alarms as the resident approaches an outside door. d. disc...

MULTIPLE CHOICE 1. An older adult patient on bed rest has been eating poorly. The patient is exhibiting abdominal distention and cramping and is passing small amounts of liquid stool. The nurse assesses these signs as an indication of: a. constipation. b. fecal impaction. c. diarrhea. d. GI tract infection. ANS: B Abdominal distention, cramping, and passage of small amounts of liquid stool are signs and symptoms of fecal impaction. The risk factors that contribute to this are bed re...

MULTIPLE CHOICE 1. The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility to: a. raise the head of the bed to 30 to 45 degrees. b. set the proper flexion and extension limits. c. elevate the machine at the foot of the bed on one pillow. d. keep the operated knee warm. ANS: B The nurse is responsible for securing the limb in the machine and setting the proper flexion and extension limits ordered by the prim...

MULTIPLE CHOICE 1. Because the patient with an abdominal dressing requires frequent dressing changes, the abdomen is beginning to show skin irritation from repeated tape removal. The nurse would change the dressing procedure in order to use: a. paper tape. b. Montgomery straps. c. Karaya paste. d. elastic adhesive tape. ANS: B Montgomery straps allow the dressing to be changed without constantly applying and removing tape. DIF: Cognitive Level: Analysis REF: p. 770 OBJ: Clini...

Chapter 31: Pain, Comfort, and Sleep Chapter 32: Complementary and Alternative Therapies Chapter 33: Pharmacology and Preparation for Drug Administration Chapter 34: Administering Oral, Topical, and Inhalant Medications Chapter 35: Administering Intradermal, Subcutaneous, and Intramuscular Injections

MULTIPLE CHOICE 1. Before integrating humor in the care of an Asian patient, the nurse should: a. develop jokes about the patient’s condition. b. develop jokes about the doctors and nurses. c. ask the patient whether jokes are understood. d. ask the patient’s feelings about hearing a joke or funny story. ANS: D Humor and laughter are used at the bedside to distract patients from pain, and they have a positive effect on the body. However, it is important to check with the patien...

MULTIPLE CHOICE 1. A nurse is assisting in the care of a patient who is receiving pain medication by the epidural route. It is most important to monitor this patient for which adverse drug effects? a. Constipation b. Headache c. Nausea d. Hypoventilation ANS: D Respiratory depression is a potentially dangerous side effect of epidural analgesia, and a patient receiving this type of pain medication requires frequent monitoring of respiratory rate. DIF: Cognitive Level: Comprehensi...

MULTIPLE CHOICE 1. The nurse has an order to administer an injection of purified protein derivative (PPD) by the intradermal route. The maximum amount of medication that can be given using this route is: a. 0.1 mL. b. 0.75 mL. c. 0.5 mL. d. 0.2 mL. ANS: A The maximum dose that can be given via the intradermal route is 0.1 mL. DIF: Cognitive Level: Knowledge REF: p. 675 OBJ: Theory #7 TOP: Mantoux Test KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity...

MULTIPLE CHOICE 1. A patient of the Cambodian culture reports that a new medication is not adequate for treatment because it is: a. colored red. b. a smaller size than the older medication. c. offered before a meal. d. is in liquid form. ANS: B Persons of Cambodian origin believe the size of the medication indicates its curative value. A small pill does not have as much curative value as a larger one. DIF: Cognitive Level: Comprehension REF: p. 654 OBJ: Theory #1 TOP: Medicat...