6
How should the nurse interpret a TB skin test reveals 17 mm induration?
A. Negative for TB
B. Positive for TB
C. Positive for an adult but not a child
D. The patient need further testing
B. Positive for TB
What is the most appropriate action to prevent the spread of disease for a patient on contact isolation?
A. Place the patient in the private room
B. Wear a gown and N95 mask when providing care
C. Use a dedicated stethoscope and BP cuff that stays in the pt's room
D. Transport pt quickly to scheduled imaging
C. Use a dedicated stethoscope and BP cuff that stays in the pt's room
Which action demonstrates the correct care and maintenance of a NGT when administering enteral feedings?
A. Flushing the tube with 30 ml of water every 4-6 hours in addition to checking placement.
B. Proper placement of NGT when gastric pH is 6
C. You identify coffee ground gastric secretions as a normal finding
D. You administer the unused formula from the refrigerator that not yet expired.
A. Flushing the tube with 30 ml of water every 4-6 hours in addition to checking placement.
Which nursing interventions are most appropriate when caring for hospice patient? Select all that apply
A. Keep pt at high fowlers to insure adequate breathing
B. Avoid going in the room to insure patient privacy
C. Administer pain medication for pain
D. Encourage the client to participate in religious practices they find comforting
E. Maintain skin integrity by turning frequently and assessing skin
C. Administer pain medication for pain
D. Encourage the client to participate in religious practices they find comforting
E. Maintain skin integrity by turning frequently and assessing skin
What statement requires further education about constipation?
A. I need to exercise for at least 30 min daily
B. I should consume a low fiber diet
C. I should eat fruits such as strawberries and raspberries
D. I need to increase my water intake
B. I should consume a low fiber diet
Which pt is has the greatest risk for falls?
A. An older pt that is confused and as urinary frequency
B. A pt that has wounds
C. Post op pt that requires assistance when getting out of bed
D. An adolescent who has a leg fx and uses crutches
A. An older pt that is confused and as urinary frequency
What information should the nurse include when instructing on providing post mortem care to the UAP?
A. Place pads on the ankles and wrists and use gauze to tie them together.
B. Place an identification tag on the body only
C. Send the personal belongings in a bag along with the body
D. Dress the body in street clothes before transporting to the morgue
A. Place pads on the ankles and wrists and use gauze to tie them together.
What nursing interventions are beneficial to a patient that is sleep deprived and refuses to take sleep medication? Select all that apply..
A. Offer coffee at hs
B. Assist client with ambulation down the hallway twice before hs
C. Avoid daytime sleeping
D. Close the door at hs to minimize environmental stimuli
E. Encourage relaxation techniques
C. Avoid daytime sleeping
D. Close the door at hs to minimize environmental stimuli
E. Encourage relaxation techniques
What should the nurse do for a patient that is receiving O2 via N/C that has dry nasal and oral mucous membranes?
A. Apply petroleum jelly to the dry areas
B. Nothing, tell the pt that they have to adjust
C. Provide humidification
D. Remove the O2 to give them a break
C. Provide humidification
Your patient's orders read keep saturation above 93%, their current saturation on Rm Air is 91%. What is the most appropriate action?
A. Apply 100% non-rebreather
B. Apply O2 @ 35% venti mask
C. Apply O2 via N/C at 4 liters
D. Apply O2 via N/C at 2 liters
D. Apply O2 via N/C at 2 liters
Which intervention takes precedence for the patient receiving hospice care?
A. Providing small meals
B. Turning and repositioning
C. Administering pain medication for comfort
D. Assisting with transfers
C. Administering pain medication for comfort
What interventions should the nurse perform to ensure safety when transferring a pt? Select all that apply
A. Hold the pt under their arms
B. Apply non-slip footwear
C. Apply gait belt
D. Have the client hold onto the IV pole to support their weight
B. Apply non-slip footwear
C. Apply gait belt
Your patient has had high stress levels for over 6 mos and their coping mechanisms are ineffective. The pt has decreased BP and increased RR and HR. What stage of the GAS this pt in?
A. Alarm
B. Tired
C. Exhaustion
D. Resistance
C. Exhaustion
What action should the nurse do in order to ensure pt safety when ambulating with a walker?
A. Pull the walker along when the patient is ambulating
B. Walk ahead of the patient while holding a gait belt
C. Adjust the height of the walker until the pt elbows are at a 30 degree angle
D. Have the patient move one leg forward before moving the walker
C. Adjust the height of the walker until the pt elbows are at a 30 degree angle
Mechanical soft diet puts a patient at an increased risk for what complication?
A. Diarrhea
B. Dehydration
C. Constipation
D. Nausea
C. Constipation
What should the nurse do when a hospice pt is requesting pain medication before the next dose is due?
A. Encourage non-pharmaceutical techniques
B. Tell the patient that medication is not due
C. Notify the health care provider
D. Tell the patient that the pain will never completely go away
C. Notify the health care provider
A. Pulse ox of 91% on room air
B. Pt desatting to 89% from 92% minimal with exertion
C. The patient takes 3 to 4 shallow breaths before coughing to minimize pain
D. Lungs are clear to auscultation
D. Lungs are clear to auscultation
How would the nurse determine that death may be imminent on a hospice patient?
A. Mottle skin and decreased bp
B. Muscle stiffness and periods of apnea
C. Increased pulse and decreased U/O
D. Hallucinations and moist mucous membranes
A. Mottle skin and decreased bp
What aspect of the admission assessment should be most concerning to the nurse?
A. Pt is unaware of a small, deep wound on left foot.
B. BP of 136/74
C. Pt ambulates with a cane
D. Hyperactive BS
A. Pt is unaware of a small, deep wound on left foot.
What is normal finding should the nurse expect from a patient experiencing a loss of a loved one?
A. Insomnia
B. Thoughts of suicide
C. Low BP
D. Cotton mouth
A. Insomnia