Deck 22: Care of Patients with Alterations in Health

Question 1

Which of the following is an appropriate nursing measure when performing tracheostomy care?

A) Wear clean gloves
B) Insert the catheter without suction
C) Suction for 1 minute before removing the catheter
D) Place the used catheter in a plastic shield for later use

Answer 1

Insert the catheter without suction

Question 2

Why should the nurse instill eye irrigation from the inner to the outer canthus?

A) To avoid harming the sclera
B) To include the conjunctiva in the irrigation
C) To keep the pupil constricted
D) To protect the nasolacrimal ducts

Answer 2

To protect the nasolacrimal ducts

Question 3

What is the nurse's first priority when a patient receiving IV fluid therapy shows an increase in blood pressure and has bilateral crackles?

A) Raise the head of the bed
B) Slow the infusion
C) Turn the patient to the left side
D) Notify the charge nurse

Answer 3

Slow the infusion

Question 4

When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula?

A) 2 L/min
B) 3 L/min
C) 4 L/min
D) 5 L/min

Question 5

When a patient asks if he can keep the heating pack on his leg all the time, the nurse reminds him of which of the following complication of long-term heat application?

A) The heat can cause extreme vasoconstriction.
B) The heat can increase the possibility of infection.
C) The heat can cause the blood pressure to increase.
D) The heat can damage epithelial cells.

Question 6

When irrigating an ear, the nurse should perform which intervention(s)? (Select all that apply.)

A) Heat the water to 115° F
B) Pull the auricle back firmly and hold it
C) Place the tip of the syringe loosely in the ear canal
D) Introduce fluid with a slow, gentle irrigation
E) Use a stronger flow if a foreign body is present

Question 7

What gauge needle should be selected by the nurse when preparing to administer blood?

A) 25
B) 22
C) 21
D) 18

Question 8

What would be the correct explanation of catheter care?

A) Cleansing the first 2 inches of the catheter with soap and water every shift
B) Disinfecting the entire catheter with alcohol every shift
C) Lubricating the catheter with antiseptic lotion every 24 hours
D) Cleansing the meatal-catheter junction every 24 hours

Question 9

Before inserting a nasogastric tube, what measurement should the nurse take?

A) Tip of the nose to the earlobe to the xiphoid process
B) Bridge of the nose to the xiphoid process
C) Nose to the top of the ear to the stomach
D) Clavicular notch to the stomach

Question 10

How does an Aquathermia pad differ from a traditional heating pad?

A) The Aquathermia pad can be folded to fit the anatomic location snugly.
B) The Aquathermia pad can be placed under the patient.
C) The Aquathermia pad has circulating water for temperature control.
D) The Aquathermia pad can be left on for as long as 2 hours.

Question 11

When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy?

A) It is always permanent
B) It drains semi-liquid stool
C) It has a much larger stoma
D) It does not need a pouch

Question 12

After a Foley catheter has been removed, the nurse should assess the patient for:

A) hemorrhage.
B) constipation.
C) urinary retention.
D) bladder spasm.

Question 13

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

Question 14

The nurse notes an edematous area around the insertion site of an IV that is cool to the touch and the skin of which appears blanched. Based on these assessment findings, what is the first priority of the nurse?

A) Apply warm compresses to the area
B) Notify the charge nurse
C) Stop the infusion
D) Reposition the arm to improve the fluid flow

Question 15

To what temperature should water for eye compress be heated?

A) 95° F
B) 110° F
C) 115° F
D) 120° F

Question 16

During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?

A) Withdraw the catheter
B) Ask the patient to bear down
C) Continue to inflate the balloon
D) Advance the catheter into the bladder

Question 17

When a patient complains of progressive hearing loss, crackling and ringing noises in his ear, and progressive ear pain, what should the nurse assess for?

A) A dead battery in the patient's hearing aid
B) Cerumen impaction
C) Sinus congestion
D) A middle ear infection

Question 18

While teaching a patient about the signs of IV therapy-associated phlebitis, how does the nurse describe an area with phlebitis?

A) Warm, edematous, and red
B) Painful and cyanotic
C) Painless and numb
D) Edematous and cool

Question 19

When an order for eye irrigation is received, to whom can the nurse delegate the procedure to?

A) The patient
B) Another nurse
C) A nursing assistant
D) A family member

Question 20

The nurse instructs a patient receiving home O? therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid?

A) Milk
B) Water
C) Tea with artificial sweetener
D) Coffee

Question 21

If a patient has a transfusion reaction, the nurse should perform the following interventions in which priority order? Put a comma and space between each answer choice (A, B, C, D, etc.).

A) Take and record vital signs
B) Notify physician and blood bank
C) Stop the transfusion
D) Monitor urine output
E) Return blood and tubing to the blood bank

Question 22

Hot moist compresses have which positive effect(s)? (Select all that apply.)

A) Improvement of circulation
B) Relief of edema
C) Consolidation of exudates
D) Enhancement of scabbing
E) Relief of pain

Question 23

The nurse is alert for a serious condition called ___________ that results from pathogens being introduced into the blood stream.

Question 24

The appliance that connects to an IV drip and delivers a continuous irrigation to the eye is known as a ________ _________ _________.