Deck 43: Self-Care Teaching in the Community

Question 1

When teaching the patient and caregiver about clean intermittent self-catheterization (CISC),why is it important for the nurse to teach about the signs and symptoms of complications?

A) Although rare,complications are always severe.
B) It is part of the process; complications almost never occur.
C) Urinary complications are common with CISC.
D) The only major complication is infection.

Answer 1

Urinary complications are common with CISC.

Question 2

What does the nurse teach the patient and caregiver to do when setting up and changing administration sets for continuous tube feedings to preserve medical asepsis?

A) Add formula to formula already hung to prevent waste.
B) Store unused formula at room temperature to prevent spasm.
C) Hang only enough formula that will be infused in a 4- to 6-hour period.
D) Change the administration set every 48 hours.

Answer 2

Hang only enough formula that will be infused in a 4- to 6-hour period.

Question 3

Which of the following is an appropriate step when teaching temperature monitoring in the home?

A) Suggest aspirin to decrease fevers.
B) Recommend using only tympanic membrane sensors.
C) Encourage the use of alcohol rubs to reduce fevers.
D) Demonstrate the technique and have the patient/caregiver perform it.

Answer 3

Demonstrate the technique and have the patient/caregiver perform it.

Question 4

Which of the following is essential in teaching the patient how to use a thermometer?

A) Reading a digital thermometer
B) Shaking down the thermometer before use
C) Using the axillary thermometer
D) Selecting the most appropriate thermometer

Question 5

What should the nurse instruct the parents to do when teaching them about temperature monitoring for a child?

A) Use only a glass mercury thermometer.
B) Take the temperature after shivering subsides.
C) Avoid the use of tepid water sponging for fever.
D) Adjust the temperature reading if the child has eaten a popsicle.

Question 6

The patient is taking levothyroxine (a thyroid medication)for hypothyroidism.What should the nurse instruct the patient to do when teaching the patient how to assess her own blood pressure and pulse?

A) Withhold the medication if her blood pressure is above the normal range or if her pulse is more than 100 beats per minute.
B) Withhold the medication if her blood pressure is below the normal range or if her pulse is less than 60 beats per minute.
C) Never withhold her medication.Have the patient take it and notify the physician at the next office visit.
D) Withhold her medication only if both her blood pressure and pulse rate are too high.

Question 7

The patient's caregiver is checking the patient's nasogastric (NG)tube for gastric residual before proceeding with the patient's next feeding.The patient aspirates 150 mL of residual.What should the caregiver do now?

A) Hold the feeding.
B) Contact the health care provider.
C) Proceed with the feeding,but do not return the aspirated contents to the stomach.
D) Proceed with the feeding after returning the aspirated contents to the stomach.

Question 8

What should the nurse instruct the patient to do when teaching the patient how to take a temperature?

A) Wait 20 to 30 minutes after smoking or ingesting hot or cold foods.
B) Take the temperature immediately upon seeing chills or shivering.
C) Wear sterile rubber gloves when taking a rectal temperature.
D) Lubricate an oral thermometer with water-soluble lubricant only.

Question 9

What is the principal difference in tracheostomy care between care given in the acute care setting and care given in the home care environment?

A) In the acute care setting,the inner cannula is cleaned.
B) In the home care setting,dressings are not necessary.
C) In the acute care setting,hydrogen peroxide is used for cleaning.
D) In the home care setting,the procedure may be done with clean technique.

Question 10

In teaching the patient how to perform intermittent self-catheterization,the nurse instructs which of the following?

A) Only strict aseptic technique should be used.
B) Intermittent self-catheterization should only be done once a day.
C) Clean intermittent self-catheterization increases the chance for infection.
D) Clean intermittent self-catheterization is a safe and effective method.

Question 11

What is an expected outcome after tracheostomy care is successfully performed?

A) A stoma site that is hard to the touch
B) An inner cannula that is free of secretions
C) Copious secretions obtained from suctioning
D) Bloody secretions that have been suctioned

Question 12

When teaching the patient about performing tracheostomy care,which of the following actions is an acceptable technique?

A) Remove the old ties before applying the new.
B) Keep two tracheostomy tubes of the same size at the bedside.
C) Place the new tracheostomy tie,then remove the old tie.
D) Dispose of all old supplies and replace with new.

Question 13

A patient is discharged and is sent home with enteral feedings.What instructions should the nurse give to the caregiver?

A) Flush the tube out after administering medications.
B) Keep the tube loose to allow for patient movement.
C) Use sterile technique when preparing and administering feedings.
D) Hang enough formula each time to cover 8 to 12 hours of feeding.

Question 14

Of the following types of thermometers available,which is not recommended for home use?

A) Digital
B) Tympanic
C) Mercury
D) Disposable single-use

Question 15

Information that should be provided to the caregiver of a patient with a nasogastric (NG)tube includes

A) keeping the head of the bed lowered for feedings.
B) keeping unused formula at room temperature.
C) aspirating every 4 hours when receiving continuous drip feedings.
D) returning the gastric contents if the residual exceeds 250 mL.

Question 16

When being taught clean intermittent self-catheterization (CISC),at what interval should the patient be taught to replace the catheter?

A) With each use
B) Daily
C) Weekly
D) Monthly

Question 17

What should the nurse first assess when preparing to teach a patient and/or caregiver how to read a thermometer?

A) Patient's actual temperature
B) Patient's ability to manipulate the thermometer
C) Caregiver's temperature
D) Patient's ability to take a pulse and respiratory rate

Question 18

The nurse is teaching the patient and caregiver how to perform tracheal suctioning.What does proper technique include?

A) Teaching how to instill normal saline before suctioning
B) Suctioning the nasal and oral pharynx before the trachea
C) Encouraging daily brushing of the teeth and oral hygiene
D) Having the patient take two to three deep breaths after the procedure

Question 19

In teaching the patient how to take his own blood pressure,which of the following is true?

A) Blood pressure cuffs that are too small will give a falsely low reading.
B) Blood pressure cuffs that are too large will give a falsely high reading.
C) Electronic blood pressure cuffs are just as accurate as other methods.
D) The cuff should be placed directly over the skin and not over clothing.

Question 20

What is an appropriate technique to use when teaching an older patient about self-medication in the home?

A) Speak very loudly.
B) Teach the caregiver separately.
C) Provide frequent pauses.
D) Provide fewer but longer teaching sessions.

Question 21

While teaching how to check for gastric residual volume (GRV),the nurse instructs the caregiver to refeed the tube feeding if he or she obtains less than _________ mL of gastric aspirate.

A) 250
B) 300
C) 350
D) 500

Question 22

Expected outcomes for patients who are being taught how to use a thermometer include which of the following outcomes? (Select all that apply.)

A) Ability to correctly measure temperature
B) Ability to properly clean and store the thermometer
C) Knowledge of normal temperature ranges
D) Knowledge of signs and symptoms of fever
E) None of the above

Question 23

In teaching the patient how to take his or her own blood pressure,the nurse instructs the patient to avoid which of the following actions 30 minutes before taking blood pressure (BP)? (Select all that apply.)

A) Exercise
B) Caffeine
C) Smoking
D) Resting

Question 24

The patient needs to be taught the signs of hypoxia.Which of the following outcomes are causes of hypoxia? (Select all that apply.)

A) Incorrect flow rate
B) Poor oxygen tubing connection
C) Use of long oxygen tubing
D) Airway plugging
E) None of the above

Question 25

Which of the following clinical findings are signs of hyperthermia? (Select all that apply.)

A) Dry,warm,flushed skin
B) Chills and piloerection
C) Uncontrolled shivering
D) Loss of memory

Question 26

In preparing to teach a patient how to self-administer mediation,the nurse realizes that many patients who are instructed to self-medicate for preventative care fail to do so.Reasons for this include which of the following rationales? (Select all that apply.)

A) Fear of adverse events
B) Inconvenient medication regimens
C) Costly prescriptions
D) Forgetfulness
E) None of the above

Question 27

In teaching the patient the best sites for assessing blood pressure (BP),which of the following actions should the patient be taught to avoid? (Select all that apply.)

A) Sites with intravenous catheters
B) Arms with arteriovenous shunts
C) Arms on the side of mastectomy
D) The left arm after a heart attack

Question 28

A ___________________ delivers oxygen through a catheter permanently inserted into the trachea,thus allowing the patient to speak and bypassing anatomical dead space.

A) reservoir nasal cannula
B) demand pulsing oxygen-delivery systems
C) transtracheal oxygen catheter
D) nonrebreather mask

Question 29

Oxygen-conserving devices (OCDs)reduce the amount of oxygen the patient uses,resulting in an overall cost reduction to the patient.The type of OCD that stores oxygen in a chamber during the expiratory phase of respirations is known as the

A) reservoir nasal cannula.
B) demand pulsing oxygen-delivery systems.
C) transtracheal oxygen catheter.
D) nonrebreather mask.

Question 30

Oxygen-conserving devices (OCDs)reduce the amount of oxygen the patient uses,resulting in an overall cost reduction to the patient.The type of OCD that delivers oxygen only during inspiration is called a _______________.

A) reservoir nasal cannula
B) demand pulsing oxygen-delivery system
C) transtracheal oxygen catheter
D) nonrebreather mask

Question 31

What instructions should the nurse provide when teaching the patient and the patient's caregiver how to administer parenteral nutrition (PN)?

A) PN solution should be kept refrigerated until time of administration.
B) Remixing separated mixture components by shaking the bag is common.
C) PN is incompatible with most intravenous (IV)medications.
D) Blood glucose monitoring will be necessary.

Question 32

The nurse is teaching the patient about the signs of hypothermia.He or she teaches that signs of hypothermia include which of the following clinical manifestations? (Select all that apply.)

A) Piloerection
B) Restlessness
C) Cool skin
D) Uncontrolled shivering

Question 33

The nurse will train the tracheostomy patient and caregiver that reusable supplies need to be disinfected at least weekly.Which of the following methods is recommended for cleaning tracheostomy supplies at home? (Select all that apply.)

A) Boil reusable (boilable)supplies for 5 minutes.Allow to cool and dry.
B) Boil reusable (boilable)supplies for 15 minutes.Allow to cool and dry.
C) Soak reusable supplies in equal parts of vinegar and water for 30 minutes.Remove,rinse thoroughly,and dry.
D) Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturer's instructions.Rinse and dry.

Question 34

Temperatures in the older person are different from those in the younger adult.The nurse knows that older persons' normal temperatures often range less than

A) 34.2°C
B) 34.8°C
C) 35°C
D) 36.1°C