Funda Saved Ms2003

7/27/2019 Funda Saved Ms2003

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FUNDAMENTALS

OF

NURSING


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1. When making an occupied bed, which of the

following is most important for the nurse to

do

A. Keep the bed in the low position

B. Use a bath blanket or top sheet for warmthand privacy

C. Constantly keep the side rails raised on

both sides

D. Move back and forth from one side to the

other when adjusting the linens


3/103

2. The nurse connects a patients single-

lumen nasogastric tube to

intermittent suction for whichpurpose?

A. Drain the stomach more effectively

B. Prevent electrolyte losses

C. Help prevent dumping syndrome

D. Help to prevent the tube from

suctioning the mucosa


4/103

3. Saline solution is used to irrigate a

nasogastric tube used for decompression

based on which rationale?

A. Irrigating with water is a contaminated

procedure

B. Saline solution is a hypertonic solution

C. Saline solution replaces electrolyte loss

through nasogastric suction

D. Saline solution is less irritating to the gastric

mucosa


5/103

4. When teaching a client a client to

irrigate a colostomy, the nurse

indicates that the distance of thecontainer above the stoma should

not be more than

A. 15 cm (6 inches)

B. 25 cm (10 inches)C. 30 cm (12 inches)

D. 45 cm (18 inches)


6/103

5. When performing a colostomy

irrigation, the nurse inserts thecatheter into the stoma:

A. 5 cm (2 inches)

B. 10 cm (4 inches)

C. 15 cm (6 inches)D.20 cm (18 inches)


7/103

6. A client is to have an enema to

reduce flatus. The rectal cathetershould be inserted:

A. 2 inches

B. 4 inches

C. 6 inchesD.8 inches


8/103

7. When suctioning a client with a

tracheostomy the nurse must remember

to:A. Use a sterile catheter with each insertion

B. Initiate suction as the catheter is being

withdrawn

C. Insert the catheter until the cough reflex is

stimulated

D. Remove the inner cannula before inserting

the suction catheter


9/103

8. During the administration of

enema, the client complains of

intestinal cramps. The nurse should

A. Give it at a slower rate

B. Discontinue the procedure

C.Stop until the cramps are gone

D. Lower the heights of the container


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9. A nurse is changing the central line

dressing of a client receiving total

parenteral nutrition. The nurse notes thatthe catheter insertion site appears

reddened. The nurse next assess which of

the following

A. Tightness of the tubing connection

B. Clients temperature

C. Expiration date of the bag

D. Time of last dressing change


11/103

10. A nurse is preparing to suction a

client through a tracheostomy tube.

Which of the following protective

items would the nurse wear to perform

this procedure?

A. Gown, mask, and sterile gloves

B. Goggles, mask, and sterile gloves

C. Mask, gown, and a cap

D. Mask, sterile gloves, and a cap


12/103

11. A nurse is inserting an indwelling urinary catheter

into a male client. As the catheter is inserted into

the urethra, urine begins to flow into the tubing.At this point, the nurse:

A. Immediately inflates the balloon

B. Withdraws the catheter approximately 1 inch andinflates the balloon

C. Insert the catheter until resistance is met and

inflates the balloon

D. Inserts the catheter 2.5 cm to 5 cm and inflates the

balloon


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12. Which action is essential when the nurse

provides a continuous enteral feeding?

a. Elevate the head of the bed

b. Position the client on the left side

c. Warm the formula before administering it

d. Hang a full days worth of formula at one

time


14/103

13. Mr. Dantes has a fecal impaction. The nurse

correctly administers an oil-retention enema

by doing which of the following?

A. Administering a large volume of solution (500

to 1,000 ml)

B. Mixing milk and molasses in equal part for an

enema

C. Instructing the patient to retain the enema forat least 30 minutes

D. Following the return-flow or Harris flush

procedure


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14. A barium enema should be done before

an UGIS because which of the following?

A. Retained barium may cloud the colon

B. Barium can cause lower gastrointestinal

bleeding

C. The physicians order are in that

sequence

D. Barium absorbed readily in the lower

intestine


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15. A patient had CVA and has

difficulty of swallowing. What

equipment should be at the

bedside?

a. suction machine

b. oxygen cannula

c. padded tongue blade

d. tracheostomy tray


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16. Upon returning from the recovery

room, the nurse notices the fluctuation

in the chest tube bottle suddenly

stopped. It indicates:

A. all the fluid and air has been removed

B. the tubing may be kinked

C. the lungs has been re-expanded

D. the suction is set too low


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17. To obtain optimal oxygenation

following immediate rightpneumonectomy, the patient

should be positioned:

a. Left side lying semi-fowler

b. Supine with pillow on the head

c. Right side lying semi-fowler

d. Orthopneic position


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18. Which action would be the priority when

administering using an oral care to a

dependent patient?A. Assisting the patient to the dorsal

recumbent position

B. Wearing disposable gloves

C. Using a firm toothbrush to cleanse the teeth

and gums

D. Irrigating forcefully with hydrogen peroxide


20/103

19. While doing range-of-motion exercise with a

patient who is bedridden, the nurse is aware

that:

A. Neck hyperextension should be encouraged,

particularly in older patient

B. Exercise should be continued until the patient

is fatigued

C. Exercises should be done frequently to lessenpain for the patient

D. Each joints is exercised to the point of

resistance but no pain


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20. When using a cane for maximal support,the nurse is aware that the patient

should:A. Hold the cane on the weaker side

B. Distribute weight evenly between thefeet and the cane

C. Keep the elbow that is holding the cane

straight and stiffD. Advance the weaker foot ahead of the

cane


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21. The physician has ordered an indwelling

catheter inserted in a hospitalized male

patient. The nurse is aware that:A. the male urethra is more vulnerable to injury

during insertion

B. normally a clean technique is required forcatheter insertion

C. the catheter is inserted 2 to 3 inches into the

meatusD. smaller catheters are usually necessary because

of the size of the urethra


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22. Nursing care for a patient with an indwelling

catheter includes which of the following?

A. Irrigation of the catheter with 30 ml of normal

saline solution every 4 hours

B. Disconnecting and connecting the drainage

system quickly to obtain urine specimen

C. Encouraging a generous fluid intake if

permittedD. Informing the patient that burning and

irrigation at the meatus are normal, subsiding

within a few days


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23. Which of the following is the primary nursing

intervention necessary for all patients with a

Foley catheter in place?

A. Maintain the drainage tubing and collection bag

level with the patients bladder

B. Irrigate the patient with 1% Neosporin solutionthree times daily

C. Clamp the catheter for 1 hour to maintain the

bladder elasticity

D. Maintain the drainage tubing and collection bag

below bladder level to facilitate drainage by

gravity.


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24. A hemovac is use to do all of the

following except?

A. Promote wound healing

B. Remove the drainage from thesurgical wound

C. Lessen postoperative discomfortD.Prevent wound infection


26/103

25. The nurse is caring for a client who has

been placed in cloth restraints. To ensure

the clients safety, the nurse should:A. Wrap each wrist with gauze dressing

beneath the restraints

B. Remove the restraints every two hours and

inspect the wrists

C. Keep the head of the bed flat at all timesD. tie the restraints using a square knot


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26. Mr. Castro has an eye infection with a

moderate amount of discharge. Which

action would be most appropriate for thenurse to use when cleansing his eyes?

A. Using hydrogen peroxide

B. Wiping from the outer canthus to the inner

canthus

C. Positioning him on the same side as theeyes to be cleansed

D. Using only one cotton ball per eye


28/103

27. Proving perineal care to a patient

requires which of the following?

A. Using clean portion of washcloth for each

stroke

B. Moving from most contaminated to leastcontaminated

C. Using sterile gloves

D. Leaving the foreskin undisturbed in

uncircumcised male


29/103

28. During morning care, Mr. Leonardo asks

the nurse to shave him with his disposable

razor. Before shaving him, the nurseshould?

A. Have him sign a permission form

B. Check to see if the patient is taking

anticoagulant

C. Tell him that family members may shave apatient

D. Position him flat in bed


30/103

29. The nurse is caring for the client who has just

returned to the nursing unit following a left-

above-the-knee amputation. How should theclient be positioned?

A. Place the stump flat on bed to prevent

contractures

B. Place the stump on a pillow to prevent edema

C. Place the client on prone position to preventcontractures

D. Place the client in reverse Trendelenburg position

to promote arterial flow


31/103

30. When suctioning a client with a

tracheostomy, which of the following is

inappropriate action by the nurse?

A. The nurse initiates suction as the catheter is

withdrawn.

B. The nurse inserts 3-5 inches of the catheter

into the tracheostomy.

C. The nurse applies suction for 5-10 secondsD. The nurse uses a new sterile catheter with

each insertion


32/103

31. On the first postoperative day after the left

modified radical mastectomy, the NCP for this

client should include which of the following?A. Encouraging the client to wear a breast

prosthesis

B. Keeping the left arm and shoulder immobilize

C. Placing the client in semi-Fowlers position

with left arm and head elevated

D. Changing the pressure dressing as necessary


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32. After a client has an enteral feeding

tube inserted, the most accurate

method for verification of placement

is

A. Abdominal x-ray

B. Auscultation

C. Flushing tube with saline

D. Aspiration for gastric contents


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33. To obtain accurate measurements of

central venous pressure (CVP), which of

the following should the nurse do?

A. wait until the fluid in the column stops

fluctuatingB. have the zero level of the manometer at

h level of the right atrium

C. tell the patient to hold the breath

D. flash the line with heparinized solution


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34. The nurses goal in positioning a client

for a vaginal examination is to

A. provide for a clients comfort

B. provide a position that promotes access

for the examination of the physician

C. provide a position of comfort for the

physician

D. provide the correct position while

ensuring the clients comfort and privacy


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35. An ambulatory client is being readied

for bed. The action that promotes safety

for the client is which of the following?

A. Turning off the light to help promote

sleep and restB. Instructing the client in the use of call

bell

C. putting the side rails up

D. placing the bed in the high position


37/103

36. While preparing o give a client a bed bath, which

of the following is the most appropriate nursing

action?

A. place the bed in the lowest position

B. expose the top side of the body, washing and

drying quickly, then doing the same on theposterior side

C. gather all the article necessary for the bath and

placing them within the easy reach of the nurseduring the bath

D. use firm, scrubbing strokes to remove the dirt and

bacteria


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37. One of the most important nursing

interventions in the care of the elderly:

A. avoid drying agent when providing skin

care

B. encourage the client to perform as manyactivities of daily living

C. gently apply moisturizing lotion to

pressure area as possible

D. apply powder to moist folds of the skin

l i l i d i d f b


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38. Carl is a male patient admitted for burns

several days ago. He has been having

intermittent NGT feeding which is to be

discontinued. What is the most important

criterion for the removal of the NGT?

A. Presence of abdominal distention

B. Absence of bowel sounds

C. Passage of flatus

D. Presence of gurgling sound upon

introduction of air in the NGT tube


40/103

39. A fireman is confined in the

hospital for extensive burns. Which

of these findings demonstrate

effective replacement therapy?

A. CVP reading of 3 cm H2O

B. Urine output of 35 ml/hr

C. Absence of bradycardia

D. Normal RR

40 A CHF patients CVP reading is 16 cm


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40. A CHF patient s CVP reading is 16 cm

H2O. Analyzing this result, the nurse

shouldA. increase the fluid intake of the patient

B. decrease the fluid intake of thepatient

C. turn the patient to the right side

D. turn the patient to the left side


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41. Nursing responsibilities in peritoneal

dialysis includes all of the following

except

A. moving the patient from side to side

during the procedure

B. heating the dialysate in a microwave

C. monitoring the amount of inflow and

outflow

D. observing the patient for headache


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42. A patient is rushed to the hospital for a

penetrating object on one eye after an

accident. What is the best first aidtreatment?

A. Administer an antibiotic to the affected eye.

B. Irrigate the eye with sterile NSS.

C. Apply gauze to both eyes.

D. Attempt to loosen the penetrating object.

43 A ti t ith h t i j i t th


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43. A patient with chest injury comes into the

ER. The nurse on duty, after seeing the

patients condition, immediately placessterile gauze on the patients opened chest

wall. What is the best explanation for this

action?

A. To prevent air from getting out of the lungs

B. To prevent the collapse of the lungs

C. To prevent secondary infection

D. To prevent further bleeding


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44.Laminectomy is done for a patient with

herniated intervertebral disc. After the

operation, the nurse should instruct thepatient that

A. ambulation is encouraged as soon as

possible

B. pain should be reported immediately

C. the head and the trunk should be in

alignment when turning to sides

D. regular diet is resumed immediately


46/103

45. A patient who has a fractured leg is

brought to the recovery unit after cast

application. What is the rationale why

the affected leg must be elevated?

A. To prevent pulmonary embolism

B. To prevent accumulation of fluid

C. To promote venous return

D. To prevent shock

46 An oxygen delivery system is prescribed


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46. An oxygen delivery system is prescribedfor a client with chronic obstructivepulmonary disease o deliver a preciseoxygen concentration. Which of thefollowing types of oxygen delivery systemwould the nurse anticipate to be

prescribed?

A. Venturi mask

B. Aerosol maskC. Face tent

D. Tacheostomy collar


48/103

47.The nurse is preparing to complete a

physical exam on a patients pelvis

and vagina. The position of the client

is placed in for this exam is:

A. Sims

B. Dorsal recumbent

C. Knee-chest

D. Lithotomy


49/103

48. The nurse is assessing the patients

abdomen to detect the area of

tenderness and/or muscle guarding.

The correct technique to use is:

A. Light palpation

B. Deep palpation

C. Percussion

D. Palpation above the pubis symphysis


50/103

49. A client complains of painful cracks in

the soles of his feet. Upon assessment

the nurse notes a linear crack thatextends into the dermis. The nurse

documents the finding as:

A. A fissure

B. An erosion

C. An excoriation

D. An ulcer


51/103

50. The nurse assessing the clients

mouth and oropharynx notes

inflammation of the oral mucosa.

The nurse documents this finding as:

A. Gingivitis

B. Glossitis

C. Stomatitis

D. Tonsilitis


52/103

51. An exposure to an organism that

causes infection during

hospitalization is called:

A. Significant exposure

B. Nosocomial infection

C. Negligent occurrenceD.Negligent exposure

52 Th i l t i t t


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52. The single most important

means of preventing the spread

of infection is:

A. Wearing disposable gloves

B. Handwashing

C. Avoiding persons with known

infections

D.Wearing a face mask


54/103

53.The nurse instructs the patient to use

tissues when coughing or sneezing and to

dispose of tissue properly after use.These instructions will prevent the

spread of infection by:

A. Airborne route

B. Droplet transmission

C. Vehicle route

D. Direct contact

54 The nurse is preparing to do a bladder


55/103

54. The nurse is preparing to do a bladder

catheterization prepares the patient for the

procedure and sets up the sterile field. As the nurse

begins to approach the patient to insert the catheter,the tip of the catheter touches the sterile drape. The

nurse should:

A. Start the procedure from the beginning

B. Wipe the tip of the catheter with sterile water and

continue

C. Continue with the procedure

D. Change the sterile drape and continue with the

procedure


56/103

55. A patient has returned from surgery with a

single lumen nasogastric tube in place for

decompression. Physician orders are forlow continuous suction. The nurse should:

A. Attach the tube to the connecting tubing,

then to the suction source

B. Check the tube for placement

C. Assess the patients bowel sound

D. Verify the patients bowel sound


57/103

56. The priority nursing diagnosis for a

client with impaired skin integrity is

which of the following:

A. Risk for infection: Inadequate primary

defensesB. Impaired physical mobility

C.Anxiety

D. Risk for infection: inadequate secondary

defenses

i i il fi ld f


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57. A nurse is preparing a sterile field for a

procedure. The nurse is adding sterile

supplies to the sterile field. Which areaaround the edge of the field is

considered contaminated?

A. 0.5 inch

B. 1 inch

C. 1.5 inches

D. 2 inches

58 Wh t ti li t ith i f ti f


59/103

58. When transporting a client with an infection from

one department to another, which of the following

would not be considered an appropriate action?

The nurse:

A. Securely covers a draining wound

B. Places a surgical mask on a client with airborneinfection

C. Notifies personnel at the receiving area of any

infection risk

D. Requests delay in transporting client until infection

is treated

59 D i di h l i th t hi


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59. During discharge planning, the nurse teaching a

patient how to prevent pruritus. Which of the

following statements is true?

A. Using alkaline soap is one way to prevent pruritus

B. The patient should take a Sitz bath at least once a

day

C. The patient should be sure to change his laundry

detergent when he gets home

D. The patient should decrease the frequency of

bathing or should avoid all soap except on the

face, axilla, and perineal area

60 A i h i l li t ith


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60. A nurse is shaving a male client with a razor.

Which of the following action is incorrect?

A. The nurse applies a moist, warm washcloth tothe face and the neck for several times before

shaving

B. The nurse dons gloves prior to shaving the

patient

C. The nurse shaves against the direction of the

hair growth

D. The nurse holds the razor at a 45-degree angle

61 Wh idi b d b h f


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61. When providing a bed bath for a

client, the nurse correctly adjusts the

temperature of the water to which ofthe following?

A. 40C - 42C

B. 37C - 40C

C. 43C - 46C

D. 46C - 49C


63/103


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62. The nurse is performing a physical

assessment on a client who just had an

endotracheal tube inserted. Which

finding would call for immediate

action by the nurse?

a. Breath sounds can be heard bilaterally

b. Mist is visible in the T-Piece

c. Pulse oximetery of 88

d. Client is unable to speak

63 Wh i t ti l b t ti i


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63. When an intestinal obstruction is

suspected, a client has a nasogastric tube

inserted and attached to suction. Criticalassessment of this client includes

observation for:

A. Edema

B. Belching

C. Dehydration

D. Excessive salivation

64 When preparing for piggyback


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64. When preparing for piggybackmedication for a client, the nurse is

aware that it is essential to:A. Use strict sterile technique

B. Rotate the bag after adding the

medication

C. Use exactly 100 ml of fluid to mix the

medicationD. Change the needle just before adding the

medication

65 Th li t i i i 5% d t i


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65. The client is receiving 5% dextrose in

water t a slower rate. The nurse should

be aware that the longest period of timethat one bottle can be infused without

producing untoward effects is:

A. 6 hours

B. 12 hours

C. 18 hours

D. 24 hours

66 Th i th t i filt ti f


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66. The nurse is aware that infiltration of a

clients IV is most likely caused by:

A. Excessive height of the IV solution

B. Failure to adequately secure the

catheter

C. Lack of sepsis during catheter insertion

D. Infusion of chemically irritating

medication

67 When catheterizing the client the nurse does


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67. When catheterizing the client, the nurse doesnot remove more than 1000 cc of urine at atime. What is the primary reason for that?

a. rapid change in capillary pressure may cause thedevelopment of shock

b. rapid removal of urine may cause the kidney to

stop producing urinec. rapid emptying of the bladder causes vigorous

spasm and obstructing of the urethra

d. over distention of the bladder causes pain whichaggravated by rapid emptying

68. A client with esophageal cancer is to receive


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total parenteral nutrition. A right subclavian

catheter is inserted by the physician. The nurse

knows that the primary reason for using acentral line is that

A. It prevents the development of phlebitis

B. There is less chance of this infusion to infiltrate

C. The large amount of blood helps to dilute the

concentrated solution

D. It is more convenient so clients use their hands

69 T f ilit t i i


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69. To facilitate maximum air

exchange, a client should be

placed in the:

A. Supine position

B. Orthopneic position

C. High-Fowlerss positionD.Semi-Fowlers position

70 The client is shot in the chest during a holdup and is


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70. The client is shot in the chest during a holdup and is

transported to the hospital. In the emergency department

chest tubes are inserted, one in the second intercostals

space and one in the base of the lung. The nurseunderstands that the tube in the second intercostals space

will:

A. Remove the air that is present in the intraplueral space

B. Drain serosnguineous fluid from the intraplueral

compartment

C. Provide access for the instillation of medication into thepleural space

D. Permit the development of positive pressure between the

layers of the pleura

71. During the first 36 hours after the insertion of


73/103

g

chest tubes, when assessing the function of the

three-chamber, closed-chest drainage system, The

nurse notes that the water in the underwater seal

tube is not fluctuating. The initial nursing

intervention should be to:

A. Inform the physician

B. Take the clients vital signs

C. Check whether the tube is kinked

D. Turn the client to unaffected side

72 An independent nursing measure that


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72. An independent nursing measure that

would be helpful in preventing the

accumulation of secretion in a clientwho has a general anesthesia for surgery

is:

A. Postural drainage

B. Cupping the chest

C. Nasotracheal suctioning

D. Frequent change in position

73 To help a client obtain maximum


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73. To help a client obtain maximum

benefit after postural drainage, the

nurse should:

A. Administer the PRN oxygen

B. Place the client in a sitting position

C. Encourage the client to cough deeply

D. Encourage the client to rest for 30

minutes

74. A client has chest tube attached to a


76/103

chest tube drainage system. When caring

for this client, the nurse should:

A. Clamp the chest tube when suctioning

B. Palpate the surrounding are for crepitus

C. Change the dressing daily using aseptic

technique

D. Empty the drainage chamber t the end of

the shift

75 The nurse should position a


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75. The nurse should position a

client recovering from general

anesthesia in a:

A. Supine position

B. Side-lying position

C. High-Fowlers positionD.Trendelenburg position

76 During the immediate postoperative


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76. During the immediate postoperative

period, the nurse should give the

highest priority to:

A. Observing for hemorrhage

B. Maintaining a patent airway

C. Recording the intake and output

D. Checking the vital signs every 15

minutes

77. A client has undergone bronchoscopy


79/103

in an ambulatory surgery unit. To

prevent laryngeal edema, the nurse

should:

A. Place ice chips in the clients mouth

B. Offer the client liberal amount of fluid

C. Keep the client in the semi-Fowlers

position

D. Tell the client to suck on medicated

lozenges

78 The physician performs a colostomy


80/103

78. The physician performs a colostomy.

During the immediate postoperative

period, nursing care should include:

a. Withholding all fluid for 72 hours

b. Limiting fluid intake for several days

c. Having the client change the stoma bag

d. Keeping the skin around the stomaclean and dry

79. A client with allergic rhinitis is instructed on


81/103

gthe correct technique for using an intranasalinhaler. Which of the following statements

would demonstrate to the nurse that theclient understands the instructions?

a. I should limit the use of the inhaler to early

morning and bedtime use.b. It is important to not shake the canister

because that can damage the spray device.

c. I should hold one nostril closed while I insertthe spray into the other nostril.

d. The inhaler tip is inserted into the nostril

and pointed toward the inside nostril


82/103

80. When caring for an intubated client

receiving mechanical ventilation, the nurse

hers the high-pressure alarm. Which action

is most appropriate?

A. Obtain arterial blood gasB. Lower the tidal volume setting

C. Remove secretions by suctioningD. Check that tubing connections are secure

81 A client is to have a gastric gavage


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81. A client is to have a gastric gavage.

When the gavage tube is being

inserted, the nurse should place theclient in the:

A. Supine position

B. Mid- Fowlers position

C. High-Fowlers position

D. Trendelenburgs position

82. Barium salts in GI series and barium enemas


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82. Barium salts in GI series and barium enemas

serves to:

A. Fluoresce and thus illuminate the alimentarytract

B. Give off visible light and illuminates the

alimentary tract

C. Dye the alimentary tract and thus provide for

color contrast

D. Absorb x-ray and thus give contrast to the soft

tissues of the alimentary tract

83.When instituting oxygen therapy, the


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g yg py,

nurse recognizes that the method of

oxygen administration least likely toincrease apprehension in the client is:

a. Tentb. Mask

c. Cannulad. Catheter

84. During a percutaneous endoscopic


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84. During a percutaneous endoscopic

gastrostomy (PEG) tube feeding, the

observation that indicates that the client isunable to tolerate a continuation of the

feeding would be:

A. A passage of flatus

B. Epigastric tenderness

C. A rise of formula in the tube

D. The rapid flow of feeding

85 Client receiving hypertonic tube


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85. Client receiving hypertonic tube

feedings most commonly develop

diarrhea because of:

A. Increased fiber intake

B. Bacterial contamination

C. Inappropriate positioningD.High osmolarity of feeding

86 The nurse should administer a


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86. The nurse should administer a

nasogastric tube feeding slowly to

reduce the hazard of:

A. Distention

B. Flatulence

C. IndigestionD.Regurgitation

87. When caring with a client with NGT


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87. When caring with a client with NGT

attached to suction, the nurse should:

A. Irrigate the tube with normal saline

B. Use sterile technique in irrigating the

tubeC. Withdraw the tube quickly when

decompression is terminated

D. Allow the client to have small chips of ice

or sip of water unless nauseated

88. After partial gastrectomy is performed, a client is


90/103

p g y p ,

returned to the unit with an IV solution infusing

and an NGT in place. The nurse notes the there has

been no nasogastric drainage for 30 minutes. There

is an order to irrigate the NGT PRN. The nurse

should insert:

A. 30 ml of normal saline and withdraw slowly

B. 20 ml of air and clamp off suction for 1 hour

C. 50 ml of saline and increase pressure of suction

D. 15 ml of distilled water and disconnect the suction

for 30 minutes

89. A serious danger to which a client


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89. A serious danger to which a client

with intestinal obstruction is

exposed because of intestinal suctionis excessive loss of:

A. Protein enzymesB. Energy carbohydrates

C. Vitamins and minerals

D. Water and electrolytes

90. The nurse in the post anesthesia care unit


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p

notices that after an abdominal

cholecystectomy, a client has serosanguinousfluid on the abdominal dressing, the nurse

should:

A. Change the dressing

B. Reinforce the dressing

C. Apply an abdominal binderD. Remove the tape and apply Montgomery

straps

91. If intubation is indicated for a client


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91. If intubation is indicated for a client

with bleeding esophageal varices,

the type of tube most likely to beused would be:

A. Levin tubeB. Salem-sump

C. Miller-Abbott tube

D. Blakemore-Sengstaken tube

92. When caring for a client with an


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g

ileostomy the nurse should:

A. Encourage the client to eat food high inresidue

B. Expect the stoma to start draining on thethird postoperative day

C. Explain that drainage can be controlled

with daily irrigation

D. Anticipate that emotional stress can

increase intestinal peristalsis

93 When receiving an enema


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93. When receiving an enema,

the client should be placed in:

A.Sims position

B.Back-lying position

C. Knee-chest position

D.Mid-Fowlers position

94. A client is receiving total parenteral solution


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(TPN) after extensive colon surgery. The purpose

of TPN is to:

A. Provide short-term nutrition after surgery

B. Assist in providing supplemental nutrition for

the client

C. Provide total nutrition when gastrointestinal

function is questionable

D. Assist people who are unable to eat but have

active gastrointestinal function

95. When teaching a client to care for a new


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colostomy, the nurse should recommend that the

irrigation be done at the same time every day. The

time selected should:

A. Be approximately 1 hour before breakfast

B. Provide ample uninterrupted bathroom use athome

C. Approximate the clients usual daily time for

elimination

D. Be about halfway between the two largest meals of

the day

96. When teaching a client with


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g

permanent colostomy what might be

expected on discharge, the nurseshould discuss:

A. Need for special clothingB. Importance of limiting activities

C. Periodic dilation of the stomaD. Bland, low-residue diet regimen

97. A client with colostomy should


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97. A client with colostomy should

follow diet that is:

A. Rich in protein

B. Low in fiber contentC. High in carbohydrate

D.As close to normal as possible

98. The solution of choice used to


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98. The solution of choice used to

maintain patency of a

nasointestinal tube is:

A. Sterile water

B. Isotonic saline

C. Hypotonic saline

D.Hypertonic glucose

99. A client has a transverse loop


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colostomy. When inserting the

catheter for irrigation, the nurseshould:

A. use an oil-based lubricantB. instruct the client to bear down

C. apply gentle but continuous forceD. direct it towards the clients right side

100. If, during colostomy irrigation, a


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100. If, during colostomy irrigation, a

client complains of abdominal

cramps, the nurse should:

A. discontinue the irrigation

B. lower the container of fluid

C. clamp the catheter for few minutes

D. advance the catheter about 2.5 cm (1

inch)

A client practices Islam and his diet must consider his

f


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religious practices and beliefs. You are aware that

this client would avoid which of the following food?

1.Shrimps and crabs 4. Pork products like bacon

2.Wine and alcoholic drinks 5. Caffeinated products like

cola drinks

3.Fish with scales

A.2, 4, and 5 B. 1, 4, and 5 C. 3, 4, and 5

D. 1, 2, and 4

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