funda saved ms2003

Download Funda Saved Ms2003

Post on 14-Apr-2018




0 download

Embed Size (px)


  • 7/27/2019 Funda Saved Ms2003





  • 7/27/2019 Funda Saved Ms2003


    1. When making an occupied bed, which of the

    following is most important for the nurse to


    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

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    3. Saline solution is used to irrigate a

    nasogastric tube used for decompression

    based on which rationale?

    A. Irrigating with water is a contaminated


    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


  • 7/27/2019 Funda Saved Ms2003


    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)

  • 7/27/2019 Funda Saved Ms2003


    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)

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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


    C. Insert the catheter until the cough reflex is


    D. Remove the inner cannula before inserting

    the suction catheter

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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


  • 7/27/2019 Funda Saved Ms2003


    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


  • 7/27/2019 Funda Saved Ms2003


    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


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

    D. Following the return-flow or Harris flush


  • 7/27/2019 Funda Saved Ms2003


    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


    C. The physicians order are in that


    D. Barium absorbed readily in the lower


  • 7/27/2019 Funda Saved Ms2003


    15. A patient had CVA and has

    difficulty of swallowing. What

    equipment should be at the


    a. suction machine

    b. oxygen cannula

    c. padded tongue blade

    d. tracheostomy tray

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


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

    patient who is bedridden, the nurse is aware


    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

  • 7/27/2019 Funda Saved Ms2003


    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


  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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


  • 7/27/2019 Funda Saved Ms2003


    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

  • 7/27/2019 Funda Saved Ms2003


    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 be