Fundamentals Of Nursing Exam 4

Fundamentals Of Nursing Exam 4 Questions & Answers

Which of the following skills can the nurse delegate to the nursing assistive personnel? Select all that apply

• Nasotracheal suctioning
• Oropharyngeal suctioning if a stable patient
• Suctioning a new artificial airway
• Permanent tracheostomy tube suctioning
• Care if an endotracheal tube

(Ans- 2,4

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ML of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?

• Record the amount and continue to monitor drainage
• Notify the physician
• Strip the chest tube starting at the chest
• Increase the suction by 10 MMHG

(Ans- 1. Record the amount and continue to monitor drainage

The nurse is reviewing the results of the patients diagnostic testing. Of the

following results the finding the falls within an expected or normal limits is:

• Palpable elevated hardened area around a tuberculosis skin testing site
• septum for culture and sensitivity identifies mycobacterium tuberculosis
• Presence of acid fast bacilli in sputum
• Arterial oxygen tension of 95MMHG

(Ans- 4. Arterial oxygen tension of 95 mm HG

A nurse is assessing a client who has had a cute respiratory infection that puts her at high-risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all that apply 1 / 4

• Restlessness
• Tachypnea
• Bradycardia
• Confusion
• Pallor

(Ans-

• Restlessness
• Tachypnea
• Confusion
• Pallor

A provider is discharging a client who has a prescription of home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? Select all that apply

• Apply petroleum jelly around and inside the Nares
• Remove the nasal cannula during meal times
• Check the position of the cannula frequently
• Report any nasal stiffness nausea or fatigue
• Post no smoking signs in a prominent location

(Ans-

• Check the position of the cannula frequently
• Report any nasal stiffness nausea or fatigue
• Post no smoking signs in a prominent location

A nurse is caring for a client who is having difficulty breathing. The client is laying in bed and it's already receiving oxygen therapy via it'll cannula.Which of the following intervention is the nurses priority?

• Increased oxygen flow
• Assist the client to Fowlers position
• Promote removal of pulmonary secretions
• Obtain a specimen for arterial blood gases

(Ans- 2 assist the client to fowlers position

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? Select all that apply 2 / 4

• Apply suction while withdrawing the catheter
• Perform suctioning on a routine basis every 2 to 3 hours
• Maintain medical asepsis during suctioning
• The new catheter for each suctioning attempt
• Limit total suctioning time to five minutes

(Ans-

• Apply suction while withdrawing the catheter
• The new catheter for each suctioning attempt
• Limit total suctioning time to five minutes

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?Select all that apply

• Apply the oxygen source loosely if the spo2 decreases during the

procedure

• Use surgical asepsis to remove and clean the inner cannula
• Clean the outer surfaces in a circular motion from the atoms site outward
• Replace the tracheostomy ties with new ties
• Cut a slit quake squares to place beneath the tube holder

(Ans-

• Apply the oxygen source loosely if the spo2 decreases during the

procedure

• Use surgical asepsis to remove and clean the inner cannula
• Clean the outer surfaces in a circular motion from the atoms site outward

A nurse is counseling in order. He describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as a priority?

• I spent my whole life dreaming about retirement and now I wish I had my

job back

• It's been so stressful for me to have to depend on my son to help around

the house

• I just heard my friend Al died. That's the third one in 3 months
• I keep forgetting which medications I have taken during the day

(Ans- D. I keep forgetting which medications I have taken during the day 3 / 4

A nurse is providing teaching for an older adult client who has lost 9.9 pounds since his last admission six months ago. Which of the following instruction should the nurse include in the teaching? Select all that apply

• Eat three large meals day
• Eat your meals in front of the television
• Eat foods that are easy to eat such as finger foods
• Invite family members to eat meals with you
• Exercise every day to increase appetite

(Ans-

• Eat foods that are easy to eat such as finger foods
• Invite family members to eat meals with you
• Exercise every day to increase appetite

A nurse is planning a presentation for a group of older adults about health promotion and Izzys prevention. Which of the following intervention should the nurse plan to recommend? Select all that apply

• Human papilloma virus immunization
• Pneumococcal immunization
• Yearly eye examination
• Periodic mental health screening
• Annual fecal occult blood test

(Ans-

• Pneumococcal immunization
• Yearly eye examination
• Periodic mental health screening
• Annual fecal occult blood test

A nursing student is caring for a 78-year-old patient with multiple sclerosis.The patient has had an indwelling Foley catheter in for three days. Eight hours ago the patient's temperature was 37.1°C. This your reports her recent assessment to the registered nurse the patient's temperature is 37.2 degrees Celsius the Foley catheter is still in place draining dark urine in the patient is uncertain what time of day it is. From what the RN knows about

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