NU 225 FOR FINAL EXAM WITH 140 QUESTIONS

NU 225 FOR FINAL EXAM WITH 140 QUESTIONS &

CORRECT ANSWERS

A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace experiences severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea?

• Keep the patient NPO for 2 hours before dressing changes.
• Give the ordered prochlorperazine before dressing changes.
• Administer the prescribed morphine sulfate before dressing changes.
• Avoid performing dressing changes close to the patient's mealtimes. -

ANSWER-ANS: C

Because the patient's nausea is associated with severe pain, it is likely that it is precipitated by stress and pain. The best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea or vomiting that occur at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition.Administration of antiemetics is not the best choice for a patient with nausea caused by pain. However, an antiemetic may be added later if the nausea persists despite pain management.

Which information about an 80-year-old man at the senior center is of most concern to the nurse?

a.Decreased appetite

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Unintended weight loss c.Difficulty chewing food d.

Complaints of indigestion - ANSWER-ANS: B

The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.

What is the best response by the nurse to a mother asking about the cause of her infant's bilateral cleft lip?

• "Did you use alcohol during your pregnancy?"
• "Do you know of anyone in your family or the baby's father's family who was

born with cleft lip or palate problems?"

• "This defect is associated with intrauterine infection during the second

trimester."

• "The prevalent of cleft lip is higher in Caucasians" - ANSWER-ANS: B

Feedback A Tobacco during pregnancy has been associated with bilateral cleft lip.B Cleft lip and palate result from embryonic failure resulting from multiple genetic and environmental factors. A genetic pattern or familial risk seems to exist.C The defect occurred at approximately 6 to 8 weeks of gestation. Second- trimester intrauterine infection is not a known cause of bilateral cleft lip.D The prevalence of cleft lip and palate is higher in Asian and Native American populations.

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Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting?

• Glass of orange juice
• Cup of coffee with cream
• Dish of lemon gelatin

d. Bowl of hot chicken broth - ANSWER-ANS: B

Clear cool liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.

An older patient reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation

• in the mid-afternoon.
• after eating breakfast.
• right after getting up in the morning.

d. immediately before the first daily meal. - ANSWER-ANS: B

The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.

The postoperative care plan for an infant with surgical repair of a cleft lip includes

• A clear liquid diet for 72 hours
• Nasogastric feedings until the sutures are removed
• Elbow restraints to keep the infant's fingers away from the mouth

d. Rinsing the mouth after every feeding - ANSWER-ANS: C

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Feedback A The infant's diet is advanced from clear liquid to soft foods within 48 hours of surgery.B After surgery, the infant can resume preoperative feeding techniques.C Keeping the infant's hands away from the incision reduces potential complications at the surgical site.D Rinsing the mouth after feeding is an inappropriate intervention. Feeding a small amount of water after feedings will help keep the mouth clean. A cleft lip repair site should be cleansed with a wet sterile cotton swab after feedings.

A 38-year old woman receiving chemotherapy for breast cancer develops a Candida albicans oral infection. The nurse will anticipate the need for

• hydrogen peroxide rinses.
• the use of antiviral agents.
• administration of nystatin tablets.

d. referral to a dentist for professional tooth cleaning. - ANSWER-ANS: C

Candida albicans infections are treated with an antifungal such as nystatin.Peroxide rinses would be painful. Oral saltwater rinses may be used but will not cure the infection. Antiviral agents are used for viral infections such as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida infection.

When caring for a patient with a history of a total gastrectomy, the nurse will monitor for

• constipation.
• dehydration.
• elevated total serum cholesterol.
• cobalamin (vitamin B12) deficiency. - ANSWER-ANS: D
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