NUR 220 Final - (NPO). The physician has now ordered the patien...

NUR 220 Final

• A patient who had a hysterectomy yesterday has not been allowed food or drink by mouth

(NPO). The physician has now ordered the patient's diet to be clear liquids. Before administering the diet, the nurse should check for

• Feelings of hunger
• Bowel sounds
• Positive Homans sign
• Gag reflex

Answer

• Bowel sounds

The absence of bowel sounds would contraindicate a diet of clear liquids.

• Skin turgor checks are performed to determine the

• temperature of the skin.
• hydration status.
• actual age.
• extent of an ecchymosis.

Answer

• hydration status.

Skin will remain tented if the patient is dehydrated or will not tent if edema is present.

• When assessing the capillary refill, the nurse may document as normal a refill time of

seconds.

• 3
• 6

3. 8 1 / 4

• 10

Answer

• 3

Capillary refill is a method of quick assessment of perfusion to the extremities. A normal capillary refill time is 3 to 5 seconds or less.

• The nurse should include the proper use of an incentive spirometer in teach- ing a preoperative

patient. Postoperative monitoring of this patient would reveal that the incentive spirometry has been effective if the patient has

• Adventitious breath sounds
• Expiratory wheezing
• Thick, green respiratory secretions
• Clear breath sounds

Answer

• Clear breath sounds

An incentive spirometer is used to promote lung expansion, which opens airways, reduces atelectasis, and stimulates coughing to clear secretions.

• Which of the following is an ABCD characteristic of malignant melanoma?
• Asymmetric borders
• Borders well demarcated
• Color of lesion is uniform
• Diameter less than 6 mm

Answer

• Asymmetric borders

ABCD melanoma mnemonic includes asymmetry, borders that are irregular, color that is not the same all over, and diameter larger than 6 mm and growing.

• A patient who has just undergone a colon resection complains to the nurse that he felt

something pop under his dressing while trying to get out of bed. The nurse removes the dressing and finds that dehiscence of the wound has occurred. The nurse's first action should be t 2 / 4

Replace the dressing; dehiscence is normal.

• Call the physician.
• Pull the wound edges together, and replace the dressing.
• Cover the wound with sterile dressings saturated with normal saline.

Answer

• Cover the wound with sterile dressings saturated with normal saline.

The first action of the nurse should be to cover the wound with saline-saturated dressings to prevent damage of the exposed organs from drying and then to call the physician.

• A patient who had been complaining of intolerable stress at work has demonstrated the

ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress?

• The patient's wife reports that he spends more time sitting quietly at home.
• He reports that his appetite, mood, and energy levels are all good.
• His systolic blood pressure has gone from the 140s to the 120s (mm Hg).
• He reports that he feels better and that things are not bothering him as much.

Answer

• His systolic blood pressure has gone from the 140s to the 120s (mm Hg). Objective measures

tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.

• The sign or symptom that suggests that a patient with impaired skin

integrity is developing a systemic infection is a

• Lesion on the patient's leg that is swollen and warm to the touch
• Temperature that has risen to 101° F
• Blood pressure that has risen from 126/84 to 130/86 mm Hg 3 / 4

• Request by the patient for medication for severe itching

Answer

• Temperature that has risen to 101° F

A rise in temperature is a systemic response. Normal blood pressure, warmth, swelling, and itching are not evidence of a systemic skin infection.

• Small, minute bruises are called

• ecchymoses.
• petechiae
• spider veins.
• telangiectasias.

Answer

• petechiae.

Petechiae are smaller than 0.5 cm in diameter. Ecchymoses are larger than 0.5 cm in diameter.Spider veins and telangiectasias are vascular lesions.

• The suprapubic area of a postoperative patient is distended. The patient states that he has

not voided since surgery approximately 9 hours ago. The nurse's first action would be to

• Notify the head nurse or physician.
• Insert a catheter and document insertion.
• Seat the patient on the side of the bed to try to void.
• Prepare the patient to return to surgery.

Answer

• Seat the patient on the side of the bed to try to void.

The patient should be encouraged to try to void in a natural position before other measures are taken. Seated on the bedside or on a bedside commode may make urination easier.

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