Nursing Skills 2

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Read and answer the questions below.

  1. The most probable nursing diagnosis with an outcome of "will have less than 50cc urinary residual." is:
  2. Your answer:
    urinary retention
    urinary incontinence
    urinary frequency
    urinary tract infection


  3. What evidence that your diet teaching has been effective?
  4. Your answer:
    "I will make sure about 55% of my total calories comes from proteins."
    "I will make sure about 55% of my total calories come from carbohydrates."
    "I will make sure that no more than 10% of my total calories comes from fats."
    "I will make sure at least 45% of my diet comes from fats."


  5. Patients complaining of gas should be taught to avoid all except:
  6. Your answer:
    walking after meals
    drinking carbonated beverages
    chewing gum or hard candies
    drinking beverages through a straw


  7. A negative nitrogen balance would least likely be caused by:
  8. Your answer:
    starvation
    prolonged immobilization
    excessive caloric intake
    infection


  9. An infant should be held in which position to correctly assess the anterior fontanelle?
  10. Your answer:
    upright
    semi-Fowlers
    cradled securely in the nurse's arms
    supine


  11. What should you do first when preparing to perform postural drainage on an infant?
  12. Your answer:
    suction the oropharynx
    position on pillows on the nurses lap
    administer an analgesic
    obtain assistance in restraining the infant


  13. An 8 month old who is unable to sit up is probably suffering from:
  14. Your answer:
    delayed mental development
    low iron unable to sit up at 8 months of age
    low iron level
    eight month olds usually are not able to sit up


  15. Which solution is most appropriate when giving an infant an enema?
  16. Your answer:
    warm sterile saline
    baby oil
    tap water
    mild soap suds


  17. The food with the highest protein content is:
  18. Your answer:
    red meat
    eggs
    navy beans
    peanut butter


  19. Which food item would be allowed on a low residue diet?
  20. Your answer:
    poached egg
    bran muffin
    orange
    whole wheat toast


  21. After starting an IV evidence that a problem exists would be:
  22. Your answer:
    raising the IV fluid container causes an increase in flow rate.
    lowering the IV fluid container below the level of the insertion site causes a backflow of blood.
    the area surrounding the site is slightly puffy and cool to the touch.
    the insertion site is pink, warm and dry.


  23. Your patient has a serum potassium level of 6.7 mEq/liter. You would expect to give:
  24. Your answer:
    Kochlor
    Kayopectate
    Kaylixer
    Kayexalate


  25. The most likely symptom of folic acid deficiency would be:
  26. Your answer:
    gastrointestinal disturbances
    depression
    vertigo and syncope
    confusion


  27. What is the body's only source of nitrogen?
  28. Your answer:
    protein
    fats
    sugars
    carbohydrates


  29. A six month old infant has not been wanting to drink and is becoming dehydrated. What lab value would you expect to be indicative of this situation?
  30. Your answer:
    decreased specific gravity
    decreased bilirubin
    decreased hematocrit
    increased central venous pressure


  31. What would the normal adult serving size from the milk group?
  32. Your answer:
    8 oz yogurt
    2 oz cheddar cheese
    4 oz whole milk
    6 oz ice cream


  33. Which of the following is a complete breakfast that includes foods from all areas of the food pyramid?
  34. Your answer:
    dry cereal with milk and bananas, and tomato juice
    toast, grapefruit half, tomato juice, egg, and milk
    pancakes with butter, bacon, orange juice, coffee, and milk
    scrambled eggs, sausage, toast, milk, prune juice


  35. Which food would be best in promoting regular bowel movements?
  36. Your answer:
    kidney beans
    lettuce
    eggs
    tomato juice


  37. Your nutritional teaching has been success if your patient tells you:
  38. Your answer:
    "I'll eat fresh vegetable and fruits daily."
    "I'll eat no more than 2-3 servings from the grain group daily."
    "I'll eat at least 4 servings of meat daily."
    "I'll eat one serving of vegetables or fruits a day."


  39. What percentage of your diet should be from carbohydrates?
  40. Your answer:
    50-60%
    75-85%
    15-30%
    < 15 %


  41. Total parenteral nutrition (TPN) can contain which substances that are not found in regular IV fluids?
  42. Your answer:
    protein, amino acids and fats
    protein and amino acids
    carbohydrates
    carbohydrates, protein, amino acids and fats


  43. Which vitamin is most frequently lost in cooking?
  44. Your answer:
    C
    K
    A
    D


  45. Red, swollen gums with loose teeth is a symptom of which vitamin deficiency?
  46. Your answer:
    D
    A
    C
    K


  47. When assessing the mucous membranes, which of the following would be a sign of ill health?
  48. Your answer:
    patchy pigmentation around gums in an African American male
    red, swollen tongue
    top surface of the tongue is slightly rough
    mucosa of the mouth is glistening, soft and pink


  49. A patient on sodium restriction should not eat:
  50. Your answer:
    navy beans
    apples
    cheeses
    macaroni


  51. Your patient, who is being given a loop diuretic, is also being given potassium supplements. You know that the first symptom of too much potassium may be:
  52. Your answer:
    anxiety and irritability
    hypersensitivity
    intestinal distention
    hypertension


  53. When giving discharge instructions to a patient, he should be given which instruction about taking his potassium elixir?
  54. Your answer:
    never take with fruit juice
    always dilute it with water
    always take it on an empty stomach for best absorption
    urine may be orange or rust colored


  55. A patient who has problems with copius amounts of flatulence should be taught to avoid which food?
  56. Your answer:
    applesauce
    peas
    cauliflower
    carrots


  57. Which finding would be evidence that your treatment for hypervolemia.
  58. Your answer:
    potassium level is now within normal limits
    patient has lost 3 pounds in two days
    abdominal girth has not increased in past 24 hours
    urinary output is 40-50cc per hour


  59. The nitrogen balance of the body can best be assess by which laboratory study?
  60. Your answer:
    creatinine clearance
    serum albumin
    BUN
    serum potassium


  61. The laboratory test that best indicates glomerular filtration is:
  62. Your answer:
    serum potassium
    creatinine clearance
    BUN
    serum albumin


  63. Chronically low oxygen levels delivered to the kidneys will cause an increase in:
  64. Your answer:
    erythropoiesis
    neutrophil destruction
    leukocytosis
    phagocytosis


  65. When beginning diet therapy for obese patient, initially, the focus should be on:
  66. Your answer:
    behavior modification
    reduction of total calorie consumption
    establishing a need to learn
    nutritional education


  67. Your female patient is having difficulty voiding. After failing to be able to use the bedpan, you take her to the bathroom and pour warm water over her perineum. She still can't void. You should:
  68. Your answer:
    obtain an order for an in and out catheterization.
    give her sufficient private time in the bathroom.
    allow her to rest undisturbed until the urge to void returns.
    explain why an empty bladder is necessary.


  69. allow her to rest undisturbed until the urge to void returns.
  70. Your answer:
    collection of a double-voided specimen
    in and out catheterization after complete emptying of the bladder
    clamp the indwelling catheter for one hour and then allow the bladder to drain completely
    24 hour urine collection


  71. Your Jewish patient follows a strictly kosher diet. Which of the following should not be served with meat?
  72. Your answer:
    apple
    milk
    hot rolls
    eggs


  73. Which of the following statements would be most helpful in obtaining information about the patient's usual intestinal pattern?
  74. Your answer:
    "Have you ever had constipation or diarrhea?"
    "How many times a day do you usually void?"
    "What is your usual pattern of elimination."
    "Do you regularly eat high-fiber foods?"


  75. Absorption of NG feedings is promoted by:
  76. Your answer:
    giving the feedings over a long period of time.
    administering all medications prior to beginning the feeding.
    maintaining the head of the bed in an elevated position for at least 30 minutes after the feeding.
    administering the feedings chilled.


  77. Prolonged NG suction causes:
  78. Your answer:
    hyperkalemia, hyponatremia
    hyperkalemia, hypernatremia
    hypokalemia, hyponatremia
    hypokalemia, hypernatremia


  79. When preparing to administer a gastrostomy feeding, you should first:
  80. Your answer:
    position the patient is a supine position
    instill 30 cc of sterile water
    check for residual
    warm the solution


  81. After giving a gastrostomy feeding, you should:
  82. Your answer:
    administer pain medication as necessary
    leave the tubing unclamped for at least 30 minutes to prevent gas build-up
    flush the tubing with the ordered amount of water.
    position the patient in the left lateral position.


  83. What fluid is most likely to be given to a patient who is hypovolemic?
  84. Your answer:
    0.9 normal saline
    2.5% dextrose
    D5/.45 normal saline
    10% dextrose


  85. An oil retention enema facilitates defecation by:
  86. Your answer:
    irritating and stimulating the intestinal mucosa
    lubricating the intestine
    lubricating the intestine
    helping expel flatus


  87. It is important to remember when digitally removing a fecal impaction, the vagal stimulation may lead to:
  88. Your answer:
    hyperventilation
    vomiting
    tachycardia
    bradycardia


  89. Hyperkalemia would most likely produce which symptom?
  90. Your answer:
    positive Trousseau's sign
    intestinal disturbances
    arrhythmias
    tetany


  91. Frequent oozing of small amounts of liquid stool is most likely a sign of:
  92. Your answer:
    fecal impaction
    electrolyte imbalance
    intestinal infection
    ileus


  93. The laboratory finding most consistent for a patient on bedrest would be:
  94. Your answer:
    hypercalcemia
    hypokalemia
    hypocalcemia
    hyperkalemia


  95. Increasing fluids in a patient with hypercalemia will help decrease calcium levels by:
  96. Your answer:
    increasing excretion of calcium through the kidneys
    decreasing serum phospate levels
    drawing calcium from the blood stream back into the bone
    exerting a dilutional effect


  97. A patient on bedrest has thick, tenacious respiratory secretions. Which nursing intervention would be most beneficial assuming there are no contradicting doctor's orders?
  98. Your answer:
    collect a sputum sample for culture and sensitivity
    initiate incentive spirometry treatments
    increase fluid intake
    assist the patient to turn, cough and deep breathe every hour


  99. A common side effect associated with antibiotic therapy is:
  100. Your answer:
    hiccoughs
    diarrhea
    drowsiness
    orange urine



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