A patient requires tracheal suctioning through the nose. Which of the following nursing action would be incorrect?
A. Lubricating the catheter with sterile water
B. Applying suction while withdrawing the catheter from the nose
C. Applying suction for a minimum of 30 seconds
D. Rotating the catheter while withdrawing it
An 85-year-old man is admitted with dementia. He continuously attempts to remove his nasogastric tube. The nurse applies cloth wrist restraints as ordered. Which of the following actions by the nurse is most appropriate?
A. Evaluate the need to restrain by observing patient's behavior once every 24 hrs
B. Perform circulation checks to the extremities every two hours
C. Remove the restraints when the patient is sleeping
D. Instruct family to limit physical contact with the patient
A patient with deep partial-thickness and full-thickness burns of the face and chest is admitted to the emergency department. The nurse must be particularly alert for:
A. Paralytic ileus
B. Respiratory distress
C. Severity of pain
D. Strong burn odor
When caring for a patient with acute pancreatitis, the patient is most likely to complain of pain which is:
A. Severe and located in the left lower quadrant and radiating to the groin
B. Burning and located in the epigastric area and radiating to the groin
C. Severe and located in the epigastric area and radiating to the back
D. Burning and located in the left lower quadrant and radiating to the back
The patient with iron deficiency anemia should be encouraged to eat which of the following foods high in iron?
A. Eggs
B. Lettuce
C. Citrus fruits
D. Cheese
A patient arrived to the Post Anesthesia Care Unit (PACU) complaining of pain after undergoing a right total hip arthroplasty. Which of the following should the nurse do to assess the patient's level of pain?
A. Determine the patient's position during surgery and how long the patient was in this position
B. Inspect the dressing, note type and amount of drainage, and insure bandage adhesive is not pulling on skin
C. Ask anesthesiologist what type of anesthesia patient received and last dose of pain medication
D. Note location, intensity and duration of pain and last dose and time of pain medication
In caring for a woman and baby day 3 postnatally, she tells you that her baby has not had a bowel action since delivery. Your appropriate response would be:
A. Reassure the mother that it is quite normal for a baby to not move their bowels until day 5 after a few days of milk feeding
B. Start a bowel chart, document all findings, and wait another 48 hours before reporting to the physician
C. Encourage more frequent warm baths for the neonate with gentle abdomen massages
D. Tell the mother that you will let the physician know, so the baby can be checked for any obstruction
A nurse can ensure she maintains her competency to practice through:
A. Being involved in continuing education programs
B. Making sure that what was learnt at nursing school is strictly followed
C. Closely carrying out instructions given by the Charge Nurse
D. Working on the same ward for at least 2 years
When checking the capillary refill time of a patient's extremity, the color returns in 7 seconds. The nurse recognizes this finding as indicative of:
A. A normal response
B. Thrombus formation in the veins
C. Lymphatic obstruction of venous return
D. Impaired arterial flow to the extremities
To promote accuracy of self-monitoring blood glucose by patients the nurse should:
A. Retrain patients periodically
B. Direct patients to rotate testing sites
C. Advise patients to buy new strips routinely
D. Compare results from patient's meter against lab results
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