Title DIAGNOSTIC EXAMINATION - NP1 - STUDENT COPY ✅

C. 30 minutes after condom catheter application, then q 24 hours D. 1 hour after condom catheter application, then q 2 days 30. hat how often should she change the condom device? A. Every 8 hours B. Every 16 hours C. Every 24 hours D. Every 32 hours 31. The nurse has changed the old condom catheter of the patient. She demonstrates understanding of the procedure if she tapes the new condom catheter in what manner? A. Vertically B. Horizontally C. Diagonally D. Spirally 32. The nurse wants to delegate the application of a condom catheter to a nursing aide. What must the nurse assess prior to delegating this task? A. Assess whether the client has unique needs. B. Measure the client’s intake. C. Assist the client out of bed to a chair. D. Assess changes in the client’s mobility status. 33. The nursing aide has applied a condom catheter to a client. The nurse should document what information about this procedure? 1. Number of mL of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis A. 1,2,3 B. 3,4 C. 4,5 D. 1,2 SITUATION: A male patient was rushed into the Emergency Room after being involved with motor vehicular accident. Assessment reveals sucking anterior and mid-axillary chest wounds. The physician on duty orders emergency thoracic operation with chest tube insertion connected to a three-way bottle system. 34. Nurse Maureen, an OR nurse has assisted the physician with the insertion of a chest tube. She monitors the client and notes oscillation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A. Inform the physician B. Continue to monitor the client C. Reinforce the occlusive dressing D. Encourage the client to deep-breathe 35. The patient’s operation was successful and is now being transferred to surgical ward. Nurse Hiromi who is currently caring for this patient, notes continuous gentle bubbling in the suction control chamber. What action is appropriate? A. Do nothing, because this is an expected finding B. Immediately clamp the chest tube and notify the physician C. Check for an air leak because the bubbling should be intermittent D. Increase the suction pressure so that the bubbling becomes vigorous 36. Nurse Hiromi also assessed the patient's chest tube insertion site. She noticed a fine crackling sound and feeling upon palpating the area. What action should the she take? A. Discontinue the chest tube suction. B. Collaborate with the client's physician. C. Mark the area involved and remove the tube. D. Reinforce the chest tube dressing. 37. The patient becomes irritable and restless. He incessantly turns from side to side. Unfortunately, the chest tube accidentally disconnects. The initial nursing action of Hiromi is to: A. Call the physician B. Place the end of the tube in a bottle of sterile water C. Immediately replace the chest tube system D. Place a sterile occlusive dressing over the disconnection site 38. The patient’s water seal drainage stopped bubbling. After checking the patient and the bottle system, nurse Hiromi found no unusual findings. The doctor was notified and ordered for chest X-ray. The result reveals re-expansion of the patient’s affected lung. The physician finally orders removal of the chest tube. While assisting the doctor during chest tube removal, she should instruct the patient to: A. Exhale slowly with pursed lips B. Inhale deeply and hold breath C. Inhale and exhale quickly D. Exhale and hold breath SITUATION: A nurse is caring for clients with varying gastro-intestinal disorders. One of the clients has biliary atresia. Nausea and vomiting was severe so the doctor ordered for Nasogastric tube placement to decompress the stomach. 39. A nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing, and as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which nursing action would least likely result in proper tube insertion and promote client relaxation? A. Pulling the tube back slightly B. Instructing the client to breathe slowly C. Continuing to advance the tube to the desired distance D. Checking the back of the pharynx using a tongue blade and flashlight 40. Nurse Billy checks the patient’s NGT placement, he knows that the best way to confirm it is? a. Checking for appearance of gastric aspirate b. Checking the X-ray result c. Checking for bubbling if immersed in a basin of water d. Checking for acidic pH of gastric aspirate 41. The client’s nasogastric (NG) tube stops draining. Which should the nurse implement first to maintain client safety? 1. Verify the tube placement. 2. Instill 30 to 60 mL of fluid. 3. Clamp the tube for 2 hours. 4. Retract the tube by 2 inches. A. 1, 3 B. 2, 4 C. 1, 2 D. 2, 3 42. The patient’s condition improved. Vomiting has lessened but the patient still cannot tolerate oral intake so the doctor made a new order for enteral feeding for nutritional support. A nurse developing a care plan for this client identifies which situations that will place the client at risk for aspiration? 1 Sedation 2 Coughing 3 An artificial airway 4 Head elevated position 5 Nasotracheal suctioning 6 Decreased level of consciousness A. 1, 2, 3, 4, 5 B. 2, 3, 4, 5, 6 C. 1, 2, 3, 5, 6 D. 1, 2, 3, 4, 5, 6 43. The nurse is preparing to initiate bolus enteral feedings via nasogastric (NG) tube to the same client. Which of the following actions represents safe practice by the nurse? A. Checks the volume of the residual after administering the bolus feeding B. Aspirates gastric contents prior to initiating the feeding and ensures that pH is greater than 9 C. Elevates the head of the bed to 25 degrees and maintains for 30 minutes after instillation of feeding D. Measures the length of the tube from where it protrudes from the nose to the end and compares it to previously documented measurements 44. If the patient is on continuous feeding via NGT, how often should the nurse check the tube’s placement? A. Every 6-8 hours TOP RANK REVIEW ACADEMY, INC. Page 3 | 7
B. Every 1-3 hours C. Every 4-6 hours D. Every 8-10 hours 45. The client’s prognosis went well and the doctor ordered the patient for possible discharge within 24 hours. As the nurse prepares the client for the removal of a nasogastric tube, she instructs the client to: A. Inhale deeply. B. Exhale slowly. C. Hold in a deep breath. D. Pause between breaths. SITUATION: Ensuring safety before, during and after a respiratory diagnostic procedure is an important responsibility of the nurse. The following questions apply. 46. A client named Daryl is suspected of having a pleural effusion. The nurse assesses him for which typical manifestations of this respiratory problem? A. Dyspnea at rest and moist, productive cough B. Dyspnea on exertion and dry, non-productive cough C. Dyspnea at rest and dry, non-productive cough D. Dyspnea on exertion and moist, productive cough 47. The nurse plans to have which of the following items available for immediate use for Daryl’s untreated condition? A. Intubation tray B. Paracentesis tray C. Thoracentesis tray D. Central venous line insertion tray 48. The nurse recalls the nursing interventions before, during, and after aspiration of fluid in the pleural cavity. She was not able to recollect accurately if she anticipates that the doctor will not insert the trocar: A. Below the seventh rib laterally and above the ninth rib posteriorly B. Below the 2nd intercostal space (ICS) anteriorly and above 4th ICS posteriorly C. Below the seventh rib laterally and below the ninth rib posteriorly D. Above the 2nd intercostal space (ICS) anteriorly and below 4th ICS posteriorly 49. The nurse is assessing Daryl’s respiratory status after thoracentesis. The nurse would become most concerned with which of the following assessment findings? A. Equal bilateral chest expansion B. Respiratory rate of 22 breaths per minute C. Diminished breath sounds on the affected side D. Few scattered wheezes, unchanged from baseline 50. Daryl has become progressively dyspneic and now has been co-diagnosed with left tension pneumothorax. Which of the following observed by the nurse indicates that his pneumothorax is rapidly worsening? A. Tracheal deviation to the left B. Tracheal deviation to the center of carina C. Pain on respiration with flat neck veins D. Tracheal deviation to the right Situation: Verbal communication is extremely important especially when the Nurse is exploring problems and disorders with the clients in any age group. Nurse Dante is assigned to different clients in the ward. 51. A client is hospitalized with a diagnosis of possible Cancer of the pancreas. On admission the client asks the nurse, “Do you think I have anything serious like cancer?” What is the nurse’s best reply? A. “What makes you think you have cancer? B. “I don’t know if you do, but let’s talk about it.” C. “Why don’t you discuss this with your doctor?” D. “Don’t worry, we won’t know until all the test result are back.” 52. Nurse Dante approaches a male client and asks how he is feeling. The client states “I’m feeling a bit nervous today.” Which of the following is the Nurse’s best reply? A. Please explain what you mean by the word nervous B. What is making you feel nervous? C. Would a backrub ease your nervousness? D. You do look like you’re nervous 53. When assessing a client what statement would indicate negative self-talk? A. Everyone has to learn something new sometime B. I am looking forward to making home visits , but I am also nervous C. This is going to be difficult, but I know I can do it D. Who can ever have enough experience to prepare for that job? 54. While receiving a preoperative enema a client starts to cry and says. “I’m sorry you have to do this messy thing me,” what is the best response by the nurse? A. “I don’t mind it.” B. “You seem to be upset.” C. “This is part of my job.” D. “Nurses get used to this.” 55. “But you don’t understand” is a common statement associated with adolescent. The best response by the nurse when communicating with an adolescent is to say: A. “I don’t understand.” B. “I would like to understand, let’s talk.” C. “I don’t understand. I was a teenager once too.” D. “I’m not sure have to I believe it’s you who has to understand.” Situation: One of the important roles of the Nurses is being a Health Educator. Clients would always seek information on Health maintenance to prevent illness. 56. Nurse Diana, daughter of Hippolita and the princess of Themycera, is teaching a client about prescribe restricted diet. What is the Nurse’s best initial comment? A. “You can eat only the on this list.” B. “What types of food do you usually eat?” C. “You need to limit the intake of food on this list.” D. “Do you understand why you have these food restrictions?” 57. Nurse Diana is preparing a nursing care plan to a client with Diabetes Mellitus (D.M.) that includes before discharge to know how to self-administer insulin, adjust the insulin dosage, understand the diet, and test the serum for glucose level. The client progresses well and is discharge 5 days following admission. Legally the: A. Nurse was properly functioning as a health teacher B. Visiting nurse should do health teaching in the client’s home C. Family members also should have been taught to administer the insulin D. Physician was responsible and the nurse should have cleared the care with the physician 58. Which teaching method has been evaluated as most effective in a new diabetic client? A. Utilizing breaks after each unit of the teaching session B. Having the client repeat the steps of insulin administration C. Encouraging the client to ask many questions D. Confirming that the client is able to give his own insulin 59. Which of the following statements by a client would alert the Nurse that further teaching on the idea of a restful sleep is indicated? A. I don’t take naps throughout the day B. I go to bed and get up routinely at the same time each day C. I have a small snack and take a bath before going to bed each day D. I went to bed earlier than usual and I rested and watched television until I fall asleep 60. What can the Nurse do to support the client’s ability to sleep in the hospital setting? A. Assess the client’s towards the end of the shift , closer to the normal awakening time B. Darken the room as much as possible by keeping the lights off C. Limit the noise and distraction on the unit D. Provide a bath or shower before bedtime Situation: Benjie, a charge nurse, is attending to the client with an intravenous fluid. 61. What does Nurse Benjie identify as the most likely cause of the infiltration of a client’s IV? A. Excessive height of the IV solution TOP RANK REVIEW ACADEMY, INC. 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