Tiêu đề DIAGNOSTIC EXAMINATION - NP1 - STUDENT COPY ✅

B. Side-lying C. Prone D. Supine Situation: You are caring for a post-craniotomy patient, 45 yrs old. The patient is lethargic but responds to stimuli, with GCS 14 E3V5M6, PR 98bpm, RR 15 cycles/min, and a BP 120/75. You use the nursing process as you care for the patient. 16. Which of these is not a purpose of the nursing process? A. It offers a plan of care to a patient that is organized according to the goals set by the nurse. B. It helps nurses identify a client’s health status, and actual or potential health care problems. C. It delivers specific nursing interventions for the client to be able to meet his identified needs. D. It diagnoses and treats human responses to actual or potential health problems. 17. In planning for your care, you decide to use the Nursing Interventions Classification (NIC) taxonomy. Which of these indicate that you need further teaching on using NIC? A. Documenting the customized activities as planned, rather than the broad NIC labels. B. Only selecting NIC intervention labels that are appropriate to the client and can fit the available resources. C. Including all the activities under the appropriate NIC label selected D. Using the nursing problems, goals, and outcomes identified as guide to selecting NIC labels 18. Which of the following principles does the nurse use in selecting interventions for the care plan? A. Always select independent interventions when possible. B. Actions should address the etiology of the nursing diagnosis. C. There is one best intervention for each goal or outcome. D. Interventions should be “doing,” not just “monitoring.” 19. Implementation is related to other steps of the nursing process. Which of the following statements is true regarding the relationship of the implementing phase to other phases? A. After implementing, the nurse moves towards the diagnosing phase. B. The data that the nurse gathered during assessment are reassessed in the implementing phase. C. The nurse’s need for actual involvement of members from other health disciplines in implementing occurs during the planning phase. D. Evaluation can begin after all interventions have been carried out. 20. Evaluation is done primarily to identify whether: A. The nursing interventions planned were carried out B. Desired outcomes have been achieved C. There was a change in the client’s condition D. The implemented activities were effective SITUATION: The nurse contributes to the assessment of a client’s health status by collecting specimens of body fluids. All hospitalized clients have at least one laboratory specimen collected during their stay in the hospital or health care facility. 21. Nursing responsibilities associated with specimen collection include: (Select all that applies) 1. To remind the medical technologist to explain the purpose of the specimen collection. 2. Provide client comfort, privacy and safety. 3. Ensure that the client or staff follows the correct procedure. 4. Transport the specimen promptly. 5. Report abnormal finding to the health care provider. A. 1,2,3 B. 3,4,5 C. 1,2,3,4 D. 2,3,4,5 22. Analysis of stool specimen can provide information about a client’s health condition. Which of the following statements is CORRECT? A. To analyze for dietary products and digestive secretions like Steatorrhea, the nurse needs to collect at least 1 inch of formed stool. B. To detect parasites in the stool it is important to let it stay in the nurse’s station for a while to let the stool cool down. C. To determine presence of blood or hidden blood in the stool, the nurse needs to perform stool culture. D. To detect bacteria and viruses. Only small amount of feces is required. Note if the client receives antibiotics. 23. Nurses need to give clients which of the following instructions in collecting stool specimen? (Select all that applies) 1. Notify the nurse as soon as possible after defecation, particularly for specimens that need to be sent to the laboratory immediately. 2. When obtaining stool samples, handling the bedpan and disposing the contents, the nurse follows a medical aseptic technique. 3. If possible do not contaminate with urine and blood. 4. Use one or two tongue blades to transfer the specimen into the container. A. 1,2,3 B. 2,3 C. 2,3,4 D. 1,2,3,4 24. Certain foods and medications may cause inaccurate results for Guaiac Test. A false negative result may occur because of ingestion of: (Select all that applies) A. Red meat such as beef, lamb, liver and processed meat. B. Raw fruits like melon C. Aspirin and Steroids D. Vitamin C 250 mg / day 25. To collect urine from a Foley (retention) catheter, the nurse should follow the following nursing actions, EXCEPT: A. To aspirate urine and to facilitate sealing of the rubber, insert the needle at a 10 degree angle. B. Withdraw the required amount of urine. 3 ml for urine culture and 30 ml for routine urinalysis. C. Clean and wipe the area with Alcohol or a Disinfectant swab prior to insertion of needle. D. For a needleless port, insert the Luer Lock Syringe at 90 degree angle. SITUATION: A nurse is caring for an ambulatory 60 y/o male patient who has overflow urinary incontinence secondary to benign prostatic hypertrophy (BPH). The physician orders external catheter application for the patient. 26. The nurse is aware that the following are the purposes of condom catheter application BUT: A. To collect urine and control urinary incontinence B. To permit physical activity of the patient C. To promote relaxation of the urinary bladder D. To prevent skin irritation 27. During condom catheter application, the nurse must follow these standards apart from: A. Roll the condom outward onto itself B. Roll the condom over the penis, leaving 2.5-inch distance from the tip of the penis to the connecting tube C. Make sure that the tip of the penis is not touching the condom and that the condom is not twisted. D. Instruct the client to keep the drainage below the level of the condom and avoid loops or kinks in the tubing. 28. The nurse is aware that she should attach the urinary drainage bag of the condom catheter to the: A. Side rails B. Bed frame C. Patient’s gown D. Patient’s leg 29. The nurse is knowledgeable that how often should she assess the penis of the patient? A. 30 minutes after condom catheter application, then q 4 hours B. 1 hour after condom catheter application, then q shift TOP RANK REVIEW ACADEMY, INC. Page 2 | 7
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