Tiêu đề WORKBOOK - FUNDA (KEY) ✅

A. Call the family so they can expect the patient at home B. Allow the patient to leave because no one can be held against his or her will C. Call security because there must be a physician’s order before a patient may leave D. Explain the risk of leaving and request that the patient sign a paper accepting responsibility for problems that may occur 12. Which among the following is the most appropriate action of the nurse during the client’s discharge? A. Tell the patient everything will be all right B. Encourage the patient not to worry C. Wish the patient well D. Introduce the patient to the office staff Situation: Hygiene is the science of health and its preservation. Hygiene is personal matter established by individual’s values and practices. The nurse must be knowledgeable in the proper ways of rendering hygienic care to clients. 13. A nurse is bathing a 10year old client with a cast on the left leg. Which of the following actions is appropriate for the nurse do when providing eye care? A. To wash from the outer canthus to inner canthus B. To cleanse dried exudate with hot water C. To avoid drying circumorbital area after washing D. To use a different section of washcloth for each eye 14. A nurse is to render perineal care to an 80 year old male client 1 day post TURP. Which among the following is most appropriate action of the nurse? A. Retract the foreskin, cleanse the penis, and allow the foreskin to return to former position B. Sprinkle powder under the foreskin to facilitate retraction of the foreskin C. Leave the foreskin slightly damp to allow retraction to its former state D. Retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion 15. Which among the following clients has the highest risk for complication of the feet? A. A young man in a career that requires standing B. A disoriented, elderly man C. A 60-year-old person with diabetes mellitus D. A 62-year-old patient with total hip replacement Situation: Pressure ulcer is any lesions brought by unrelieved pressure leading to the damage of the underlying tissue. It is most common among clients who are confined in bed. 16. When the nurse is placing the client on a 30 degrees lateral position, she is preventing the client to develop pressure ulcer over which of the following areas? A. Spinous processes B. Ischial tuberosities C. Greater tronchanters D. Temporal area 17. Which among the following pertains to stage III pressure ulcers? A. Nonblanchable reddened areas where the skin is intact B. Full-thickness skin loss extending to but not through the fascia C. Extensive destruction of skin and muscle with possible sinus tracts D. Areas of full-thickness skin loss with possible extension to the bone Situation: Conduction of surgical procedures may vary in every health care institution but providing quality care and ensuring client’s safety is a mutual aim among every health care facilities. 18. A nurse is caring for a female client with Penrose drain in the left lower quadrant, who has been returned to the medical-surgical unit from the post anesthesia care unit. The nurse knows that the Penrose drain was placed to A. instill solution for wound irrigation B. prevent blockage of a passageway C. drain the wound area by suction D. drain the wound area by gravity 19. While doing an assessment to the client, the nurse noticed that the client’s abdominal wound eviscerated, the nurse should; A. Place her in high Fowler’s position B. Give her fluids to prevent shock C. Replace dressings with sterile fluffy pads D. Apply warm, moist sterile dressings 20. A client was prescribed to wear an antiembolic stocking. The nurse should initially; A. Measure the legs before applying stockings to assure proper fit B. Apply the stockings while the client is sitting in a chair C. Massage the legs when removing the stockings D. Leave the stockings in place for one week intervals 21. The OR nurse must be aware of the surgical environment and the proper attire in each area. Which of the following constitute a break in infection control which may cause contamination in the OR? A. The spouse of the client enters the unrestricted area in street clothes. B. The OR nurse wear surgical attire when going to the storage areas. C. The OR nurse is wearing scrub attire in the restricted area. D. The OR nurse wear surgical scrubs alone in the OR room when preparing for the instruments. Situation: Infection control is one of the most important parts of health care. It is concerned on preventing nosocomial or health care related infection 22. To be able to protect the client’s first line of defense against infection, the nurse should do which of the following? A. Turn the client who is immobilized every 2 hours so the skin does not break down. TOP RANK REVIEW ACADEMY, INC. Page 2 | 9

D. Injecting air into the tube with a syringe and listening for rush of air. 35. Which of the following is the most appropriate initial action of the nurse when the client vomits 200 ml after the nasogastric tube insertion? A. Change the suction applied to the nasogastric tube from intermittent to continuous. B. Advance the nasogastric tube 2”(5cm). C. Replace a nasogastric contents with a large one. D. Ensure that the head of the patient is elevated 36. Which among the following methods would be most helpful to the nurse when measuring the length of the nasogastric tube to be inserted to the client? A. Center of forehead to top of nose to end of sternum B. Tip of nose to tip of earlobe to end of sternum C. Lips to tip of ear to just below the umbilicus D. Tip of ear to midway between end of sternum and umbilicus 37. How should the nurse check the proper placement of the nasogatric tube after insertion? A. The patient no longer complains of pain or nausea B. 30 ml of normal saline can be injected with ease C. Bubbles occur when the tube is submerged into water D. Gastric contents are aspirated with cone tipped syringe 38. Another client is receiving an enteral feeding through the open system container. A knowledgeable nurse knows that the difference between an open and closed system enteral feeding is that; A. An open system uses an open top container uses a syringe for administration B. An open system uses an open top container or a syringe for administration and a closed system consists of prefilled container that is spiked with enteral access device. C. Closed system uses prefilled comtainer that can hang for 24 hours if sterile technique is used and open system should have no more than 24 hours of formula feedings poured at one time D. Open system uses prefilled container and closed system uses open top container 39. During the report, the nurse indicates that the client’s NG tube quit draining over the last hour. Prior to that, it was draining 100 ml of fluid q 2 hr. which plan would best assist this client? A. Anchor a new NG tube B. Reposition the tube to promote drainage C. Order a chest X-ray to determine the placement D. Force 50 ml of normal saline down the tube 40. Which of the following actions of the nurse would indicate a need for further teaching about the methods used to safely ensure proper NGT placement? A. When confirming tube placement, place the tube’s end in a container of water B. Use tongue blade and penlight to examine mouth and throat for signs of a coiled section of tubing C. Stop advancing tube when tape mark reaches the client’s nostril. D. Inject 10 cc of air into tube. At the same time, auscultated for air sounds with stethoscope placed over the epigastric region. 41. The nurse is to remove the client’s nasogastric tube. Which of the following is the correct sequence of actions the nurse should follow? 1. Assist client into semi-Fowler’s position 2. Ask the client to hold her breath 3. Assess bowel function by auscultation for peristalsis 4. Flush tube with 10 ml of normal saline 5. Withdraw the tube gently and steadily 6. Monitor client for nausea and vomiting A. 5, 3, 1, 4, 2, 6 B. 4, 2, 1, 6, 3, 5 C. 3, 1, 4, 2, 5, 6 D. 1, 3, 2, 4, 6, 5 Situation: A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube. This is indicated for clients who need long term airway support. 42. The nurse is caring for a 45 year old male client diagnosed with throat cancer. He was tracheostomized two days ago and the nurse needs to clean his tracheostomy tube. Which among the following parts of the tracheostomy tube can the nurse remove for cleaning? A. Outer cannula B. Inner cannula C. Single-lumen tube D. Double-lumen tube 43. As the nurse of a client with tracheostomy tube, which among the following safety precaution should you make? A. Keep a crash cart in the room B. Be prepared to put him on a ventilator C. Keep curved hemostat at the bedside D. Be prepared to remove the tube 44. What is the purpose of keeping an obturator on the bedside of a client with tracheostomy tube? A. To facilitate insertion of the outer cannula B. To secure the ties of the tube C. To be kept by the client D. To be used to make an opening for the tube 45. To remove crusty secretion on the incision site and tube flange of the client’s tracheostomy tube, the nurse should soak the sterile applicator in what solution? A. Ethyl alcohol B. Isopropyl alcohol C. Hydrogen peroxide (Full strength) D. Hydrogen peroxide ( half-strength solution mixed with sterile normal saline) 46. A nurse in the medical-surgical unit noticed that the adult clients who need long term airway support have a tracheostomy tube with cuffs. The nurse is aware that the main purpose of a tracheostomy tube with inflatable cuff is; TOP RANK REVIEW ACADEMY, INC. Page 4 | 9