Tiêu đề WORKBOOK - FUNDA (SC).pdf ✅

D. Desensitize the client by providing small doses of allergen. 23. A client was admitted to the hospital after sustaining a traumatic abdominal injury. Prior to undergoing a surgery to remove the spleen, the nurse should instruct the client to avoid which of the following? A. Carcinogens such as smoking B. Animal dander causing allergies C. Cuts leading to bloodstream infections D. Irritants causing dermatitis 24. Which of the following actions of the nurse demonstrates surgical asepsis? A. Wearing clean gloves to change linen. B. Cleaning the client’s skin with povidone/iodine and alcohol before inserting an intravenous catheter. C. Putting on a HEPA mask when entering the room of a client with tuberculosis. D. Placing a used syringe in a sharps container. 25. Which element of the chain of infection is being broken when the nurse uses sterile technique in changing soiled surgical dressing? A. Transmission B. Infectious agent C. Host D. Reservoir 26. Which of the following actions would be helpful in preventing the development of hospital acquired infection among clients? A. Wearing a mask when changing the dressing on the client’s central line B. Rising the suction catheter with normal saline after suctioning the client’s tracheostomy tube C. Wearing clean gloves to remove the lunch tray of a client with hepatitis A. D. Wearing clean gloves to empty a would drain 27. Older clients are at a higher risk of acquiring infection because of which of the following characteristics? A. Increased production of saliva B. Increased cough effort C. Increased cell-mediated immunity D. Thinning of the skin SITUATION: Basic nursing skills are essential for they are vital in many nursing procedures. Such skills are needed in order to promote health, prevent illness, cure a disease and rehabilitate infirmities. 28. A client with anemia is prescribed to receive iron injection. The nurse is aware that this medication should be administered in the: A. Gluteal muscle using Z-Track technique B. Deltoid muscle using an air lock C. Subcutaneous tissue of the abdomen D. Anterolateral thigh using 5/8-inch needle 29. A 28 year old female client is to undergo cerebral angiogram. Prior to the procedure the nurse should assess the client for: A. Claustrophobia B. Excessive weight C. Allergy to eggs D. Allergy to iodine or shellfish 30. The physician ordered for a client to have a wound culture to be obtained during the next wound irrigation and dressing change. Which of the following is the most appropriate solution to be use for the wound irrigation prior to the procedure? A. Povidone-iodine (Betadine) B. One-half-strength hydrogen peroxide C. Normal saline D. Acetic acid 31. To determine the necessity to perform an airway suctioning, the nurse should check the client’s: A. Oxygen saturation measurement B. Respiratory rate C. Breath sounds D. Arterial blood gas results 32. A nurse is caring for a diabetic client. She is assisting the client in performing self monitoring of blood glucose level. The nurse should teach the client to do which of the following to obtain an adequate capillary sample? A. Cleanse the hands beforehand using cool water B. Let the arm hang dependently and milk the digit C. Puncture the center of the finger pad D. Puncture the finger with enough depth Situation: A 45 year old male client has been admitted to the medical surgical unit with a diagnosis of acute pancreatitis. The nurse assigned to him took the initial vital sign and obtained a blood pressure of 136/76 mmHg, pulse rate of 96 beats per minute and temperature of 101°F (38.3°C). During the interview the nurse noted that the client has a history of hyperlipidemia and alcohol abuse. 33. The client is prescribed to have a nasogastric tube insertion. Prior to the procedure the nurse explains its purpose to the client. Which among the following is the most appropriate statement the nurse should make? A. “It empties the stomach of fluids and gas.” B. “It prevents spasm of the sphincter of Oddi.” C. “It prevents air from forming in the small and large intestine.” D. “It removes bile from the gall bladder.” 34. Which among the following is the most reliable method of checking the placement of the nasogastric tube? A. Assessing the patient’s respiration and skin color. B. Inserting the end of the tube in water and checking for bubbling. C. Aspirating gastric contents with a syringe and checking ph. 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 TOP RANK REVIEW ACADEMY, INC. Page 3 | 9
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; A. Anchoring the tube in place B. Distributing a low even pressure over the trachea C. A guide for easy removal of the tracheostomy tube TOP RANK REVIEW ACADEMY, INC. Page 4 | 9