Question 1

Which of the following is an appropriate nursing measure when performing tracheostomy care?

Accepted Answer

Insertion of the suction catheter without suction reduces the probability of tissue injury. Sterile gloves should be used for tracheostomy care. Suctioning should be done for a maximum of 10 seconds at a time. A used catheter should be disposed of appropriately.

Question 2

Why should the nurse instill eye irrigation from the inner to the outer canthus?

Accepted Answer

The irrigation flow is directed to the outer canthus to protect the nasolacrimal ducts from contaminants.

Question 3

What is the nurse's first priority when a patient receiving IV fluid therapy shows an increase in blood pressure and has bilateral crackles?

Accepted Answer

When signs of circulatory overload are observed, the infusion is slowed down initially, then the nurse should notify the charge nurse.

Question 4

When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula?

Accepted Answer

Administering O? at more than 2 L/min to a person with chronic pulmonary disease may cause respiratory failure.

Question 5

When a patient asks if he can keep the heating pack on his leg all the time, the nurse reminds him of which of the following complication of long-term heat application?

Accepted Answer

Prolonged contact with heat can cause damage to the epithelial cells.

Question 6

When irrigating an ear, the nurse should perform which intervention(s)? (Select all that apply.)

Accepted Answer

The water is heated to body temperature, the auricle is pulled gently back, the tip is placed loosely in the ear canal, and the flow is gently introduced. Irrigation is contraindicated if a foreign body is in the canal.

Question 7

What gauge needle should be selected by the nurse when preparing to administer blood?

Accepted Answer

A large-bore needle will allow blood flow without clogging.

Question 8

What would be the correct explanation of catheter care?

Accepted Answer

The first 2 inches of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift.

Question 9

Before inserting a nasogastric tube, what measurement should the nurse take?

Accepted Answer

The measurement is from the tip of the nose to the ear lobe to the xiphoid process.

Question 10

How does an Aquathermia pad differ from a traditional heating pad?

Accepted Answer

The Aquathermia pad should not be folded or placed under the patient, nor should it be left on for longer than 20 minutes. The Aquathermia pad has water that circulates and stays warm for the entire time of the treatment with no need to reheat the compress.

Question 11

When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy?

Accepted Answer

The ileostomy is higher in the GI tract and drains semi-liquid stool. The ileostomy is very similar in appearance to the colostomy, may not be permanent, and needs a pouch.

Question 12

After a Foley catheter has been removed, the nurse should assess the patient for:

Accepted Answer

While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine after the removal of the catheter.

Question 13

The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff?

Accepted Answer

The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube.

Question 14

The nurse notes an edematous area around the insertion site of an IV that is cool to the touch and the skin of which appears blanched. Based on these assessment findings, what is the first priority of the nurse?

Accepted Answer

The infusion should be stopped and restarted in another location. Warm compresses are contraindicated. Repositioning the arm will not remedy the infiltration. The charge nurse can be notified after the fact.

Question 15

To what temperature should water for eye compress be heated?

Accepted Answer

Water for an eye compress may be heated to no more than 120° F.

Question 16

During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?

Accepted Answer

Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.

Question 17

When a patient complains of progressive hearing loss, crackling and ringing noises in his ear, and progressive ear pain, what should the nurse assess for?

Accepted Answer

Symptoms of cerumen impaction are progressive hearing loss, bothersome noises in the ear, and progressive ear pain.

Question 18

While teaching a patient about the signs of IV therapy-associated phlebitis, how does the nurse describe an area with phlebitis?

Accepted Answer

Areas of phlebitis are warm, edematous, and red.

Question 19

When an order for eye irrigation is received, to whom can the nurse delegate the procedure to?

Accepted Answer

Performing eye irrigation requires the skills of a licensed nurse.

Question 20

The nurse instructs a patient receiving home O? therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid?

Accepted Answer

Water is the best option. Drinks with caffeine, sugar, or dairy products are not helpful to liquefy secretions.

Quiz 22: Care of Patients with Alterations in Health