Unit Test 1
Objectives
1. |
Orientation to the Course/ Safety/ Handwashing/ Restraints |
2. |
Orientation to Admissions Office: Rules of Admission/ Discharge/ Transfer |
3. |
Orientation to Patient’s Assessment: Vital Signs/ Pain Assessment |
4. |
Orientation to Hospital Documentation: Documenting in the Nursing Records/ Giving and Receiving verbal report with shift responsibility for care |
5. |
Medical Terminology |
6. |
Bed Making |
7. |
Personal Hygiene |
8. |
Medication Administration: Oral |
9. |
Medication Administration: Topical & Others |
10. |
Medication Administration: Injections |
11. |
Medication Administration: IV therapy |
12. |
Oral Nutrition/ Dysphagia |
13. |
Nasogastric and Feeding Tubes |
14. |
Bowel Elimination. Urinary Elimination |
15. |
Diagnostic Testing |
16. |
Assisting with Diagnostic Manipulations |
CHAPTER 1
Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.
____ 1. Prior to all diagnostic tests, the nurse must do all of the following EXCEPT
a. |
take vital signs |
b. |
be sure the client is wearing an identification band |
c. |
ask the client about allergies |
d. |
push fluids |
____ 2. A minimally depressed level of consciousness during which the client maintains a patent airway is called
a. |
conscious sedation |
c. |
regional anesthesia |
b. |
local anesthesia |
d. |
general anesthesia |
____ 3. Blood is collected in a red-topped tube. The nurse knows this tube has
a. |
no additive |
c. |
sodium citrate |
b. |
EDTA |
d. |
potassium oxalate |
____ 4. What should the nurse do to prevent hemoconcentration when collecting blood specimens?
a. |
Encourage the client to drink fluids. |
b. |
Do not keep the tourniquet on the arm too long. |
c. |
Dilute the specimen immediately. |
d. |
Use a large-bore needle. |
____ 5. When performing a venipuncture for a specimen, the nurse should
a. |
select an arm in which an IV is infusing |
b. |
apply the tourniquet 6 to |
c. |
not palpate a distal pulse following application of the tourniquet |
d. |
select a vein that is not dilated |
____ 6. Which condition would alert the nurse to pay particular attention when performing an arterial puncture?
a. |
The client has been vomiting. |
b. |
The client is receiving oxygen therapy. |
c. |
The client has a respiratory condition. |
d. |
The client is on anticoagulant therapy. |
____ 7. After arterial puncture, the nurse should do which of the following?
a. |
apply heat to the puncture site |
c. |
apply pressure for at least 5 minutes |
b. |
observe for fresh rash and dyspnea |
d. |
encourage immediate range of motion |
____ 8. Which site is not appropriate for a capillary puncture?
a. |
heel |
c. |
earlobe |
b. |
fingertip |
d. |
antecubital space |
____ 9. When performing a capillary puncture, the nurse should
a. |
hold the lancet at a 45-degree angle to the skin |
b. |
puncture the skin 5-mm deep |
c. |
wipe off the first drop of blood with a sterile gauze |
d. |
apply heat to the puncture site |
____ 10. An adult is to collect a 24-hour urine specimen from
a. |
Collect all your urine between |
b. |
At |
c. |
Void at |
d. |
Void at |
____ 11. When a clean-voided specimen is ordered, the nurse should instruct the client to
a. |
clean the area as directed and collect the initial urine voided |
b. |
clean the area as directed, start to void into the toilet, collect the urine in the sterile cup after a good flow of urine has been established |
c. |
clean the area as directed and collect all the urine voided |
d. |
clean the area as directed, start to void and collect three samples at different times during the voiding |
____ 12. Granulocytes, monocytes, and lymphocytes are what type of blood cell?
a. |
red blood cells |
c. |
platelets |
b. |
white blood cells |
d. |
plasma cells |
____ 13. An adult client has a hematocrit of 64%. With what condition is this most consistent?
a. |
dehydration |
c. |
anemia |
b. |
leukemia |
d. |
hemorrhage |
____ 14. Where are red blood cells made in an adult?
a. |
shaft of the long bones |
c. |
all bones |
b. |
membranous bones |
d. |
toes and fingers |
____ 15. The client is to have a prothrombin time blood test. What must the nurse include on the requisition form?
a. |
age of the client |
b. |
diagnosis |
c. |
medications the client is taking |
d. |
foods to which the client is allergic |
____ 16. The blood test used to diagnose hemolytic anemia is
a. |
red blood cell count |
c. |
complete blood count |
b. |
white blood cell count |
d. |
hemoglobin electrophoresis |
____ 17. What is the normal fasting blood glucose level?
a. |
50 to 70 mg/dl |
c. |
120 to 150 mg/dl |
b. |
70 to 115 mg/dl |
d. |
150 to 190 mg/dl |
____ 18. The client is to have a glucose tolerance test performed. The nurse should instruct the client to
a. |
have nothing to eat or drink before the test |
b. |
eat a large meal before the test |
c. |
have only clear liquids before the test |
d. |
expect to eat a large meal during the test |
____ 19. Which of the following is an anion?
a. |
sodium |
c. |
calcium |
b. |
potassium |
d. |
chloride |
____ 20. CPK(MB) is a blood test used to assist in the diagnosis of which condition?
a. |
liver disease |
c. |
myocardial infarction |
b. |
diabetes |
d. |
rheumatoid arthritis |
____ 21. A client has an elevated AST. Which condition is the client most likely to have?
a. |
hepatitis |
c. |
rheumatoid arthritis |
b. |
diabetes |
d. |
prostate cancer |
____ 22. A client has an elevated acid phosphatase. Which condition is the client most likely to have?
a. |
diabetes |
c. |
nephrotic syndrome |
b. |
hyperthyroidism |
d. |
metastatic prostate cancer |
____ 23. The client has a serum cholesterol of 250 with a low HDL and high triglycerides. What is the client’s coronary heart disease risk?
a. |
low |
b. |
borderline |
c. |
high |
d. |
not enough information to determine |
____ 24. Which instruction is not appropriate for the nurse to give the client who is to have lipid level testing?
a. |
Eat a regular diet for 3 to 7 days before the test. |
b. |
Exercise the morning of the test. |
c. |
Do not drink caffeinated beverages or smoke for 24 hours before the test. |
d. |
Do not eat anything for 12 hours before the test. |
____ 25. To determine trough levels of a drug being administered to a client, the nurse would expect to draw a blood sample at which time?
a. |
immediately before giving the drug |
b. |
immediately after giving the drug |
c. |
one-half hour after giving an IV drug |
d. |
halfway between doses |
____ 26. Which of the following is normally found in the urine?
a. |
protein |
c. |
ketones |
b. |
glucose |
d. |
none of the above |
____ 27. Prior to obtaining a stool specimen for occult blood, the client should be given which instruction?
a. |
Avoid red-colored gelatin for 3 days. |
b. |
Eat no fish for 3 days. |
c. |
Eat no meats for 3 days. |
d. |
Avoid red-colored beverages for 3 days. |
____ 28. Which statement is true about collecting any type of specimen for culture?
a. |
The client should be fasting. |
b. |
The specimen should be collected early in the morning. |
c. |
The specimen should be collected before antibiotics are started. |
d. |
The client should drink a lot of fluids before the specimen is obtained. |
____ 29. What instructions should the nurse give the woman who is scheduled for a cervical Pap smear?
a. |
“Douche immediately before coming for the test.” |
b. |
“The test should be done during menstruation.” |
c. |
“Drink plenty of liquids before the test.” |
d. |
“Do not have sexual intercourse for 24 hours before the test.” |
____ 30. The client is scheduled for a barium enema, an intravenous pyelogram (IVP), and thyroid function tests. In which order should the tests be done?
a. |
IVP, barium enema, thyroid function tests |
b. |
thyroid function tests, barium enema, IVP |
c. |
thyroid function tests, IVP, barium enema |
d. |
barium enema, IVP, thyroid function tests |
____ 31. Prior to any test in which a contrast medium is used, the nurse should ask which of these questions?
a. |
“When did you last void?” |
b. |
“Are you allergic to any foods or other substances?” |
c. |
“How old are you?” |
d. |
“How tall are you?” |
____ 32. The client has just had a barium enema. What order should the nurse expect?
a. |
NPO for 8 hours |
c. |
cleansing enema |
b. |
stool specimen to lab |
d. |
observe for rash |
____ 33. The client has had a cardiac catheterization. Following the procedure, the nurse’s efforts are aimed at preventing and detecting which common problems?
a. |
chills and fever |
c. |
diuresis and dehydration |
b. |
clotting and bleeding |
d. |
muscle spasm and joint pain |
____ 34. The client is to have an IVP. What question is essential for the nurse to ask the client before the procedure?
a. |
“Are you allergic to shellfish?” |
b. |
“Have you had a barium enema before?” |
c. |
“Are you taking birth control pills?” |
d. |
“When was your last bowel movement?” |
____ 35. The client has just returned from a bronchoscopy under local anesthesia. What nursing action is essential?
a. |
administer sips of water |
b. |
encourage fluid intake |
c. |
keep client NPO until return of gag reflex |
d. |
assess for allergy to iodine |
____ 36. A pelvic ultrasound is ordered for a pregnant woman. What instruction(s) should the nurse give the client?
a. |
“Do not eat or drink anything after midnight the night before the test.” |
b. |
“Avoid iodine-containing foods for 3 days before the test.” |
c. |
“Give yourself an enema the night before the test.” |
d. |
“Drink 6 to 9 glasses of water and do not urinate before the procedure.” |
____ 37. What instruction(s) should the nurse give the client who is to have an electrocardiogram performed?
a. |
“Eat a full meal before the test.” |
b. |
“Do not smoke or drink caffeinated beverages for 24 hours before the test.” |
c. |
“Take a laxative the night before the test.” |
d. |
“Exercise vigorously before coming in for the test.” |
____ 38. The client is to have a paracentesis performed. What must the nurse do immediately before the procedure?
a. |
have the client void |
b. |
encourage fluid intake |
c. |
position the client in a supine position |
d. |
keep the client NPO for 4 hours |
____ 39. The nurse is positioning a client who is to have a lumbar puncture performed. What position is appropriate?
a. |
prone |
b. |
supine |
c. |
semi-Fowler’s |
d. |
side-lying with knees drawn up to chest |
____ 40. Which of the following is an invasive procedure?
a. |
mammography |
c. |
computed tomography |
b. |
ultrasonography |
d. |
angiography |
____ 41. Which statement is incorrect about the naming of drugs?
a. |
The nonproprietary name is the name assigned by the United States Adopted Names Council to the manufacturer who first develops the drug. |
b. |
The official name may be the same as the nonproprietary name. |
c. |
A generic drug may have only one trade name. |
d. |
The proprietary name is the trade name. |
____ 42. Fifty percent of the drug’s original dose is in the blood 4 hours after administration. What is the half-life of the drug?
a. |
1 hour |
c. |
4 hours |
b. |
2 hours |
d. |
8 hours |
____ 43. Which is not a route for parenteral administration of drugs?
a. |
intradermal |
c. |
IV |
b. |
subcutaneous |
d. |
oral |
____ 44. A drug is ordered to be given sublingually. How should the nurse administer this drug?
a. |
Have the client swallow the drug. |
b. |
Place the drug under the client’s tongue. |
c. |
Put the drug in the client’s cheek. |
d. |
Apply the drug to the client’s skin. |
____ 45. The movement of a drug from the blood into various body fluids and tissues is called
a. |
absorption |
c. |
metabolism |
b. |
distribution |
d. |
excretion |
____ 46. Where are most drugs metabolized?
a. |
kidneys |
c. |
skin |
b. |
adrenal glands |
d. |
liver |
____ 47. A highly unpredictable response to a drug is called
a. |
drug tolerance |
c. |
drug allergy |
b. |
idiosyncratic reaction |
d. |
adverse effect |
____ 48. A client who abuses antacids is at risk for which condition?
a. |
osteomalacia |
c. |
heart rhythm problems |
b. |
peripheral neuritis |
d. |
vitamin C deficiency |
____ 49. A drug is ordered to be given OD. The nurse should administer this drug
a. |
in the right eye |
c. |
in the left eye |
b. |
every day |
d. |
by mouth |
____ 50. A drug is ordered to be given stat. The nurse should administer this drug
a. |
in the subcutaneous tissue |
c. |
at the hour of sleep |
b. |
immediately |
d. |
in a suspension |
____ 51. The physician writes an order for medication to be given every 4 hours p.r.n. How should the nurse administer this drug?
a. |
every 4 hours around the clock |
b. |
every 4 hours if the client’s condition indicates a need for it |
c. |
as many as four times a day |
d. |
every 4 hours if the client asks for it |
____ 52. The physician has written an order for a drug for a client. The nurse believes the drug dosage to be in error. What is the nurse’s responsibility?
a. |
Make a notation on the client’s medication administration record. |
b. |
Ask another nurse if the order is correct. |
c. |
Withhold the drug and ask the physician. |
d. |
Administer the drug and question the physician later. |
____ 53. Which unit of measurement is the largest?
a. |
fluid dram |
c. |
teaspoon |
b. |
fluid ounce |
d. |
minim |
____ 54. The order is for heparin 10,000 units SC. The dose on hand is 40,000 units/ml. How much should the nurse administer?
a. |
4 ml |
c. |
0.4 ml |
b. |
0.25 ml |
d. |
0.004 ml |
____ 55. Before administering a drug to a client, the nurse should
a. |
ask another nurse if the drug is prepared correctly |
b. |
check the label on the drug container three times |
c. |
ask the client if this is the correct drug |
d. |
have another nurse prepare the medication |
____ 56. Which statement is correct about the nurse’s responsibility for the care and administration of narcotics?
a. |
Narcotics must be counted at the change of each shift by the nurse going off duty and the nurse coming on duty. |
b. |
When giving a narcotic, the nurse must get another nurse to verify the amount of drug given. |
c. |
Narcotics must be stored in a separate container from other drugs, but do not need to be under lock and key. |
d. |
When recording the administration of a narcotic, the nurse must record only the name of the drug and the client to whom it was given. |
____ 57. To which substance is the most prevalent addiction problem in the
a. |
cocaine |
c. |
alcohol |
b. |
marijuana |
d. |
heroin |
____ 58. When taking a drug history from a client, the nurse should do all the following except ask the client about
a. |
prescription drugs taken |
c. |
drug allergies |
b. |
over-the-counter drugs taken |
d. |
cost of the medications |
____ 59. The client has a medication prescribed. When assessing the client, the nurse discovers the client does not understand why the drug is being administered or exactly when it should be taken. The most appropriate nursing diagnosis is
a. |
Altered Health Maintenance |
b. |
Altered Nutrition |
c. |
Knowledge Deficit |
d. |
Ineffective Management of Therapeutic Regimen |
____ 60. What is essential for the nurse to assess before administering an oral medication to a client?
a. |
the client’s knowledge of the drug being administered |
b. |
the client’s ability to swallow |
c. |
the client’s understanding of why she is receiving the drug |
d. |
the client’s ability to describe the possible side effects of the drug |
____ 61. The client asks the nurse to leave his sleeping pill at the bedside because he wants to read for a few more minutes before going to sleep. The most appropriate action for the nurse to take is to
a. |
leave the pill as requested |
b. |
tell the client to call the nurse when he is ready for his medication |
c. |
tell the client he can take it now or not at all since this is when it is ordered |
d. |
leave the pill as requested and check back in half an hour to be sure the client took the medication |
____ 62. Which statement is correct about the administration of oral drugs?
a. |
When preparing liquids, pour the liquid from the bottle to the client’s mouth. |
b. |
Remove unit dose drug from wrapper before getting to the bedside. |
c. |
Prepare liquids by placing the label side of the bottle on the outside away from the hand. |
d. |
Check the client’s armband before administering the medications. |
____ 63. Which statement is true about administering drugs via enteral instillation?
a. |
Tablets and capsules should be administered whole. |
b. |
The nurse should wear sterile gloves. |
c. |
Verify that the tube is in the stomach. |
d. |
Administer only enteric-coated tablets. |
____ 64. Which gauge needle is the largest needle?
a. |
18-gauge |
c. |
22-gauge |
b. |
20-gauge |
d. |
25-gauge |
____ 65. Which statement is true about administering medications?
a. |
The nurse should change needles after drawing up medication from an ampule. |
b. |
The nurse should recap the needle after administering an injection. |
c. |
When drawing up medication from an ampule, the nurse should inject air equal to the amount of medication to be withdrawn. |
d. |
Break the ampule by snapping the top off with bare fingers. |
____ 66. Which statement is true about administering injections?
a. |
Intradermal injections should be given at a 30-degree angle. |
b. |
Subcutaneous injections may be given in the upper arm and thigh areas. |
c. |
Intramuscular injections should be given at a 60-degree angle. |
d. |
Intramuscular injections may be given to the infant in the dorsogluteal and deltoid muscles. |
____ 67. The nurse is to give an intramuscular injection to an obese adult. What size needle is most appropriate?
a. |
27-gauge, 3/8 inch |
c. |
23-gauge, 1 1/2 inch |
b. |
25-gauge, |
d. |
21-gauge, |
____ 68. Which statement is correct regarding the administration of a Z-track injection?
a. |
Z-track is used for intramuscular and subcutaneous injections. |
b. |
Before inserting the needle, the skin is pulled to one side. |
c. |
The needle should be inserted at 60-degree angle. |
d. |
The site should be massaged following removal of the needle. |
____ 69. Which statement is true about giving IV medications?
a. |
A heparin or saline lock provides continuous venous access without the need for a continuous IV. |
b. |
When giving IV push medications into a continuous infusion line, the nurse should allow the fluid in the primary line to continue dripping. |
c. |
When giving IV piggyback medications, the primary solution should be higher than the secondary solution. |
d. |
The nurse should wear gloves when administering an IV piggyback medication. |
____ 70. Which is not correct regarding topical medications?
a. |
Topical medications can provide local and systemic effects. |
b. |
When applying a paste, cream, or ointment, the nurse should use a sterile tongue depressor to remove the medication from the container. |
c. |
Topical medications should be applied to moistened skin. |
d. |
Apply topical medications in long, smooth strokes in the direction of the hair follicles. |
____ 71. When giving eyedrops, the nurse should not
a. |
place the drops on the cornea of the eye |
b. |
use a separate bottle for each client |
c. |
discard any solution remaining in the dropper after instillation |
d. |
discard the dropper if the tip is accidentally contaminated |
____ 72. Eardrops are ordered for a client. Which assessment finding would cause the nurse to question the order?
a. |
The client states she is hard of hearing. |
b. |
The client’s tympanic membrane is perforated. |
c. |
The client has wax in her ear. |
d. |
The client states she has an earache. |
____ 73. For which client could a rectal suppository be ordered? A client who has just had
a. |
a heart attack |
c. |
gastric surgery |
b. |
rectal surgery |
d. |
prostate surgery |
____ 74. Which statement made by the client indicates a need for further instruction regarding the use of vaginal suppositories?
a. |
“If I have any vaginal drainage, I will tell my physician.” |
b. |
“I will not use a tampon right after inserting the suppository.” |
c. |
“I will lie down for 15 minutes after inserting the suppository.” |
d. |
“I will wear a perineal pad after inserting the suppository.” |
____ 75. Standard precautions are not necessary when administering which type of drug?
a. |
eye ointment |
c. |
vaginal suppository |
b. |
oral capsule |
d. |
rectal suppository |
____ 76. A major risk for injury among adolescents is
a. |
disease |
c. |
substance abuse |
b. |
abduction by strangers |
d. |
bicycle injuries |
____ 77. The major source of injury among older adults is
a. |
falling |
c. |
unsafe workplace |
b. |
automobile accidents |
d. |
substance abuse |
____ 78. Which of the following is classified as a client behavior accident?
a. |
The client sustained burns while smoking in the bathroom. |
b. |
The client was given the wrong medication by a nurse. |
c. |
The client fell while being transferred from the bed to the chair. |
d. |
The client received a shock from electrocautery during surgery. |
____ 79. Which of the following is not considered an occupational hazard for nurses?
a. |
back injury |
b. |
latex allergy |
c. |
toxic reaction to chemotherapeutic agents |
d. |
infections following dressing changes |
____ 80. The nurse is making a home visit to an older adult who has severe rheumatoid arthritis with flexion contractures of all four extremities. She is confined to bed. What nursing diagnosis is appropriate in relation to safety?
a. |
Risk for Poisoning |
c. |
Risk for Trauma |
b. |
Risk for Suffocation |
d. |
Risk for Disuse Syndrome |
____ 81. Which nursing action is not a part of an adult fall prevention protocol?
a. |
Instruct the client at risk for falls to call for help when performing activities of daily living. |
b. |
Keep side rails down. |
c. |
Keep bed in lowest position. |
d. |
Provide adequate lighting. |
____ 82. Which of the following is not an acceptable reason for using restraints?
a. |
Restraints are part of the medical treatment. |
b. |
All other interventions have been tried first. |
c. |
The client is restless. |
d. |
Other disciplines have been consulted for assistance. |
____ 83. A child is to have an IV needle started in the scalp. The child is fearful and actively thrashing around. What type of restraint would be most appropriate?
a. |
mummy |
c. |
jacket |
b. |
elbow |
d. |
hand |
____ 84. Which of the following is essential when restraints are applied to a client?
a. |
Assess restraints and skin integrity every 12 hours. |
b. |
Use a square knot. |
c. |
Assess the extremity for circulation and neurological integrity every 2 hours. |
d. |
Secure the restraint to the side rail. |
____ 85. What are the priority nursing interventions in the event of a fire?
a. |
Calling the fire department and fighting the fire. |
b. |
Protecting the client from injury and containing the fire. |
c. |
Removing hazards and containing the fire. |
d. |
Fighting the fire and preventing secondary outbreaks. |
____ 86. A type A fire extinguisher should be used for which type of fire?
a. |
electrical fire |
c. |
flammable gases |
b. |
flammable liquid |
d. |
paper |
____ 87. The nurse is caring for a client who received an electrical shock. What is the most appropriate initial action for the nurse?
a. |
immediately start CPR |
b. |
turn off or remove the electrical source |
c. |
assess the client’s pulse and respirations |
d. |
notify the physician |
____ 88. The nurse is caring for a client who is receiving internal radiation. Which is not an appropriate safety measure for the nurse?
a. |
limit the time spent with the client |
b. |
maximize distance from the client |
c. |
wear rubber gloves when handling radioactive materials |
d. |
wear a badge that measures the amount of radiation exposure |
____ 89. The nurse is discussing the risk of poisoning with the mother of two toddlers and a preschool-age child. Which statement made by the mother indicates a need for more teaching by the nurse?
a. |
“I keep all medicines and chemicals in a locked cabinet.” |
b. |
“The children take their medicine well when I tell them it is candy.” |
c. |
“I have syrup of ipecac just in case anything does happen.” |
d. |
“I always get child-resistant containers.” |
____ 90. Hot or warm water baths are used to
a. |
reduce muscle spasms |
c. |
sooth skin irritations |
b. |
prevent swelling |
d. |
remove dead tissue |
____ 91. The nurse is performing hygienic care for a comatose client. Which action is not correct?
a. |
Clean the eyes by washing from the inner canthus to the outer canthus. |
b. |
Turn the head to the side when flossing and brushing the teeth. |
c. |
Following mouth care, immediately turn the client to a prone position. |
d. |
Keep the client’s mouth open with a padded tongue blade. |
____ 92. The nurse notes that the client has inflammation of the gums. This inflammation should be charted as which of the following?
a. |
halitosis |
c. |
gingivitis |
b. |
pyorrhea |
d. |
stomatitis |
____ 93. When working with a client in which type of isolation would it be necessary to use a N-95 respiratory?
a. |
standard precautions |
c. |
droplet precautions |
b. |
airborne precautions |
d. |
contact precautions |
____ 94. The nurse walks into a client’s room and finds the draperies to be on fire. No one is in the room. Which type of fire extinguisher should the nurse use?
a. |
Type A |
c. |
Type C |
b. |
Type B |
d. |
any of the above |
____ 95. When bathing an elderly client, the nurse must do all of the following EXCEPT
a. |
handle skin carefully to avoid tearing or shearing the delicate tissue |
b. |
make sure the hearing aids, if needed, are in while bathing the head and neck area to be sure the client can hear the nurse. |
c. |
replace the eyeglasses, if necessary, after the bath to assist the client in remaining independent |
d. |
protect the client from hypothermia since elders are at high risk for hypothermia |
____ 96. While providing oral care to a client as a nurse, you note inflammation of the oral mucosa. You should document this as
a. |
halitosis |
c. |
stomatitis |
b. |
pyorrhea |
d. |
gingivitis |
____ 97. What is digestion?
a. |
The mechanical and chemical processes that convert nutrients into a physically absorbable state. |
b. |
The process by which monosaccharides, fatty acid chains, vitamins, minerals, and water pass through the epithelial membranes in the intestine into the blood or lymph systems. |
c. |
The aggregate of all chemical reactions and other bodily functions as they relate to the distribution of nutrients in the blood after digestion. |
d. |
The breakdown of glucose by enzymes. |
____ 98. Which substance does not require chemical digestion by enzymes for absorption?
a. |
carbohydrates |
c. |
fats |
b. |
proteins |
d. |
vitamins |
____ 99. What function does dietary fiber serve in the body?
a. |
absorbs water in the large intestine |
b. |
increases the absorption of vitamins and minerals |
c. |
assists in the breakdown of vitamins and minerals |
d. |
stimulates anabolism |
____ 100. The process in which smaller molecules are converted to larger molecules is
a. |
catabolism |
c. |
deglutition |
b. |
anabolism |
d. |
glycolysis |
____ 101. Which statement is not true about water?
a. |
The normal daily turnover of water is 4% of an adult’s total bodyweight. |
b. |
Water is the most abundant nutrient in the body. |
c. |
Body water increases as body fat increases. |
d. |
Body water decreases with aging. |
____ 102. Which of the following is a water-soluble vitamin?
a. |
Vitamin A |
c. |
Vitamin C |
b. |
Vitamin B |
d. |
Vitamin K |
____ 103. Which vitamin is necessary for bone and tooth development?
a. |
Vitamin A |
c. |
Vitamin C |
b. |
Vitamin B |
d. |
Vitamin D |
____ 104. What function does insulin serve in the human body?
a. |
It aids in the diffusion of glucose into the liver and muscle cells and in the synthesis of glycogen. |
b. |
It breaks down glucose so it can be used by the body. |
c. |
It converts triglycerides into glucose for use by the body. |
d. |
It converts proteins into energy for use by the body. |
____ 105. Which statement is true about proteins?
a. |
Proteins are the least abundant intracellular substances. |
b. |
Proteins contaiitrogen. |
c. |
Animal proteins are classified as incomplete proteins. |
d. |
The end product of protein digestion is fat. |
____ 106. Which of the following is a complete protein?
a. |
beans |
c. |
wheat |
b. |
corn |
d. |
eggs |
____ 107. Which client is least likely to develop negative nitrogen balance? The client who
a. |
has severe burns |
b. |
had an appendectomy |
c. |
has a high fever |
d. |
is confined to bed due to severe rheumatoid arthritis |
____ 108. Which contains saturated fatty acid?
a. |
coconut oil |
c. |
olive oil |
b. |
nuts |
d. |
sunflower seeds |
____ 109. Which type of lipoproteins are responsible for the formation of atherosclerosis?
a. |
very low-density lipoproteins |
c. |
intermediate-density lipoproteins |
b. |
low-density lipoproteins |
d. |
high-density lipoproteins |
____ 110. What should the nurse suggest to the client who needs to reduce dietary fat?
a. |
Eat more meat and less fish. |
b. |
Add flour, bread crumbs, and coating when preparing foods. |
c. |
Use butter not margarine. |
d. |
Eat fresh fruits for dessert. |
____ 111. The client reports frequent nosebleeds and petechiae. These findings suggest a deficiency in
a. |
Vitamin A |
c. |
Vitamin C |
b. |
Vitamin B |
d. |
Vitamin K |
____ 112. The client has a body mass index (BMI) of 28. This client is classified as
a. |
extremely underweight |
c. |
normal weight |
b. |
slightly underweight |
d. |
overweight |
____ 113. For which test is it necessary to note height and weight on the laboratory request slip?
a. |
serum albumin |
c. |
serum transferrin |
b. |
prealbumin |
d. |
creatinine excretion |
____ 114. The postoperative client is prescribed a clear liquid diet. All of the following are on the tray. Which should the nurse remove from the tray?
a. |
milk |
c. |
water |
b. |
apple juice |
d. |
gelatin |
____ 115. Which client is most likely to have enteral nutrition prescribed? The client who
a. |
has an intestinal obstruction |
c. |
has severe diarrhea |
b. |
is unconscious |
d. |
has malabsorption syndrome |
____ 116. Which statement is true regarding parenteral nutrition?
a. |
Parenteral nutrition consists of carbohydrates and fats, but not proteins. |
b. |
Clients with known egg allergy should not receive TPN with lipid emulsions. |
c. |
Clients on peripheral nutrition should be gaining at least |
d. |
The tubing should be changed weekly. |
____ 117. An expected outcome for a client with the nursing diagnosis Imbalanced Nutrition: More Than Body Requirements would be
a. |
verbalization of factors contributing to excess weight |
b. |
loss of 4- |
c. |
exercise at least 1 hour daily |
d. |
maintain current interests and activities |
____ 118. The main reason the nurse flushes the port of a nasogastric tube after administering each medication is to
a. |
prevent aspiration of medication |
c. |
prevent clogging of the tube |
b. |
dilute the medication |
d. |
increase the water intake |
____ 119. A high fiber diet has been found to be effective in preventing all of the following EXCEPT
a. |
hypercholesterolemia |
c. |
diverticular disease |
b. |
colon and rectal cancer |
d. |
diabetes mellitus |
____ 120. Depression can be linked to a deficiency of
a. |
Vitamin A |
c. |
Vitamin C |
b. |
Vitamin B |
d. |
Vitamin D |
____ 121. Which food group would be permitted for a client on a low-residue diet?
a. |
whole grain bread |
c. |
raw apples |
b. |
chicken |
d. |
sunflower seeds |
DEPENDENT PATIENT FEEDING
VOL: 99, ISSUE: 10, PAGE NO: 31
DEPENDENT PATIENT FEEDING
– The dependent patient who does not require enteral or parenteral feeding may still need help with eating. Many conditions, including cancer, cerebrovascular accident (CVA) and multiple sclerosis, can cause feeding difficulties.
– The task requires nursing knowledge and skill, although it is often given low priority or not seen as a nursing intervention.
– The Department of Health class=”itxtrst itxtrstimg itxthookicon” v:shapes=”itxthook0icon”> has stressed the importance of assisting patients with nutrition by setting this as a benchmark in The Essence of Care (DoH, 2001).
PHASES OF SWALLOWING
Swallowing occurs in three phases:
– The oral phase – the food is chewed and mixed with saliva to make a bolus.
– The pharyngeal phase – the swallowing reflex is triggered when the bolus touches the back of the patient’s oral cavity. The epiglottis is lowered and the larynx moves under the base of the tongue closing the airway. The presence of the bolus in the pharynx stimlates a wave of peristalsis.
– The oesophageal phase – the bolus is moved through the oesophagus to the stomach by peristalsis.
BEFORE FEEDING
– The dependent patient’s ability to eat must be fully assessed.
– Aspiration of food or drink is a particular risk. Aspiration can cause a blockage in the bronchus and lead to aspiration pneumonia.
– If the patient has dysphagia, a swallowing assessment should be carried out by a competent practitioner using an appropriate assessment tool. Referral to a speech and language therapist and dietitian should be considered. They may recommend that foods are thickened to help prevent aspiration.
– Information can also be obtained through a barium swallow test.
– The patient should be placed in an upright position with his or her head tilted slightly forward to aid swallowing.
DURING FEEDING
– Keep the patient upright.- The nurse who is helping the patient to eat should sit in the patient’s line of vision and provide prompting, encouragement and direction, both verbally and non-verbally, when appropriate.
– Avoid hovering with the next spoonful of food as this may cause a patient to hurry and worsen any swallowing difficulties. Patience, attention and time are essential.
– Allow at least 5-10 seconds for each bite or sip.
– Allow the patient to take a drink between each mouthful of food to ease the process of eating.
– The patient should be observed for pouching (the unconscious collecting of food on one side of the mouth), particularly after a stroke. When the patient has a hemiplegia the head should be tilted slightly towards the stronger side to avoid pouching.
– The patient should remain upright for 15 minutes after eating.
– Ensure that suction apparatus at the bedside has been checked.
– Report and document any instances of choking.
Apply a Containment Device
Condom Catheter
The condom catheter is a device that resembles a condom with a large-caliber connector at its distal end (Figure 39-9). This is connected to a drainage bag via a leg bag or bedside container for urinary containment. Procedure 39-2 discusses the application of a condom catheter.
Administering an Electrocardiogram
Magnetic Resonance Imaging (MRI)
Assisting with Computed Tomography (CT) Scanning
Assisting with a Thoracentesis
Assisting with an Abdominal Paracentesis