3801Unit II PALS practice questions – Flashcards
Unlock all answers in this set
Unlock answersquestion
1. What is the functional unit in the kidney? a. Glomerulus b. Nephron c. Tubules d. Ureters
answer
B. Nephron
question
2. What are related to stress incontinence? Select all that apply. a. Stress before you take an exam b. Women who have had multiple births c. Leakage between urination d. Pressure on the muscles
answer
B. C. D.
question
3. What are some factors that influence urination? Select all that apply a. Infection control b. Muscle tone c. Hygiene d. Bowel movements e. Age and gender
answer
A. B. C. E.
question
4. Which nursing actions will prevent a UTI? Select all that apply. a. Use sterile technique with equipment b. Educate patient on self care c. Wipe "front to back" d. Wipe "back to front" e. Ask about last void and BM
answer
A. B. C. E.
question
5. A patient is in the hospital after a surgery. The nurse is monitoring their fluid balance. If the patient is having less urine output that in the normal range, what would the nurse chart? a. Oliguria b. Anuria c. Nocturia d. Diuresis
answer
A.
question
6. What is a urinary diversion? a. the person has stomas or pockets; diversion of urine to an outside spot b. the person is not able to urinate c. the person urinates often but does not feel empty d. the person is having pain while urinating
answer
A.
question
7. Which statements below are correct? Select all that apply. a. All organs of the urinary system must be intact and functional for urination to happen b. The bladder holds urine until the urge to urinate develops c. The ureters remove waste from the blood to form urine d. The urethra transports the urine from the kidneys to the bladder
answer
A. B.
question
8. The nurse is caring for an 80-year old patient in the hospital. He is experiencing diarrhea. Of the following problems, which is the most important to consider? a. Malnutrition b. Dehydration c. Skin breakdown d. Pressure ulcers
answer
B.
question
9. An elderly male patient tells the nurse he is having problems starting and stopping his urinary stream but feels he needs to void. What would be the best intervention for this patient? a. Give him a urinal b. Tell him to stand when trying c. Try using a condom catheter d. Use an I&O catheter to release urine e. Initiate Kegel exercises
answer
E.
question
10. When assessing urine, the nurse will document on which features in addition to output? A. Color, amount, type of particulate B. Volume, transparency, type of incontinence C. Color, clarity, odor D. Color, odor, rating on pain scale with urination
answer
C.
question
11. It is important for the nurse to promote normal defecation. This can be done by (select all that apply): A. Providing the patient with privacy B. Positioning them in high-fowlers C. Initiate bowel meds with admission due to risk of constipation D. Determine patient's bowel routine E. Lay patient flat on bedpan to avoid pressure ulcers on the glute F. Offer the bedpan or commode an hour after a meal
answer
A. B . D. F.
question
12. True or False? A nurse uses sterile technique to insert a nasogastric tube.
answer
False
question
13. A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first? a. Administers PRN pain medication b. Slows down the rate of instillation c. Tells the patient to breathe slowly and relax d. Stops the installation and obtains vital signs
answer
D.
question
14. The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient? a. Describe your bowel movements. b. How often do you have a bowel movement? c. When was the last time you moved your bowels? d. Do you routinely use stool softeners, laxatives, or enemas?
answer
C.
question
15. Nurses discourage patients from straining on defecation primarily because it causes: (Select all that apply.) a. Pain. b. Impaction. c. Hemorrhoids d. Dysrhythmias
answer
C. D.
question
16. The nurse is caring for a patient with a colostomy. Which intervention is most important? a. Cleansing the stoma with hot water b. Inserting a deodorant tablet in the stoma bag c. Selecting a bag with an appropriate-size stoma opening d. Wearing sterile gloves while caring for the stoma
answer
C.
question
1. The nurse is providing care for a 23-year-old woman who is a strict vegetarian. To prevent the consequences of iron deficiency, what should the nurse recommend? a. Brown rice and kidney beans b. Cauliflower and egg substitutes c. Soybeans and hot breakfast cereal d. Whole-grain bread and citrus fruits
answer
C.
question
2. The nurse teaches a patient who has had a surgery to increase which nutrient to help with tissue repair? a. Fat b. Protein c. Vitamin d. Carbohydrates
answer
B.
question
3. The nurse is caring for a patient with dysphagia. Which interventions help decrease the risk of aspiration? Select all that apply. a. Sit the patient upright in a chair b. Give liquids at the end of the meal c. Place food in the strong side of the mouth d. Provide thin foods to make it easier to swallow e. Feed the patient slowly f. Encourage the patient to lie down and rest for 30 minutes after eating
answer
A. C. E.
question
4. A patient received a nasogastric tube after a laryngectomy. What should the nurse's priority intervention be before starting the feeding? a. Aspiration b. Set head of bed at 45 degrees c. Verify tube placement on x-ray d. Complete vital signs
answer
C.
question
5. A patient is on a lacto-ovo vegetarian diet. What type of foods can the patient eat? a. Chicken, cheese, and grilled eggplant b. Boiled eggs and chocolate milk c. Fish, milk, and poached egg d. Oysters, yogurt, and turkey
answer
B.
question
6. A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract? a. Thoroughly cooking all foods b. Offering yogurt and buttermilk between meals c. Forcing fluids d. Providing small, frequent meals
answer
D.
question
7. The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: A. Fastens the tube to the gown with tape. B. Places the patient supine while giving a bath. C. Performs oral care for the patient. D. Elevates the head of the bed 45 degrees.
answer
B.
question
8.Which assessment should the nurse prioritize in the care of a patient who has recently begun receiving parenteral nutrition (PN)? A. Skin integrity and bowel sounds B. Electrolyte levels and daily weights C. Auscultation of the chest and tests of blood coagulability D. Peripheral vascular assessment and level of consciousness (LOC)
answer
B.
question
9. The nurse calculates a client's body mass index as being 25.2. According to the Classification of Body Mass Index in Adults, which of the following can the nurse accurately document about this finding? a. This client is overweight. b. This client is mildly malnourished. c. This client is of normal weight. d. This client is obese.
answer
A.
question
10. A client tells the nurse that she takes high volumes of multiple vitamins, various mineral supplements, and two additional herbs on a daily basis. Which of the following should the nurse include when instructing this client on her nutritional status? a. Review the role of iron. b. Be sure to include high doses of vitamin C. c. There are dangers associated with oversupplementation with herbs, vitamins, and minerals. d. High doses of fish oil would add to her supplementation regime.
answer
C.
question
11. The nurse is reviewing the food pyramid with a client who avoids fruits and vegetables. Which category of the pyramid would address this client's issue? a. Personalization b. Proportionality c. Moderation d. Variety
answer
D.
question
12. A patient who has dysphagia as a consequence of a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into this patient's care? A. Flush the tube with 30 mL of normal saline every 4 hours. B. Flush the tube before and after feedings if the patient's feedings are intermittent. C. Flush the PEG with 100 mL of sterile water before and after medication administration. D. To prevent fluid overload, avoid flushing when the patient is receiving continuous feeding.
answer
B.
question
13. What are necessary interventions prior to beginning an enteral tube feeding? Select all that apply. a. Patient should be lying down in bed during feeding b. Feedings can be started after bowel sounds are heard following tube placement. c. Tube length does not need to be measured after placement so you may begin right away d. Patient should be between 30-45 degrees during feeding.
answer
B. D.
question
A severely malnourished patient reports that he is Jewish. The nurse's initial action is to meet his nutritional needs will be to: a. have family members bring in food b. ask the patient about food preferences c. teach the patient about nutritious Kosher foods d. order nutrition supplements that are manufactured Kosher
answer
B.
question
1. The nurse is caring for a 47-year-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take action? a. Check the patient's oxygen saturation. b. Notify the patient's health care provider. c. Measure the tube feeding residual volume. d. Stop administering the continuous feeding.
answer
The correct order (D, A, C, B)
question
2. Which action should the nurse take first when preparing to teach a frail 79-year-old Hispanic man who lives with an adult daughter about ways to improve nutrition? a. Ask the daughter about the patient's food preferences. b. Determine who shops for groceries and prepares the meals. c. Question the patient about how many meals per day are eaten. d. Assure the patient that culturally preferred foods will be included.
answer
B.
question
4. The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) A. Avoid grapefruit and grapefruit juice, which impair drug absorption. B. Increase the amount of carbohydrates for energy. C. Take a multivitamin that includes vitamin D for bone health. D. Cheese and eggs are good sources of protein. E. Limit fluids to decrease the risk of edema.
answer
A. C. D.
question
6. The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? A. TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. B. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. C. Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. D. Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention.
answer
A.
question
7. A patient is experiencing oliguria. Which action should the nurse perform first? A. Increase the patient's intravenous fluid rate. B. Encourage the patient to drink caffeinated beverages. C. Assess for bladder distention. D. Request an order for diuretics.
answer
C.
question
8. A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? A. Suggest he stand at the bedside B. Stay with the patient C. Give him the urinal to use in bed D. Tell him that, if he doesn't urinate, he will be catheterized
answer
A.
question
9. An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to: A. Help him stand to void. B. Place a condom catheter. C. Have him practice Credé's method. D. Initiate Kegel exercises.
answer
D.
question
10. A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (Select all that apply.) A. Infection. B. Retention. C. Stagnant urine. D. Reflux of urine
answer
A. D.
question
11. The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first? A. Encourage fluid intake B. Administer pain medication C. Catheterize the patient D. Turn on the bathroom faucet as he tries to void
answer
D.
question
12. Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (Select all that apply.) A. Incontinence B. Frequency C. Urgency D. Urinary retention E. Urinary tract infection F. Kidney stones
answer
A. B. C. D. E.
question
13. When taking a health history, the nurse screens for manifestations suggestive of diabetes type I. Which of the following manifestations are considered the primary manifestations of diabetes type I and would be most suggestive of diabetes type I and require follow-up investigation? a. Excessive intake of calories, rapid weight gain, and difficulty losing weight b. Poor circulation, wound healing, and leg ulcers, c. Lack of energy, weight gain, and depression d. An increase in three areas: thirst, intake of fluids, and hunger
answer
D.
question
14. The nurse is working with an overweight client who has a high-stress job and smokes. This client has just received a diagnosis of Type II Diabetes and has just been started on an oral hypoglycemic agent. Which of the following goals for the client which if met, would be most likely to lead to an improvement in insulin efficiency to the point the client would no longer require oral hypoglycemic agents? a. Comply with medication regimen 100% for 6 months b. Quit the use of any tobacco products by the end of three months c. Lose one pound per week until weight is in normal range for height and exercise 30 minutes daily d. Practice relaxation techniques for at least five minutes five times a day for at least five months
answer
C.
question
15. Risk factors for type 2 diabetes include all of the following except: a. Advanced age b. Obesity c. Smoking d. Physical inactivity
answer
C.
question
16. Blood sugar is well controlled when Hemoglobin A1C is: a. Below 7% b. Between 12%-15% c. Less than 180 mg/dL d. Between 90 and 130 mg/dL
answer
A.
question
17. A 37-year-old forklift operator presents with shakiness, sweating, anxiety, and palpitations and tells the nurse he has type 1 diabetes mellitus. Which of the follow actions should the nurse do first? A. Inject 1 mg of glucagon subcutaneously. B. Administer 50 mL of 50% glucose I.V. C. Give 4 to 6 oz (118 to 177 mL) of orange juice. D. Give the client six to eight glucose tablets.
answer
C.
question
18. A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."
answer
B.
question
19. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."
answer
D.
question
20. The nurse plans care for a client with chronic obstructive pulmonary disease (COPD) knowing that the client is most likely to experience what type of acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
answer
A.
question
21. The nurse is caring for a client with a nasogastric tube is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? a. Respiratory acidosis b.Respiratory alkalosis c.Metabolic acidosis d. Metabolic alkalosis
answer
D.
question
22. When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is a. mental status. b. skin turgor. c. capillary refill. d. heart sounds.
answer
A.
question
23. A patient has the following ABG results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. The nurse interprets these results as a. respiratory acidosis. b. respiratory alkalosis. c. metabolic acidosis. d. metabolic alkalosis.
answer
C.
question
25. A nurse assesses a patient experiencing prolonged anxiety and records a respiration rate of 32 breaths per minute. This patient is most at risk for which acid-base imbalance? a. metabolic alkalosis b. metabolic acidosis c. respiratory acidosis d. respiratory alkalosis
answer
D.
question
A 60-year-old man who is hospitalized with an abdominal wound infection has only been eating about 50% of meals and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake? a. Order six small meals daily. b. Make a referral to the dietitian. c. Teach the patient about high-calorie foods. d. Have family members bring in favorite foods
answer
D.
question
When caring for a 63-year-old woman with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will a. avoid giving medications through the feeding tube. b. flush the tubing after checking for residual volumes. c. administer continuous feedings using an infusion pump. d. replace the tube every 3 days to avoid mucosal damage.
answer
B.
question
Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur, the patient must be in a. Negative nitrogen balance. b. Positive nitrogen balance. c. Total dependence on protein for kcal production. d. Neutral nitrogen balance.
answer
B.
question
The nurse is assessing a patient for nutritional status. In doing so, the nurse must a. Choose a single objective tool that fits the patient's condition. b. Combine multiple objective measures with subjective measures. c. Forego the assessment in the presence of chronic disease. d. Use the Mini Nutritional Assessment for pediatric patients.
answer
B.
question
In creating a plan of care to meet the nutritional needs of the patient, the nurse needs to explore the patient's feelings about weight and food. The nurse must do this to a. Determine which category of plan to use. b. Set realistic goals for the patient. c. Mutually plan goals with patient and team. d. Prevent the need for a dietitian consult.
answer
C.
