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The nurse inserting an NG tube through the nostril into the back of the throat of a patient would instruct the patient to:
open mouth and extend tongue.
hyperextend the head.
drop head forward and begin to swallow.
The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals?
Serum bilirubin 0.4 mg/dL
Serum cholesterol 175 mg/dL
Albumin 1.4 g/dL
PLT (platelet count) 425,000/mm3
A nurse gets a positive Chvostek’s sign on a young woman with bulimia who has been giving herself frequent enemas containing phosphate. The nurse anticipates a laboratory finding of ___ mEq/L.
The nurse suggests to a diabetic patient to eat complex carbohydrates, which include: (Select all that apply.)
whole grain foods.
A patient who has undergone endoscopy is fully awake and asks the nurse for something to drink. After confirming that liquids are allowed on the physician order sheet, the nurse should:
listen to lung sounds.
take a blood pressure and pulse.
assist the patient to the bathroom to void.
check for the return of gag and swallow reflexes.
When the patient has just finished receiving a tube feeding, the nurse leaves the head of the patient’s bed elevated for 30 to 60 minutes after feeding in order to:
maintain skin integrity to the buttocks.
facilitate stomach emptying and prevent aspiration.
prevent feeding tube from clogging.
facilitate lung drainage and promote ventilation.
A patient with a history of severe chronic obstructive pulmonary disease (COPD) is most likely to have:
The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection?
Radioreceptor assay for HCG
Renal scan and angiography
Culture and sensitivity (C&S)
Complete blood count (CBC)
The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test?
The patient has profound hearing loss.
The patient is breastfeeding her newborn infant
The patient is severely allergic to iodine and latex.
The patient has an implanted insulin pump.
A patient is scheduled to receive an intermittent tube feeding. This feeding should be allowed to flow in over how many minutes?
A patient drank a cup of coffee, a half glass of orange juice, and half a carton of milk with breakfast. Using common equivalents of food containers as a guide, the nurse notes on the intake column of the intake and output sheet that the patient consumed ___ mL.
A patient who is on a low-cholesterol diet verbalizes that he enjoys eating meats and doesn’t intend to stop. The nurse’s most helpful response would be, “You can enjoy your meat if you will concentrate on such meats as:
broiled sirloin steak.”
baked turkey breast.”
The physician orders fluid restriction for a patient with severe fluid-volume excess. When a patient is placed on a fluid restriction, the allowance of fluids should be:
greatest during the night shift.
greatest during the day shift.
spaced in equal increments for all shifts.
greatest during the evening shift.
The nurse caring for the patient receiving total parenteral nutrition (TPN) should monitor the flow rate every ___ hours.
A patient has a new order to have an NG tube removed. The nurse should initially:
encourage mouth care as needed.
pinch the tube while removing it.
wash her hands and apply clean gloves.
explain the procedure to the patient.
An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to:
breathe through a re-breather mask.
pant with mouth open.
Prior to the nurse transporting the patient to have a magnetic resonance imaging (MRI), it is essential that the nurse confirm that the patient:
has a Foley catheter in place.
is not wearing anything with metal.
has drunk a liter of fluid.
has eaten a meal.
A patient with healthy kidneys experiences metabolic alkalosis resulting from episodes of vomiting. The nurse takes into consideration that the kidneys can clear the alkaline substances and fully stabilize the patient’s pH in approximately:
3 to 5 minutes.
12 to 24 hours.
A patient in the outpatient clinic has provided a urine sample. To perform a urine dipstick test accurately, the nurse wets the dipstick and starts timing:
after 5 seconds.
after 30 seconds.
after 10 seconds.
The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed?
Shrimp and scallops
Gluten and lactose
Peanuts and cashews
Stopping the infusion and checking for residual, the nurse aspirates 155 mL of gastric contents. The nurse should next:
replace the aspirate and stop feeding for 1 to 2 hours.
throw the aspirate away and flush the tubing.
throw the aspirate away and stop feeding for 2 hours.
replace the aspirate and continue with the feeding.
The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse?
Inform the patient that the procedure has been completed.
Provide a quiet, dark environment so that the patient can rest comfortably.
Monitor the patient’s pulse oximetry and respirations closely.
Assess the patient’s bowel sounds and passage of flatus.
The nurse points out that non-electrolyte products of metabolism are as important to health as electrolytes. Non-electrolytes include:
The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results?
The patient’s insurance provider
The patient’s physician
The patient’s spouse
The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus?
Upper GI endoscopy
Positron emission tomography (PET) scan
MRI scan with contrast
The nurse instructing in the collection of a midstream urine catch would tell the patient to first cleanse the external genitalia and then to:
begin voiding into the specimen cup.
let a few drops of urine dribble into the specimen cup.
pass a small amount of urine into the toilet and then collect the specimen.
void until the bladder is almost empty and then collect the end portion of the voiding in the cup.
When assisting a patient with a severe visual impairment who wishes to feed himself, the nurse could best facilitate the patient’s eating by:
seating the patient in a chair and placing the over-the-bed table appropriately.
placing the plate on his lap.
orienting the patient to the position of foods on the plate using a clock-face description.
placing each food in a separate container or bowl.
Because of the patient’s dysphagia, the nurse recommends to the physician that the patient be placed on a Level II texture level diet, which means that the food is:
thickened to prevent aspiration.
minced into bite-size pieces.
pureed to a pudding consistency.
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