Tips and Tidbits — Study and Testing Strategies Practice Test Select the best response based on your test taking strategies and nursing knowledge. Do not write in the boxed area. 1. Sandra is in the hospital because of severe weight loss and refusal to eat. A nasogastric tube has been inserted for feedings. The next time the nurse enters the room, the patient has removed the tube. The patient tells the nurse he doesn't need that thing. What is the most appropriate response for the nurse to make? @. you shouldn't have done that! Now | will have to put it down again. b. why did you pull that tube out? Do you want to die? c. Can you tell me what you do not like about the tube? d. Your mother is going to be really upset with you about this. Key words: ‘Most appropriate response, NG tube, doesn't need that thing Subject: Patient Issue. ‘Communication with patient Type: True ‘What is question asking: | How to talk with patient | What do T know | Needs nourishment, refuses to eat ‘Which strategy touse: | Communication — feeling oriented, respectful, therapeutic 2. A patient is to have a perineal examination, which requires the dorsal recumbent Position. Which of these nursing actions provides the patient with the most privacy? a. Position a blanket so two corners wrap around the patient's legs and one comer is draped between the legs b. Drape a draw sheet over the clients knees covering the abdomen and the legs tucking under the feet ¢. Fold one blanket in a triangle and place so that the triangle covers the legs with a second blanket over the truncal area d. Close the curtain and make sure the door is closed during the examination Key words: Nursing actions, most privacy_ Subject Patient issue: Privao) [Type True Whatis question asking: | Protecting patient privacy What do Tknow: Keep patient covered, door closed, confidential information Which strategy to use: | Similarity in stem and optionsTips and Tidbits — Study and Testing Strategies Practice Test 5. The nurse is performing a developmental evaluation of 2 year old Stacie. Which ‘observation would the nurse consider a good indicator of normal development in this child? ‘a. having command of a vocabulary of six words b. the ability to walk up and down stairs without help c. the ability to dress and undress a doll alone d. the ability to point to what she wants (Keywords: ‘Observation, good indicator ‘Subject: patient Tssue: normal growth and development Type: ‘true ‘Whatis question asking, | Do you know normal expectations for a 2 year old? What do know: ‘Atwo year old can : two — three word sentences, do stairs alone Pointing and few word vocabulary is one year old, dressing 6 year old, ‘Which strategy to use: _| Nursing Process, diagnosis — interpreting and validating data 6. An elderly patient is in a nursing home and is confined to bed. In planning care for this patient, the nurse knows that the most essential nursing intervention to prevent skin prevent breakdown and pressure ulcers is to: a. massage all bony prominences with lotion b. keep skin clean and dry c. turn the patient at least every two hours d. place a pressure reducing mattress on the bed Key words: Essential intervention Subject: Patient issue: ‘Skin breakdown prevention Type: True | | Whats question asking: | Methods of preventing skin breakdown and pressure wounds What do know: Pressure, either intense and short, or less but prolonged is primary cause of pressure wounds, contributing factors include age, nutritional status, medications, cleanliness, moisture, Which strategy to use| Nursing process — planning — selecting intervetionsTips and Tidbits — Study and Testing Strategies Practice Test 7. Inpreparing a patient to be discharged home with his family, the nurse teaches him to position himself for postural drainage. To achieve success in this teaching program, which information about the patient does the nurse recognize to be most important? ‘a. The type of bed the patient will be using at home for the procedure b. The amount of time required for the patient to change positions ¢. The client's desire concerning his ability to be seff sufficient d. The client's ability to move about without assistance from others Key words: ‘Success, information, most important Subject Patient issue: teaching procedure for home continuance Type: True ‘Whats queston asking: | Does the patient know what to do? What things could prevent him from learning or doing what needs to be done? | | What do Tknow: The patientfamily has to want to know what to do and how, and have the desire to do it — postural drainage requires the assuming of different — sometimes extreme positions to allow for lung lobe drainage Which strategy ouse!__| Teaching learning — focus first on motivation 8. The nurse would interpret which finding as an indication of improvement in an infant who is receiving treatment for acute dehydration? ‘a. weight gain of 24 ounces in 24 hours b. Three wet diapers in 24 hour period c. cool skin with tenting d. frequent stooling Key words: Thterpret — indication - improvement Subject Infant issue: Physical status of infant Type: True ‘What is question asking: | How do | know if the child is getting rehydrated and treatment is working? Wat do know: Fluid is 80% of infant body weight, dehydration very dangerous in infants, no fluid - body conservation of water= little to no urine production, normal output — 6-10 diapers per day ‘Which strategy to use: | Nursing process — evaluation — comparing desired with actual outcomesTips and Tidbits ~ Study and Testing Strategies Practice Test 9. The nurse learns in report that the assigned patient has an accucheck blood glucose result of 100 at 0700. The patient is to receive NPH insulin 15 units every morning. Based on the morning report, which action of the nurse is most appropriate? a. hold the morning dose of insulin b. administer the AM dose of ordered insulin c. call the doctor to report the blood glucose results d. repeat the finger stick blood glucose at 0800 Key words: Most appropriate, action ‘Subject: Patient Issue: Giving insulin safel Type: True ‘What is question asking: | Is it safe to give the AM dose of insulin based on the current | reported blood sugar What do Tknow: Blood sugar of 100 is within normal ranges Which stategy o use: | Nursing process, intervention ~performing interventions, assessing risk factors during care 10. The nurse is taking care of a patient who has a Nasogastric tube to low suction. The nursing assistant reports that the patient has just vomited 100 mi. of light yellow-green fluid. Which of the nursing action would it be most important to do initially? a. check the medication record for an antiemetic b. check the nasogastric tube for correct placement ©. add the emesis to the total output for the shift . ask the patient if the need to vomit has stopped Key words: | Most important Subject: Patient Issue: ‘Vomiting with NG tube in place Type: True Whatis question asking: | Why is the patient vorniting when a NG tube is in place ‘What do | know: NG tubes — stopped up or not in correct position will not pull stuff out of stomach causing accumulation of materials and possibly lead to voriting Which stategy to use: | Nursing process Assessment — need to gather more informationTips and Tidbits — Study and Testing Strategies Practice Test 14. The nurse is notes that a newly admitted patient is complaining of itching and shortness of breath and notes a rash all over the body. The nurse also notes that the patient received an antibiotic in the emergency room, but has no known drug allergies. Which nursing response is most appropriate at this time? a. inform the doctor of the objective and subjective complaints 'b. inspect the patient's skin and describe the rash cc. ask the patient to avoid scratching the areas d. check the medication record for an antihistamine medication Key words: Most appropriate Subject: pateint Issue: Possible allergic reaction — itching and rash Type: ‘true Whatis question asking: | What should the nurse do when noting abnormal situation that has not occurred before, and there is probable cause What do Tknow: Itching and rash are common allergic type responses to the release of histamine. The patient had an antibiotic earlier — reaction? Prioritizing — Maslow / ABC — potentially life threatening but certainly physiologic concern 12. The nurse is assigned to a patient who believes that wearing a copper bracelet will relieve her arthritic pain. When providing care for this patient, what is the most important thing for the nurse to do in this case? a. encourage the patient to use the anti-inflammatory medication b. inform the patient that copper bracelet have no proven value ©. explain the pathophysiology of arthritis to the patient d. respect the patient's beliefs as the bracelet will do no harm Key words: Most important , believes Subject: Patient Issue. Patient beliefs ri copper bracelet Type: true What is question asking:_| How to support pt belief respectfully, and safely a What do I know: ‘Copper jewelry has no medicinal effects or adverse effects, patient believes it will help, mind is often stronger than science. Which strategy to use: Communication — respond to patient feelings/ beliefsTips and Tidbits — Study and Testing Strategies Practice Test 13. The nurse admits an elderly man with a medical diagnosis of dehydration. In developing the nursing diagnosis, it is most important for the nurse to: a. establish nursing diagnosis that are based on medical diagnosis b. focus on nursing diagnosis that affect fluid balance ¢. gather data to support actual nursing diagnosis d. include both actual and risk for diagnosis Key words: Develop nursing diagnosis, most important, ‘Subject: nurse Issue: Planning appropriate care for dehydrated elderly man Type: True ‘What is question asking: | What are nursing approaches to alleviate or modify effects of medical condition ‘What do I know: Dehydration disallows normal metabolic processes to proceed normally and must be corrected, the medical problem only Which stategy touse: | Nursing process- assessment — need more information ~ no information about how patient is effected by dehydration 14.To ensure accuracy when assessing a patient for presence of bowel sounds, the nurse would auscultate the abdomen: a. using a warmed stethoscope b. prior to palpation and percussion c. first in the left lower quadrant, moving counterclockwise d. for a minimum of three minutes in each quadrant Key words: Ensure accuracy ‘Subject Nurse [ssue: ‘Assessment skills for bowel sounds Type: True How to accurately assess for bowel sounds What do I know: Must observe then auscultate before manipulation of abdomen — listen to all four quadrants carefully, normal bowel sounds are | active and able to be heard in a minute or less, failure to hear for 5 minutes = absent sounds Which strategy to use: | Nursing process — assessment — gathering and validating dataTips and Tidbits — Study and Testing Strategies Practice Test 15. An elderly patient is scheduled for surgery in the moming. As the nurse enters the patient's room, she notices flames coming from the waste basket. Which action would demonstrate an understanding of safety priorities? a. Placing the folded blanket from the patient's bed over the trashcan b. Finding the nearest first extinguisher to put out the flames. . Telling the patient he is not supposed to be smoking in his room d. Running down the hall to the nurses station to call the fire department Key words: Demonstrates understanding, safety priorities | Subject Nurse ([Tesue: Fire safety Type: True What is question asking: | How to deal with a fire in the hospital What do Tknow: Fires require fuel and oxygen in order to bum, patient's must be rescued immediately before or at the same time alarm is made known ‘Which strategy to use: Priority - Maslow’s — safety e careful not the read into the question — especially for option c — there is no indication in the case scenario that this patient is a smoker 16. Which is the best nursing action to prevent the spread of infection among hosphalzed pliant? Using sterile technique when performing any invasive procedure ‘ Washing hands before coming into contact with any patient c. Wearing gloves to perform all nursing activities regardless of patient contact d. Wearing mask and gowns when performing nursing activities with any patient Key words: Best nursing action ‘Subject: nurse Issue: Infection control Type: True ‘What is question asking: | Preventing spread of infection in hospitalized patients What do Tiknow: Chain of infection, any break in the chain stops the process, hand washing is prime mechanism to remove bacteria and prevent transfer ‘Which strategy to use: | Similar words — stem and optionsTips and Tidbits — Study and Testing Strategies Practice Test 17.A patient is admitted to the hospital with a diagnosis of active pulmonary tuberculosis. An immediate nursing goal is to control or prevent the spread of infection. To control the spread of active tuberculosis, which activity would the nurse initiate in the care of this patient? a. Wear a mask and gown when caring for the patient b. Recommend that the patient wear a mask when visitors are in the room ¢. Teach the patient to cover nose and mouth with a tissue when coughing d. Use blood and needle precautions in addition to standard precautions Key words: Active TB, control spread, nurse activity Subject Patient Issue Infection control Type: ‘true | Whatis question asking: | Best method to control spread of airborn infection What do I know: ‘TB is airborn infection — requires respiratory isolation, masks | needed to filter bacteria from recipients — those coming into the room need masks Which strategy to use: | Nursing process — implementation | Remember ~ partially wrong response cannot be right 18.An elderly patient is to receive a shower. When preparing the shower, the nurse would avoid which unsafe action? a. Warm up the room prior to starting the bath . Gather all needed materials and take to room before beginning bath c. Test the water temperature by putting the patient's hand under shower head 4. Place a nonskid mat on the floor of the shower Key words: Unsafe action ‘Subject: patient Bath safety False — looking for what NOT to do ‘What is question asking: [How to make sure patient safety is assured during a shower bath What do know: This is a nursing procedure, gather all equipment before starting so you don't have to leave patient alone, nonskid surfaces important r/t slipperiness of wet floors, elderly do not tolerate cool temperatures — warm room up, water should be warm but not too hot as to damage skin ‘Which strategy to use: | Nursing process — implementation — performing aclivities, minimizing risk during activitiesTips and Tidbits — Study and Testing Strategies Practice Test 19. An elderly male is admitted to the hospital with complaints of abdominal pain and distention. He has not had a bowel movement for the last 10 days. After a diagnostic evaluation, it is determined that he has a fecal impaction. Which treatment will the nurse expect to give first? a. Soap suds enema's until clear b. Bisacodyl (Dulcolax) suppository ©. Oil retention enema 4. Tap water enema Key words: Fecal impaction — first treatment Subject: Patient Issue: Constipation — impaction Type: True ‘What is question asking: | What is most effective to move or remove impaction What do know Impacted fecal masses need to be softened first, enema’s will not usually get behind the mass to push it downward Which strategy touse: | Nurse process — planning C- only option that addresses the problem of impaction 20. A patient is scheduled for bowel surgery. The doctor orders a cleansing enema for the morning of surgery. What is the best nursing approach? a. Wear gloves when inserting the tubing b. Use standard precautions and provide comfort measures during the procedure cc. Lubricate the tubing well prior to insertion into the anus d. Position the patient on his side and drape with a blanket for warmth and privacy Key words: Best nursing approach, cleansing enema ‘Subject: Patient Issue: Procedure for enema administration Type: True ae What is question asking: _| Correct procedural steps for enema administration What do know: Position on left side, warm water, 18° high, well lubricated tip, insert smoothly, help patient relax, ensure privacy, use standard precautions, Which sirtegy to use: | Global response