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Reviewer for the Board Exam part 4

Reviewer for the Board Exam part 4

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Published by jamchan
i hope it can help to my fellow nursing student:)
i hope it can help to my fellow nursing student:)

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Categories:Types, Reviews, Book
Published by: jamchan on Nov 28, 2010
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08/24/2014

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Lesson 5: Basic Care and Comfort
Questions are numbered by the order in which they
 appeared in the test.* Represents the correct answer.
Question 1
 
The nurse is planning care for a client with acerebral vascular accident (CVA). Which of thefollowing measures planned by the nurse would be
most
effective in preventing skin breakdown?A)Place client in the wheelchair for four hours each dayB) Pad the bony prominenceC) Reposition every two hoursD)
Massage reddened bony prominence
Review Information
: The correct answer is C:Reposition every two hoursClients who are at risk for skin breakdowndevelop fewer pressure ulcers when turned everytwo hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury ismaintained.
Question 2
 
After a client has an enteral feeding tubeinserted, the
most
accurate method for verification of placement isA) abdominal x-rayB) auscultationC) flushing tube with salineD)
aspiration for gastric contents
Review Information
: The correct answer is A:abdominal x-rayPlacement should be verified by radiograph todetermine that the tube is in the stomach or intestine rather than in the airways.
Question 3
 
The nurse has been teaching a client withcongestive heart failure about proper nutrition.Which of these lunch selections indicates theclient has learned about sodium restriction?A) Cheese sandwich with a glass of 2% milk B)Sliced turkey sandwich and canned pineappleC) Cheeseburger and baked potatoD)
Mushroom pizza and ice cream
Review Information
: The correct answer is B:Sliced turkey sandwich and canned pineappleSliced turkey sandwich is appropriate since it isnot a highly processed food and canned fruits arelow in sodium. All of the other choices containone or more high-sodium foods.
Question 4
 
The nurse is caring for a 7 year-old with acuteglomerulonephritis (AGN). Findings includemoderate edema and oliguria. Serum blood ureanitrogen and creatinine are elevated. Whatdietary modifications are
most
appropriate?A) Decreased carbohydrates and fatB) Decreased sodium and potassiumC) Increased potassium and proteinD)
Increased sodium and fluids
Review Information
: The correct answer is B:Decreased sodium and potassiumChildren with AGN who have edema,hypertension oliguria, and azotemia have dietaryrestrictions limiting sodium, potassium, fluids,and protein.
Question 5
 
After a myocardial infarction, a client is placedon a sodium restricted diet. When the nurse isteaching the client about the diet, which meal plan would be the
most
appropriate to suggest?A)3 oz. broiled fish, 1 baked potato, ½ cupcanned beets, 1 orange, and milk B)3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 appleC)A bologna sandwich, fresh eggplant, 2 ozfresh fruit, tea, and apple juiceD)
3 oz. turkey, 1 fresh sweet potato,1/2 cup fresh green beans, milk,and 1 orange
Review Information
: The correct answer is D: 3oz. turkey, 1 fresh sweet potato, 1/2 cup freshgreen beans, milk, and 1 orangeCanned fish and vegetables and cured meats arehigh in sodium. This meal does not contain anycanned fish and/or vegetables or cured meats.
Question 6
 
What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?A) Presence of blood in stoolsB) Oozing liquid stool
1
 
C) Continuous rumbling flatulenceD)
Absence of bowel movements
Review Information
: The correct answer is B:Oozing liquid stoolWhen the bowel is impacted with hardened feces,there is often a seepage of liquid feces around theobstruction. This is often mistaken for uncontrolled diarrhea.
Question 7
 
The nurse is teaching the client to select foodsrich in potassium to help prevent digitalistoxicity. Which choice indicates the clientunderstands dietary needs?A) three apricotsB) medium bananaC) naval orangeD)
 baked potato
Review Information
: The correct answer is D: baked potatoA baked potato contains 610 milligrams of  potassium.
Question 8
 
When administering enteral feeding to a clientvia a jejunostomy tube, the nurse shouldadminister the formulaA) every four to six hoursB) continuouslyC) in a bolusD)
every hour 
Review Information
: The correct answer is B:continuouslyUsually gastrostomy and jejunostomy feedingsare given continuously to ensure proper absorption. However, initial feedings may begiven by bolus to assess the client''s tolerance toformula.
Question 9
 
An 86 year-old nursing home resident who hasimpaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe.When the nurse assists the client with a clear liquid diet, the client begins to cough. Whatshould the nurse do next?A) Add a thickening agent to the fluidsB) Check the client’s gag reflexC) Feed the client only solid foodsD)
Increase the rate of intravenousfluids
Review Information
: The correct answer is B:Check the client’s gag reflexWhen a new problem emerges, the nurse should perform appropriate assessment so that suitablenursing interventions can be planned. Aspiration pneumonia follows aspiration of material from themouth into the trachea and finally the lung. A lossor an impairment of the protective cough reflexcan result in aspiration.
Question 10
 
An 85 year-old client complains of generalizedmuscle aches and pains. The
first
action by thenurse should beA) assess the severity and location of the painB) obtain an order for an analgesicC)reassure him that this is not unusual for his ageD)
encourage him to increase hisactivity
Review Information
: The correct answer is A:assess the severity and location of the painMost older adults have 1 or more chronic painfulillnesses, and in fact, they often must be askedabout discomfort (rather than "pain") to reveal the presence of pain. There is no evidence that pain of older adults is less intense than younger adults. Itis important for the nurse to assess the painthoroughly before implementing pain relief measures.
Question 11
 
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measurewill provide the most comfort to the client?A)Allow the client to melt ice chips in themouthB) Provide mints to freshen the breathC)Perform frequent oral care with a toothspongeD)
Swab the mouth with glycerin2
 
swabs
Review Information
: The correct answer is C:Perform frequent oral care with a tooth spongeFrequent cleansing and stimulation of the mucousmembrane is important for a client with anasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mintscould be contraindicated, and do not stimulate thetissue. Glycerin swabs do not cleanse since theyonly moisturize.
Question 12
 
The nurse is instructing a 65 year-old femaleclient diagnosed with osteoporosis. The
most
important instruction regarding exercise would be toA) exercise doing weight bearing activitiesB) exercise to reduce weightC)avoid exercise activities that increase therisk of fractureD)
exercise to strengthen muscles andthereby protect bones
Review Information
: The correct answer is A:exercise doing weight bearing activitiesWeight bearing exercises are beneficial in thetreatment of osteoporosis. Although loss of bonecannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogenreplacement and calcium supplements in their treatment protocol.
Question 13
 
A nurse is assessing several clients in a longterm health care facility. Which client is at
highest
risk for development of decubitusulcers?A)A 79 year-old malnourished client on bedrestB) An obese client who uses a wheelchair C)An incontinent client who has had 3diarrhea stoolsD)
An 80 year-old ambulatorydiabetic client
Review Information
: The correct answer is A: A79 year-old malnourished client on bed restWeighing significantly less than ideal bodyweight increases the number and surface area of  bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydrationand inadequate protein intake.
Question 14
 
Constipation is one of the most frequentcomplaints of elders. When assessing this problem, which action should be the nurse's priority?A) obtain a complete blood countB) obtain a health and dietary historyC)refer to a provider for a physicalexaminationD)
measure height and weight
Review Information
: The correct answer is B: obtain ahealth and dietary historyInitially, the nurse should obtain information about thechronicity of and details about constipation, recentchanges in bowel habits, physical and emotional health,medications, activity pattern, and food and fluidhistory. This information may suggest causes as well asan appropriate, safe treatment plan.
Question 15
 
A nurse is working with a client in an extendedcare facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?A)All 4 side rails up, wheels locked, bedclosest to door B) Lower side rails up, bed facing doorwayC)Knees bent, head slightly elevated, bed inlowest positionD)
Bed in lowest position, wheelslocked, place bed against wall
Review Information
: The correct answer is D: Bed inlowest position, wheels locked, place bed against wallIt is no longer advisable to use only the lower side rails.Using all 4 side rails (upper and lower siderails at thetop and bottom of the bed) is an inappropriate use of restraint without an order. If all 4 are pulled up, anorder for protective restraints is needed that usually hasto be renewed in 48 to 72 hours along with morefrequent documentation. Having all 4 side rails raisedlimits the client’s autonomy and freedom of movement.Using 3 of the 4 side rails pulled up is acceptable, because clients can safely exit the bed on their owninitiative. Placing the bed against the wall permitsgetting out of bed on only 1 side. Locking the wheelskeeps the bed from sliding. Keeping the bed in thelowest position (without bending limbs to restrictmovement) provides a shorter distance to the ground if the client chooses to get out of bed.
Question 16
 
The nurse is teaching an 87 year-old clientmethods for maintaining regular bowelmovements. The nurse would caution the clientto
avoid
A) glycerine suppositories
3

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