Foundations Kaplan Prep

Question 1

You are taking a stool sample. Your samples should be the size of a _______ and taken from ___ different places in the stool.

Answer 1

walnut sized from 2 different places

Question 2

Does immobility cause hypocalcemia or hypercalcemia?

Answer 2

hypercalcemia

Question 3

Why does immobility increase cardiac workload?

Answer 3

Blood pools due to gravity, and there is no muscular activity helping to move blood.

Question 4

How often and what should a patient with very limited mobility eat?

Answer 4

small, frequent meals of high protein and adequate carbs

Question 5

What are the nursing interventions for pneumonia?

Answer 5

turn, cough, deep breathe and use incentive spirometer

Question 6

What are the 2 permissible uses for confidential medical records?

Answer 6

diagnosis and treatment

Question 7

What is the patient position for thoracentesis?

Answer 7

sitting up and leaning over a table

Question 8

Define “pressure ulcer.”

Answer 8

Localized area of necrotic tissue that occurs when soft tissue is compromised, usually over bony prominences.

Question 9

What are 4 causes of pressure ulcers?

Answer 9

Altered level of mobility, shear, friction, moisture

Question 10

What do we look for when assessing for pressure ulcers?

Answer 10

non-blanching skin

Question 11

List the signs of hypoxia.

Answer 11

Apprehension, restlessness, dizzy, confusion, fatigue, tachycardia, hyperpnea, dyspnea

Question 12

What is the nursing intervention for orthopnea?

Answer 12

Put pillows under their head or elevate the head of the bed.

Question 13

What are wet to dry dressings used for?

Answer 13

debridement

Question 14

List 4 purposes of bronchoscopy.

Answer 14

take a sample, get rid of mucus plug, instill meds, collect secretions

Question 15

What are 7 nursing considerations for bronchoscopy?

Answer 15

Explain procedure, pt. NPO for 6-12 hours, look for infection, remove dentures, pt. may have sore throat afterwards, Post test—remain sitting and lying on side—make sure gag reflex is present before feeding, assess for respiratory difficulty

Question 16

Where should you clamp a Foley catheter when collection a urine sample?

Answer 16

below the port

Question 17

For a soap suds enema, insert tube __ inches.

Answer 17

4

Question 18

What position should patient be in for suctioning?

Answer 18

semi-Fowler’s

Question 19

What should the nurse do before suctioning?

Answer 19

explain the procedure and hyperoxygenate the patient

Question 20

Which is correct: suctioning while pushing catheter in, or suctioning while pulling catheter out?

Answer 20

while pulling catheter out

Question 21

What condition makes it most important to have patient repeat back what he/she is told?

Answer 21

Presbycusis (age related hearing impairment) and other hearing impairment

Question 22

Before MRI, what are 3 nursing tasks?

Answer 22

Assess for claustrophobia, remove jewelry, assess for implanted metal.

Question 23

What are the benefits of proper positioning?

Answer 23

Proper body alignment, prevent injuries, facilitate breathing and cardiovascular function, ADLs

Question 24

What tool helps prevent friction and pressure when repositioning?

Answer 24

draw sheets

Question 25

What are 2 common places for a bone marrow biopsy?

Answer 25

Iliac crest and sternum

Question 26

Where do you place the stethoscope to listen to apical pulse?

Answer 26

L 5th intercostal at midclavicular line

Question 27

How do you assess for a pulse presure deficit?

Answer 27

With another person, one counting the apical pulse and one counting the peripheral pulse: the difference between the numbers is the pulse pressure deficit.

Question 28

How do you calculate the insertion depth for an NG tube?

Answer 28

Nose to ear to xiphoid process

Question 29

What assessment do you make before putting Ted Hose on the patient?

Answer 29

circulation

Question 30

Is a doctor's order needed for a nurse to put compression stockings on a patient?

Answer 30

yes

Question 31

What question must you ask a patient before an angiogram?

Answer 31

Are you allergic to shellfish, iodine or dyes?

Question 32

What are the 5 skin breakdown stages?

Answer 32

1, 2, 3, 4, and unstageable

Question 33

What is the first step in the nursing process?

Answer 33

identify the nursing issues

Question 34

What instructions does the nurse give for using an incentive spirometer?

Answer 34

seal lips over the end, inhale slowly while trying to get the marker to the point the doctor recommended while the ball (or disc) stays in the middle, hold your breath for 3 seconds, exhale slowly, repeat. Following the session, have the patient cough to clear the lungs.

Question 35

What is the angle for Fowler's position?

Answer 35

45-60 degrees

Question 36

What is the angle for low Fowler's position?

Answer 36

15-30 degrees

Question 37

What is the angle for semi-Fowler's position?

Answer 37

30-45 degrees

Question 38

What is the angle for High Fowler's position?

Answer 38

60-90 degrees

Question 39

What is the most basic need, according to Maslow? What is the second most basic need, which can be addressed once the basic level need is filled?

Answer 39

Physiological is the most basic, followed by safety and security which can only be address once physiological needs are met.

Question 40

What are the 3 highest levels of Maslow's hierarchy?

Answer 40

Level 3: Love and belonging needs Level 4: Self-esteem needs Level 5: (highest) Self-actualization needs

Question 41

How do you know when you have irrigated a wound long enough?

Answer 41

solution runs clear or prescribed amount of solution is used up

Question 42

What is the patient position for lumbar puncture?

Answer 42

lateral recumbent fetal position

Question 43

What assessment is performed after a lumbar puncture, and how often?

Answer 43

neurological assessment, every 15-30 minutes, make sure the patient has fluid intake

Question 44

How long following a lumbar puncture does the patient have to lie flat?

Answer 44

4-12 hours

Question 45

What diseases make airborne precautions necessary?

Answer 45

varicella, rubeola, TB, SARS

Question 46

What are the characteristics needed for a room to be used in airborne precautions?

Answer 46

private room monitored negative air pressure 6-12 air changes per hour Keep door closed and patient in room

Question 47

What is the purpose of EKG/ECG?

Answer 47

watch heart rhythm: sinus tachy, brady, V fib

Question 48

When you move a patient, should you push or pull?

Answer 48

push

Question 49

A timer is a critical piece of equipment for what therapy?

Answer 49

hot/cold

Question 50

Over what time period is I/O measured?

Answer 50

24 hours

Question 51

Why do you monitor glucose during a ccentral line feeding?

Answer 51

to avoid glucose overload if feeding is done too fast

Question 52

parenteral feeding goes through the central line of a ____ line

Answer 52

PICC (peripherally inserted central catheter)

Question 53

What are the usual pulse sites?

Answer 53

Temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial, apical

Question 54

What angle should patient be positioned for NG tube feeding?

Answer 54

30 degrees

Question 55

What should gastric pH be?

Answer 55

4 or less

Question 56

Why should you check pulse while doing fecal deimpaction?

Answer 56

vagal nerve stimulation could cause drop in pulse rate

Question 57

What is ADPIE?

Answer 57

The way to remember the nursing process: assessing | diagnosing, planning, implementing, evaluating

Question 58

What is QSEN?

Answer 58

Quality and Safety Education for Nurses

Question 59

When you wear a gown in the patient's room for infection control, where do you take it off?

Answer 59

In the patient's room before leaving.

Question 60

When you wear a respirator in the patient's room for infection control, where do you take it off?

Answer 60

Outside the patient's room

Question 61

The difference between blood pressure in a person's arms is normal if it is under ____ mm Hg.

Answer 61

10

Question 62

What is the Valsalva maneuver? What does it do to pulse rate?

Answer 62

performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon. It slows the pulse rate by stimulating the vagus nerve.

Question 63

Fraction of inspired oxygen (FiO2) is ___ L/min for nasal cannula, ___ L/min for rebreather mask, ___ L/min for partial rebreather mask, ___ for Venturi mask.

Answer 63

1-6 for nasal cannula, 12 for nonrebreather mask, 8-11 for partial rebreather mask, 4-10 for Venturi mask

Question 64

What is the rule of thumb method for determining approximate ideal body weight?

Answer 64

For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet.

Question 65

Which theorist supports the developmental framework of family assessment?

Answer 65

Duvall

Question 66

Which medications will delay healing of a postoperative wound?

Answer 66

corticosteroids

Question 67

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

Answer 67

hydrocolloid dressings

Question 68

What size catheter is used for and adult?

Answer 68

14F to 16F

Question 69

Which meds change the color of urine?

Answer 69

Levodopa and injectable iron compounds can cause brown or black urine. Phenazopyridine can cause orange or orange-red urine. Amitriptyline can cause green or blue-green urine, and diuretics can lighten the color of urine to pale yellow.

Question 70

An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of ____.

Answer 70

impending dehiscence

Question 71

If dehiscence occurs, what should the nurse do?

Answer 71

cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician.

Question 72

lateral movement of a body part toward the midline of the body

Answer 72

adduction

Question 73

lateral movement of a body part away from the midline of the body.

Answer 73

abduction

Question 74

Define pyuria.

Answer 74

pus in the urine

Question 75

How do cholinergics cause frequent urination?

Answer 75

they stimulate the detrusor muscle

Question 76

How often should the nurse irrigate a Foley catheter?

Answer 76

Irrigation should be avoided unless there is an obstruction

Question 77

Common side effect of antibiotics

Answer 77

diarrhea

Question 78

What is sedation level 1?

Answer 78

awake and alert

Question 79

When would you draw blood to assess a medication's trough level?

Answer 79

in the 30 minute interval before the next dose