NP lab stuff

Question 1

NP Q:
Marie has a history of Gastritis secondary to H. pylori infection in 2020. OGD revealed a 2 x 2 cm ulcer
on the gastric fundus.
After conducting a physical assessment on the patient, the nurse documents and analyses the
findings. Which of the following should the nurse IMMEDIATELY report?

A. Bowel sounds can be heard but very soft.
B. Dullness is heard over the lower abdomen.
C. A surgical scar is seen on the right side of abdomen.
D. Air floats to the top of the abdomen in the supine position are presented.

Answer 1

B

Question 2

NP Q:
Marie has a history of Gastritis secondary to H. pylori infection in 2020. OGD revealed a 2 x 2 cm ulcer
on the gastric fundus.
During the morning round, Marie complained of pain. Which of the following nursing management will
be the MOST APPROPRIATE?

The nurse can:
A. teach the patient to monitor her bowel movement.
B. advise soft diet when Marie experiences abdominal pain.
C. allow Marie to express her concerns to her family.
D. monitor characteristic of the pain, types of ingested food, and time food is consumed.

Answer 2

D

Question 3

NP Q:
Ms Yap is a 52-year-old female who presented to the Emergency Department (ED) with new-onset abdominal swelling. Examination of her abdomen showed distension with mild diffused tenderness, shifting dullness and (+) fluid wave. No peripheral oedema is noted. Portal hypertension secondary to Liver Cirrhosis is considered.
To prevent hepatic encephalopathy, which nursing management is the MOST APPROPRIATE?

The nurse should:
A. monitor her body weight strictly.
B. check her level of consciousness closely.
C. check her bowel movements every 8 hours.
D. monitor her intake and output every 8 hours.

Answer 3

B because hepatic encephalopathy

Question 4

During the first 5 minutes of Melissa Cohen’s transfusion of packed red blood cells, she reports a headache and low back pain. When you assess her, you find that she has a temperature of 101°F (up
from 98.9°F earlier) and she is shivering. What actions would be most appropriate at this time?

Answer 4

hemolytic transfusion reaction; incompatibility of the donor blood with the recipient’s blood
1. Stop the blood immediately.
2. Disconnect the blood and begin infusing normal saline to keep vein open via a different, new administration set.
3. Notify the physician
4. obtain required blood samples from site
5. obtain first voided urine
6. Treat shock if present
7. Return blood product, filter and administration tubing to laboratory.

Question 5

The nurse is caring for a patient with a new permanent sigmoid
colostomy and explaining information about care once the patient
returns home. Which statement by the patient indicates that he or
she requires further instruction on the topic?
1 “When I wash the stoma, I should just use warm water to clean the skin.”
2 “If I eat a well balanced diet, the stool will be soft and formed.”
3 “I’ll need to look at the skin around the stoma each time I change the pouch to be sure that there is no irritation.”
4 “The stoma will stay the shape it is; so it will be easy to buy bags that fit.”

Answer 5

4
Rationale: The stoma will initially be edematous. The swelling
will decrease normally over 4 to 6 weeks, and the size may change
during that time.

Question 6

You are assigned to care for Janeé Bell, a 28-year-old engineer. She has been admitted for elective colon removal secondary to a 10-year history of ulcerative colitis. She is scheduled for an ileal pouch anal anastomosis with J-pouch construction and will have a temporary ileostomy.

What information about the ostomy pouch should the nurse include when teaching Janeé about care at home? It must be: Explain your choice.
1 changed daily.
2 emptied when it is one-third to one-half full.
3 emptied every 4 to 6 hours.
4 changed weekly.

Answer 6

2
Rationale: To avoid having the pouch get too heavy and loosen from the skin, it should be emptied when it is one-third to one-half full. The pouch should not be changed daily because this could cause skin breakdown. Pouch emptying cannot be done on a prescribed schedule. The frequency varies with food and fluid intake. An expected wear time for an ileostomy pouch is 3 to 5
days.

Question 7

You are assigned to care for Janeé Bell, a 28-year-old engineer. She has been admitted for elective colon removal secondary to a 10-year history of ulcerative colitis. She is scheduled for an ileal pouch anal anastomosis with J-pouch construction and will have a temporary ileostomy.

Which of the following will be part of her preoperative preparation?
1 A chance to empty a pouch
2 A nutrition consultation
3 Stoma site marking with a qualified ostomy care nurse
4 A barium enema
Explain your choice.

Answer 7

3
Rationale: Stoma site should be marked before surgery to avoid
having a stoma in a location that would make pouching difficult such as in a fold or crease or a location that the patient cannot see.
It is not feasible for a patient to empty a pouch until after surgery.
A nutrition consultation may be needed after surgery, but often there are few dietary restrictions with an ileostomy. The diagnosis of ulcerative colitis has already been made; thus this diagnostic test for colon disease would be unnecessary before surgery.

Question 8

You are assigned to care for Janeé Bell, a 28-year-old engineer. She
has been admitted for elective colon removal secondary to a 10-year
history of ulcerative colitis. She is scheduled for an ileal pouch anal
anastomosis with J-pouch construction and will have a temporary
ileostomy.

When Janeé returns from surgery, the nurse assesses the stoma.
How should the stoma look immediately after surgery? Explain your
choice.
1 Red and moist
2 Appear just below the skin level
3 Have stents protruding from it
4 Pink and dry

Answer 8

1
Rationale: The stoma should be red and moist. Retraction of the
stoma below skin level is usually secondary to necrosis and does
not occur until about 2 weeks after surgery. Stents protruding from
a stoma are seen with a urostomy, not an ileostomy. The stoma
may be pink after surgery, but it would be moist and producing
mucus.

Question 9

You are assigned to care for Janeé Bell, a 28-year-old engineer. She
has been admitted for elective colon removal secondary to a 10-year
history of ulcerative colitis. She is scheduled for an ileal pouch anal
anastomosis with J-pouch construction and will have a temporary
ileostomy.

Janeé notes that her bowel movement is always liquid. She asks
when it will be formed as it was before she got sick. What does the
nurse tell her?

Answer 9

You will explain that the effluent from an ileostomy is always liquid, although it may be thick or thin. This is a normal finding with an ileostomy. The patient should not expect a formed bowel
movement.

Question 10

Place the steps for an ostomy pouch change in the correct order.
____ Close the end of the pouch.
____ Measure the stoma.
____ Cut the hole in the wafer.
____ Press the pouch into place over the stoma.
____ Remove the old pouch.
____ Trace the correct measurement onto the back of the wafer.
____ Observe the stoma and the skin around it.
____ Clean and dry the peristomal skin.

Answer 10

1 Observe the stoma and the skin around it.
2 Remove the old pouch.
3 Clean and dry the peristomal skin.
4 Measure the stoma.
5 Trace the correct measurement onto the back of the wafer.
6 Cut the hole in the wafer.
7 Press the pouch into place over the stoma.
8 Close the end of the pouch.

Question 11

A patient who had colostomy surgery 3 days ago now has air that
is filling his pouch, but he has not had any fecal matter from his
stoma. Which of the following is the accurate assessment of this
situation?
1 There is infection present causing air to fill the pouch.
2 The patient has an ileus and should not be allowed to have
any oral intake.
3 This is normal flatus, indicating that bowel function is
returning.
4 The patient should be given a laxative because his bowels are
not moving.

Answer 11

3
Rationale: Air in the pouch is a normal and expected sign following ostomy surgery. It is still too early to expect significant fecal drainage.

Question 12

A patient anticipating an ileostomy because of severe ulcerative
colitis asks, “Will I really be able to have a normal life after having
this procedure?” What is the most appropriate reply?
1 “Let’s talk about this when you’re recovering from the surgery.”
2 “I’m going to have a person with an ostomy visit you before the surgery.”
3 “Why don’t you talk with your surgeon about your concerns?”
4 “Tell me the specific questions you have about life after the surgery.”

Answer 12

4
Rationale: Assessment is the first step of the nursing process; and, by using an open-ended question, you can determine a patient’s specific concerns. Shifting responsibility to the health care provider is inappropriate, and waiting until after the surgery to address
the issue only increases a patient’s anxiety. Having a person with
an ostomy visit the patient before surgery may be helpful, but
assessment needs to be done first.

Question 13

[sterile technique] A nurse with a latex allergy needs to perform a sterile procedure and finds that the only sterile gloves available are latex. Which action by the nurse would be most effective in solving the problem?
1 Rubbing petroleum jelly on the hands to provide a barrier between the hands and the gloves
2 Putting a pair of synthetic gloves on before donning the latex sterile gloves
3 Using a larger pair of sterile gloves so they’re not as tight
4 Rinsing the hands with cold water before putting on the sterile gloves

Answer 13

2 Putting a pair of synthetic gloves on before donning the latex sterile gloves
Rationale: The pair of synthetic gloves affords some protection from the latex. All other options offer no protection

Question 14

[sterile technique] When opening a sterile pack, which action compromises the sterility of the contents?
1 Keeping the contents of the pack away from the table edge
2 Holding or moving the object below the waist
3 Opening the pack just before the procedure
4 Allowing movement around the sterile field that does not touch near the sterile field

Answer 14

2 Rationale: The area below the waist is more likely out of direct vision and can become contaminated easier by contact with a nonsterile surface.

Question 15

[sterile technique] A nurse is preparing to change a dressing using sterile gloves. It is most important to remember which concept when putting them on?
1 Grab only the inside of the glove with the ungloved hand.
2 Grab only the cuffs of the gloves with the bare hand.
3 Wear a glove that is as tight as possible.
4 Keep the glove fingertips parallel to the body.

Answer 15

1 Rationale: The inside of the glove becomes unsterile when it comes in contact with the ungloved hand.

Question 16

A teenager with spina bifida is to have a urinary catheter inserted.
Which action is most important before performing this
procedure?
1 Washing the insertion area with soap and water before
insertion of the catheter
2 Positioning the patient as comfortably as possible
3 Asking the patient if he or she is allergic to eggs
4 Obtaining a nonlatex catheter for the procedure

Answer 16

4 Rationale: Individuals with spina bifida are at risk for latex allergy; thus the nurse should use a nonlatex catheter and nonlatex gloves. Individuals with spina bifida who have a latex sensitivity may also be allergic to bananas, avocados, kiwi fruit, and tomatoes, but
not eggs.

Question 17

A nurse is supervising a nursing student setting up for a sterile dressing change. Which action by the nursing student would require intervention from the nurse?
1 The first flap of the sterile package is opened away from the student’s body.
2 The glove for the dominant hand is pulled on first.
3 When pouring a solution on to the sterile field, the label of the solution bottle is facing the floor.
4 The bottle of solution is kept above the student’s waist.

Answer 17

3 Rationale: The label of the bottle should be facing the student’s palm so it does not become distorted or ruined if fluid runs down the bottle.

Question 18

Sterilization of surgical instruments and surgical dressings is accomplished by using:
1 An autoclave.
2 Soap and water.
3 Ethylene oxide gas.
4 Chemicals such as alcohol.

Answer 18

1 Rationale: Provides steam under pressure, the most effective means of sterilizing instruments and packaged dressings

Question 19

A nurse has a cold and needs to change a dressing on a patient who is immunocompromised. Which action by the nurse would be most appropriate?
1 Asking another nurse to change the dressing
2 Wearing a gown and mask when changing the dressing
3 Performing hand hygiene for a longer time before putting on sterile gloves
4 Asking the patient if it’s all right with him if he changes the dressing

Answer 19

1 Rationale: When a nurse is sick and needs to get close to an open wound of a patient whose immune system is not functioning well, it is appropriate to ask someone else to change the dressing rather than put the patient at risk. This is the best answer and the only one that keeps the sick nurse away from the patient

Question 20

In setting up a sterile field, which of the listed actions would require intervention?
1 The bottle of solution is poured with the label facing up.
2 The sterile drape is allowed to unfold above the waist.
3 The first flap of the sterile package is opened toward the nurse.
4 The glove for the dominant hand is pulled on first.

Answer 20

3 Rationale: Opening the first flap toward the nurse would require the nurse to reach over the sterile field to completely open the pack. The flap should open away from the nurse.

Question 21

Place an S next to the procedures requiring sterile (aseptic) technique. (Select all that apply.)
1 Urinary catheterization
2 Insertion of a feeding tube
3 Tracheal suctioning
4 Lumbar puncture
5 Insertion of a rectal suppository
6 Sitz bath

Answer 21

1, 3, 4 Rationale: Procedures listed invade sterile body cavities.

Question 22

A patient is to receive a blood transfusion. Which nursing action has the greatest impact on preventing a potential transfusion reaction?
1 Administering an antihistamine 15 minutes before the
transfusion
2 Comparing the patient’s identification bracelet with the blood bag label number
3 Ensuring that the patient knows his or her blood type
4 Obtaining the patient’s previous transfusion history

Answer 22

2 Rationale: Comparing a patient’s identification bracelet with the blood bag label number is the most important step to take.

Question 23

A patient receiving a blood transfusion begins having signs and symptoms of a transfusion reaction. In addition to stopping the transfusion and assessing vital signs, what else should the nurse do?
1 Hang a new infusion setup with D5W to maintain an access for medications
2 Finish infusing the blood remaining in the tubing and flush the tubing with the normal saline hanging on the Y-tubing
3 Keep the existing tubing patent with a dextrose solution in case diphenhydramine is needed
4 Hang a new infusion setup with normal saline to maintain an intravenous (IV) access

Answer 23

4 Rationale: It is essential to maintain an IV access, but you do not want the patient to receive any more of the current blood. Another blood administration set should be primed with a new bag of normal saline in case more blood needs to be given. Remember to keep the old blood bag and saline and the administration set and
send them to the appropriate department per protocol for analysis.

Question 24

Place the following steps for the administration of a unit of packed red blood cells (PRBCs) in the correct order.
1 Verbally compare and correctly verify patient and blood
product
2 Check appearance of blood for leaks, bubbles, clots, or
purplish color
3 Prepare Y-tubing administration set with 0.9% normal saline solution (NSS)
4 Obtain baseline vital signs

Answer 24

4, 2, 1, 3

Question 25

During the administration of blood the health care provider orders intravenous (IV) antibiotics to be infused. The most appropriate intervention is to:
1 Stop the transfusion.
2 Piggyback into the transfusion.
3 Question the order.
4 Start a new IV site.

Answer 25

4 Rationale: No medications or solutions (other than 0.9% normal saline solution [NS]) are to be administered with blood. Blood should never be stopped to administer another medication or solution; therefore starting a new IV is the most appropriate action.

Question 26

Administration of blood and blood products can be delegated to the nursing assistive personnel (NAP).
1 True
2 False

Answer 26

2 Rationale: Only a registered nurse (RN) (or in some states a licensed practical nurse [LPN]) may administer blood or blood products; the task may not be delegated.

Question 27

A patient with A− blood type needs a blood transfusion. Which blood types are appropriate for the patient to receive?
1 A+ or A−
2 A− or O+
3 A− or O−
4 A+ or AB–

Answer 27

3 Rationale: Only negative blood types can be given to a patient with a negative blood type.

Question 28

A patient is to receive blood that has been stored for a long period of time. Which recent laboratory value should the nurse check before administering the unit?
1 Sodium
2 Hematocrit
3 Hemoglobin
4 Potassium

Answer 28

4 Rationale: When blood is stored, there is continual destruction of red blood cells, which release potassium from the cells into the plasma. If blood is transfused rapidly, there may be transient hyperkalemia before the potassium is reabsorbed. The hematocrit and hemoglobin values would indicate whether a patient needs a blood transfusion. The sodium level is not relevant to this situation.