NUFT 204 Exam 3 Review Questions

NUFT 204 Exam 3 Review Questions (Latest -

• The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first

while the nurse initiates the nurse-patient relationship?

• Appearance and behavior
• Measurement of vital signs
• Observing specific body systems
• Conducting a detailed health history

Answer:1

• The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal

hysterectomy. Which assessment finding would require immediate follow-up?

• Auscultation of an apical heart rate of 76
• Absence of bowel sounds on abdominal assessment
• Respiratory rate of 8 breaths/min
• Palpation of dorsalis pedis pulses with strength of +2

Answer:3

• Which statement made by a patient who is at average risk for colorectal cancer indicates an

understanding about teaching related to early detection of colorectal cancer?

• "I'll make sure to schedule my colonoscopy annually after the age of 60."
• "I'll make sure to have a colonoscopy every 2 years."
• "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55."
• "I'll make sure to have a fecal occult blood test annually once I turn 45.

Answer:4

• The nurse is teaching a patient to prevent heart disease. Which information should the nurse include?

(Select all that apply.)

• Add salt to every meal.
• Talk with your health care provider about taking a daily low dose of aspirin.
• Work with your health care provider to develop a regular exercise program.
• Limit daily intake of fats to less than 25% to 35% of total calories.
• Review strategies to encourage the patient to quit smoking.

Answer:3,4,5

• The nurse is assessing the cranial nerves. Match the cranial nerve with its related function.

Cranial Nerves

• XII Hypoglossal
• V Trigeminal
• VI Adducens
• IV Trochlear 1 / 4

• X Vagus

Cranial Nerve Function

• Motor innervation to the muscles of the jaw

• Lateral movement of the eyeballs
• Sensation of the pharynx
• Downward, inward eye movements
• Position of the tongue

Answer:

Matching the cranial nerves with their related functions:

XII Hypoglossal - e. Position of the tongue V Trigeminal - a. Motor innervation to the muscles of the jaw VI Abducens - b. Lateral movement of the eyeballs IV Trochlear - d. Downward, inward eye movements X Vagus - c. Sensation of the pharynx

• The nurse is teaching a patient how to perform a testicular self-examination. Which statement

made by the patient indicates a need for further teaching?

• "I'll recognize abnormal lumps because they are very painful."
• "I'll start performing testicular self-examination monthly after I turn 15."
• "I'll perform the self-examination in front of a mirror."
• "I'll gently roll the testicle between my fingers."

Answer:1

• The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which

action by the student nurse requires the nurse to intervene?

• The student stands at a midline position behind the patient, observing for position of the spine and

scapula.

• The student palpates the thoracic muscles for masses, pulsations, or abnormal movements.
• The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.
• The student places the palm of the hand over the intercostal spaces and asks the patient to say

"ninety-nine."

Answer:3

• A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include

assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.)

• Place the fingers behind and below the medial malleolus.
• Have the patient slightly flex the knee with the foot resting on the bed.
• Have the patient relax the foot while lying supine. 2 / 4

• Palpate the groove lateral to the flexor tendon of the wrist.
• Palpate along the top of the foot in a line with the groove between the extensor tendons of the

great and first toes.

Answer:1,2,5

• The faith community nurse is teaching the community center women's group about breast cancer

risk factors. Which factors does the nurse include? (Select all that apply.)

• First child at the age of 26 years
• Menopause onset at the age of 49 years
• Family history with BRCA1 inherited gene mutation
• Age over 40 years

• Onset of menses before the age of 12
• Recent use of oral contraceptives

Answer: 3,4,5,6

• 1. It is important to take precautions to prevent medication errors. A nurse is administering an oral

tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication?

• Logging on to automated dispensing system (ADS) or unlocking medicine drawer or cart.
• Before going to patient's room, comparing patient's name and name of medication on label of

prepared drugs with MAR.

• Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of

medication on label with MAR or computer printout.

• Comparing MAR or computer printout with names of medications on medication labels and patient

name at patient's bedside.

Answer:4

• 2. The health care provider has written the following orders. Which orders does the nurse need to

clarify before administering the medication? Provide rationale for your answers, and rewrite the order so that it follows the ISMP current medication order safety guidelines.Timoptic .25% solution 1 drop OD BID Metoprolol 12.50 mg QD Insulin Glargine 6 u SC twice a day Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100

Answer:

Timoptic 0.25% solution: Instill 1 drop in the affected eye(s) twice daily.

Metoprolol 12.5 mg: Administer 12.5 mg orally once daily.

Insulin Glargine 6 units: Administer 6 units subcutaneously once daily.

Enalapril 2.5 mg: Administer 2.5 mg orally three times daily; hold doses if systolic blood pressure is less than 100 mmHg.

• 3. An older adult states that she cannot see her medication bottles clearly to determine when to take

her prescription. What should the nurse do? (Select all that apply.) 3 / 4

• Provide a dispensing system for each day of the week.
• Provide larger, easier-to-read labels.
• Tell the patient what is in each container.
• Have a family caregiver administer the medication.
• Use teach-back to ensure that the patient knows what medication to take and when.

Answer:1,2,3,5

• 4. The nurse must take a verbal order during an emergency on the unit. Which of the following

guidelines can be used for taking verbal or telephone orders? (Select all that apply).

• Only authorized staff may receive and record verbal or telephone orders. The health care agency

identifies in writing the staff who are authorized.

• Clearly identify patient's name, room number, and diagnosis.
• Read back all orders to health care provider.
• Use clarification questions to avoid misunderstandings.

• Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and

complete order; sign the name of the health care provider and nurse.

Answer:1,3,4,5

• 5. A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order

for the administration of the ointment.

• Clean eye, washing from inner to outer canthus.
• Assess patient's level of consciousness and ability to follow instructions.
• Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva.
• Have patient close eye and rub lightly in a circular motion with a cotton ball.
• Ask patient to look at ceiling, and explain the steps to patient.

Answer:

The correct order for administering ophthalmic ointment is:

Assess patient's level of consciousness and ability to follow instructions.Ask patient to look at ceiling, and explain the steps to patient.Clean eye, washing from inner to outer canthus.Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva.Have patient close eye and rub lightly in a circular motion with a cotton ball.

• 6. The nurse is administering an IV push medication to a patient who has a compatible IV fluid

running through intravenous tubing. Place the following steps in the appropriate order.

• Release tubing and inject medication within amount of time recommended by agency policy,

pharmacist, or medication reference manual. Use watch to time administration.

• Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept

a needleless syringe. Use IV filter if required by medication reference or agency policy.

• After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate.
• Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe

containing prepared drug through center of injection port

• / 4