Basic Care and Comfort – Part 2

1. A nurse is coming onto her shift at 0700 and is assigned four patients on an orthopedic medical-surgical unit. The first patient is post-op day two from a left-knee replacement and has had uncontrolled pain through the night, rating the pain 9/10. The second patient is post-op day one and ordered an antibiotic IV at 0730. The third patient has physical therapy at 0800 and is requesting pain medication one hour before therapy. The fourth patient is complaining of SOB and hematemesis. Which patient would the nurse see first?

2. Which of the following signs or symptoms indicates a possible nutritional deficiency?

3. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client’s enteral feedings. In which method does the nurse measure the correct length of the tube?

4. In which of the following ways can a nurse promote sleep for a client who is experiencing insomnia?

5. A client begins to choke on food while eating in her room and a nurse is attempting to perform the Heimlich maneuver. After several seconds, the client becomes unconscious. What is the next action of the nurse?

6. A nurse is providing discharge instructions to a patient who will be discharged to a transitional care unit following a right-sided CVA. The patient is ordered a standard walker for ambulation. Which statement by the nurse is the correct discharge instructions for the patient?

7. The nurse is assessing a patient at 1900 who has underwent a total knee replacement. The patient was ordered antiembolic stockings by his physician to prevent thrombus formation. The stockings were applied at 1100 and have not yet been removed. The following action taken by the nurse is a priority:

8. A nurse is preparing to attach a TENS unit to a client who is experiencing pain. Which of the following actions is most appropriate in this situation?

9. When cleansing the genital area during perineal care, the nurse should _______________.

10. How does shock usually progress?

11. Patients who cannot move in their bed on their own should be turned at least ________________.

12. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness fluids for her. Water is not a honey thickness fluid. It is much thinner. What should you do?

13. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

14. Mr. Thomas is a well groomed 68 year old male patient. He had prostate surgery two days ago. He has an indwelling catheter and a urinary drainage bag. You have weighed him at 9 am each morning for 3 mornings in a row. Today, on the 4th day, his morning weight is 3 pounds more than it was the day before. Why could he have gained these 3 pounds in one day, on a 1000 calorie diet?

15. Your patient has shown the following signs and symptoms : Feeling very thirsty Large amount of water intake Dryness of the mouth Urinary frequency What physical disorder does this patient most likely have?

16. You are providing mouth care to a patient who is in a coma. You should________________ to provide good and safe mouth care.

17. This particular gland of the endocrine system secretes a hormone that is known to assist with the sleep/ wake cycle. What gland is it?

18. Digestion, elimination and ___________ are the three functions of the digestive system.

19. Which of the following is an example of restorative care?

20. Renal failure is broadly divided into specific categories. Which type is the type II diabetic patient most likely to experience secondary to the diabetes?

21. Tommy R., your 68 year old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy’s ______________ in order to prevent him from falling again.

22. A home care nurse is instructing a patient about routine ostomy care who was recently discharged from the hospital following a bowel resection. The following statement by the patient indicates that the patient understands the nurse’s instructions:

23. Albert B. is incontinent of urine. He also wears glasses and hearing aids. His ____________ lead(s) to his risk for falls.

24. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.