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ARIZONA COLLEGE OF NURSING NURS 355 EXAM 3 STUDY GUIDE WITH COMPLETE SOLUTION!!
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ARIZONA COLLEGE OF NURSING NURS 355 EXAM 3 STUDY GUIDE WITH COMPLETE SOLUTION!!
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ARIZONA COLLEGE OF NURSING NURS 355 EXAM 3 STUDYGUIDE WITH COMPLETE SOLUTION!!
The nurse is caring for a 47-yr-old female patient who is comatose and is receiving
continuous enteral nutrition through a soft nasogastric tube. The nurse notes the
presence of new crackles in the patient's lungs. In which order will the nurse take
action? (Put a comma and a space between each answer choice [A, B, C, D].)
Answers :Answers:
C. Stop administering the continuous feeding
A. Check the patient's oxygen saturation
D. Measure the gastric residual volume per agency policy.
B. Notify the patient's health care provider
Rationale: The assessment data indicate that aspiration may have occurred. The
nurse's first action should be to turn off the enteral feeding to avoid further
aspiration. The next action should be to check the oxygen saturation because this
may indicate the need for immediate respiratory suctioning or oxygen
administration. The residual volume provides data about possible causes of
aspiration. Finally, the health care provider should be notified and informed of all
the assessment data the nurse has just obtained.
Which information about an 80-yr-old male patient at the senior center is of most
concern to the nurse?
Answers :Answer: Unintended weight loss
Rationale: Unintentional weight loss is not a normal finding and may indicate a
problem such as cancer or depression. Poor appetite, difficulty in chewing, and
,indigestion are common in older patients. These will need to be addressed but are
not of as much concern as the weight loss.
2. An older patient reports chronic constipation. To promote bowel evacuation,
when should the nurse suggest that the patient attempt defecation?
Answers :Answer: After eating breakfast
Rationale: The gastrocolic reflex is most active after the first daily meal.
Awakening, the anticipation of eating, and mid-afternoon timing do not stimulate
these reflexes.
What condition should the nurse anticipate when caring for a patient with a history
of a total gastrectomy?
Answers :Answer: Cobalamin
Rationale: The patient with a total gastrectomy does not secrete intrinsic factor,
which is needed for cobalamin (vitamin B12) absorption. Because the stomach
absorbs only small amounts of water and nutrients, the patient is not at higher risk
for dehydration, elevated cholesterol, or constipation.
The nurse is caring for a patient with an obstructed common bile duct. What
condition should the nurse expect?
Answers :Answer: Steatorrhea
Rationale: A common bile duct obstruction will reduce the absorption of fat in the
small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by
,common bile duct obstruction. Serum cholesterol levels are increased with biliary
obstruction. Direct bilirubin level is increased with biliary obstruction.
The nurse receives the following information about a patient who is scheduled for
a colonoscopy. Which information should be communicated to the health care
provider before sending the patient for the procedure?
Answers :Answer: The patient declined to drink the prescribed laxative solution.
Rationale: If the patient has had inadequate bowel preparation, the colon cannot be
visualized and the procedure would be rescheduled. Because contrast solution is
not used during colonoscopy,
the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic
resonance imaging but not to colonoscopy. The nurse should instruct the patient
about the sedation used during the examination to decrease the patient's anxiety
about discomfort.
Which statement to the nurse from a patient with jaundice indicates a need for
teaching?
Answers :Answer: "I use acetaminophen (Tylenol) every 4 hours for pain."
Rationale: Chronic use of high doses of acetaminophen can be hepatotoxic and
may have caused the patient's jaundice. The other patient statements require further
assessment by the nurse but do not indicate a need for patient education.
, Which is the correct technique for the nurse to palpate the liver during a head-to-
toe physical assessment?
Answers :Answer: Place one hand on the patient's back and press upward and
inward with the other hand below the patient's right costal margin.
Rationale: The liver is normally not palpable below the costal margin. The nurse
needs to push inward below the right costal margin while lifting the patient's back
slightly with the left hand. The other methods will not allow palpation of the liver.
Which finding by the nurse during abdominal auscultation indicates a need for a
focused abdominal assessment?
Answers :Answer: Absent bowel sounds
Rationale: Absent bowel sounds are abnormal and require further assessment by
the nurse. The other sounds may be heard normally.
What action should the nurse take after assisting with a needle biopsy of the liver
at a patient's bedside?
Answers :Answer: Place the patient on the right side with the bed flat
Rationale: After a biopsy, the patient lies on the right side with the bed flat to splint
the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does
not exert adequate pressure to splint the site.
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