NUR 220 Final Questions| With Complete Solutions
well written and explained ( verified 100% ) graded
A+
A patient who had a hysterectomy yesterday has not been allowed food
or drink by mouth (NPO). The physician has now ordered the patient's
diet to be clear liquids. Before administering the diet, the nurse should
check for:
1. Feelings of hunger
2. Bowel sounds
3. Positive Homans sign
4. Gag reflex - ✔✔ANSWER✔✔-2. Bowel sounds
The absence of bowel sounds would contraindicate a diet of clear
liquids.
Skin turgor checks are performed to determine the:
1. temperature of the skin.
2. hydration status.
3. actual age.
4. extent of an ecchymosis. - ✔✔ANSWER✔✔-2. hydration status.
Skin will remain tented if the patient is dehydrated or will not tent if
edema is present.
,When assessing the capillary refill, the nurse may document as normal
a refill time of __________ seconds.
1. 3
2. 6
3. 8
4. 10 - ✔✔ANSWER✔✔-1. 3
Capillary refill is a method of quick assessment of perfusion to the
extremities. A normal capillary refill time is 3 to 5 seconds or less.
The nurse should include the proper use of an incentive spirometer in
teaching a preoperative patient. Postoperative monitoring of this
patient would reveal that the incentive spirometry has been effective if
the patient has:
1. Adventitious breath sounds
2. Expiratory wheezing
3. Thick, green respiratory secretions
4. Clear breath sounds - ✔✔ANSWER✔✔-4. Clear breath sounds
An incentive spirometer is used to promote lung expansion, which
opens airways, reduces atelectasis, and stimulates coughing to clear
secretions.
,Which of the following is an ABCD characteristic of malignant
melanoma?
1. Asymmetric borders
2. Borders well demarcated
3. Color of lesion is uniform
4. Diameter less than 6 mm - ✔✔ANSWER✔✔-1. Asymmetric borders
ABCD melanoma mnemonic includes asymmetry, borders that are
irregular, color that is not the same all over, and diameter larger than 6
mm and growing.
A patient who has just undergone a colon resection complains to the
nurse that he felt something pop under his dressing while trying to get
out of bed. The nurse removes the dressing and finds that dehiscence
of the wound has occurred. The nurse's first action should be to:
1. Replace the dressing; dehiscence is normal.
2. Call the physician.
3. Pull the wound edges together, and replace the dressing.
4. Cover the wound with sterile dressings saturated with normal saline.
- ✔✔ANSWER✔✔-4. Cover the wound with sterile dressings saturated
with normal saline.
The first action of the nurse should be to cover the wound with saline-
saturated dressings to prevent damage of the exposed organs from
drying and then to call the physician.
, A patient who had been complaining of intolerable stress at work has
demonstrated the ability to use progressive muscle relaxation and deep
breathing techniques. He will return to the clinic for follow-up
evaluation in 2 weeks. Which data will best suggest that the patient is
successfully using these techniques to cope more effectively with
stress?
1. The patient's wife reports that he spends more time sitting quietly at
home.
2. He reports that his appetite, mood, and energy levels are all good.
3. His systolic blood pressure has gone from the 140s to the 120s (mm
Hg).
4. He reports that he feels better and that things are not bothering him
as much. - ✔✔ANSWER✔✔-3. His systolic blood pressure has gone from
the 140s to the 120s (mm Hg).
Objective measures tend to be the most reliable means of gauging
progress. In this case, the patient's elevated blood pressure, an
indication of the body's physiologic response to stress, has diminished.
The wife's observations regarding his activity level are subjective, and
his sitting quietly could reflect his having given up rather than improved.
Appetite, mood, and energy levels are also subjective reports that do
not necessarily reflect physiologic changes from stress and may not
reflect improved coping with stress. The patient's report that he feels
better and is not bothered as much by his circumstances could also
reflect resignation rather than improvement.
The sign or symptom that suggests that a patient with impaired skin
integrity is developing a systemic infection is a:
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller doctorfirstbest. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $15.99. You're not tied to anything after your purchase.
