300-Item NLE Practice Exam

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Questions and Answers

What is the correct process to obtain a urine specimen for culture and sensitivity from a catheterized patient?

Disconnect the drainage bag, obtain a sterile syringe and draw the specimen from the drainage bag

Clamp the catheter for 30 minutes, alcoholize the tube above the clamp site, obtain a sterile syringe and draw the specimen on the tube above the clamp

Alcoholize the self sealing port, obtain a sterile syringe and draw the specimen on the self sealing port (correct)

Disconnect the tube, obtain a sterile syringe and draw the specimen from the tube

Which option demonstrates an example of secondary prevention?

Screening patients for hypertension (correct)

Immunizing infants with BCG

Teaching the diabetic client on obtaining his blood sugar level using a glucometer

Providing PPD on a construction site

Identify the abnormal condition in which a person must sit, stand, or use multiple pillows when lying down.

Eupnea

Apnea

Dyspnea

Orthopnea (correct)

Which aspect should be prioritized when assigning care for geriatric patients?

Safety of the client, especially those who frequently fall Signup and view all the answers

What is the highest priority component before conducting a physical examination?

Physical preparation of the client Signup and view all the answers

Legally, who owns the patient's chart?

Owned by the hospital and should not be given to anyone who requests it other than the doctor in charge Signup and view all the answers

Which of the following is a form of primary prevention?

Immunization Signup and view all the answers

What is typically seen in the water seal bottle during inhalation of the patient?

It fluctuates Signup and view all the answers

What is the appropriate position for draining the anterior and posterior apical segments of the lungs when performing percussion?

Client lying on his back and then flat on his abdomen on Trendelenburg position Signup and view all the answers

Which aspect should NOT be included when documenting the outcome of Richard's treatment?

Amount of fluid intake of client before and after the procedure Signup and view all the answers

When assessing Richard for chest percussion or vibration, which factor would be least relevant?

Amount of food and fluid taken during the last meal before treatment Signup and view all the answers

Which of the following is a special consideration when performing postural drainage and percussion?

Client has no signs of infection Signup and view all the answers

What distinguishes chest percussion from vibration?

Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle Signup and view all the answers

What is a primary reason for having Richard sit upright before treatment?

To decrease the risk of aspiration during the procedure Signup and view all the answers

Which would be the least effective action in helping a client with excessive secretions?

Limiting fluid intake to minimize congestion Signup and view all the answers

During the assessment of a client for percussion therapy, which observation is least relevant?

The client's emotional state regarding the procedure Signup and view all the answers

Which type of bath is recommended for a patient experiencing pruritus?

Colloidal (oatmeal) Signup and view all the answers

What type of burn is characterized by a whitish, leathery, and painless burned area on the skin?

Third degree burn Signup and view all the answers

During the first 24 hours after a burn, which nursing measure should be prioritized?

Input and output hourly Signup and view all the answers

What is the priority nursing intervention during the acute phase of burn management?

Prevention of infection Signup and view all the answers

What is the most fatal electrolyte imbalance in burn clients during the emergent phase?

Hyperkalemia Signup and view all the answers

Which ECG change is associated with hypokalemia?

U wave Signup and view all the answers

What is the preferred route for administering pain medications to burn patients?

IV Signup and view all the answers

Which type of debridement uses proteolytic enzymes?

Chemical Signup and view all the answers

What role does a warm and caring nurse play in the context of a mentally ill person's positive response?

Mother surrogate Signup and view all the answers

What is likely to be Camila's premorbid personality if her past history is reviewed?

Ambivert Signup and view all the answers

When receiving telephone orders, how long does a physician have to sign the order after it is documented?

24 hours Signup and view all the answers

What is the most critical goal for a nurse to set with a family if a child is determined to be physically abused?

Child and any siblings will live in a safe environment Signup and view all the answers

How is cocaine classified based on its effects on the central nervous system?

Stimulant Signup and view all the answers

What should an 85-year-old widow focus on to complete the tasks of older adulthood successfully?

Feel a sense of satisfaction in reflecting on her productive life Signup and view all the answers

What is the concept called when a nurse understands their own values and feelings and how they impact others in a therapeutic relationship?

Self awareness Signup and view all the answers

Which observation would indicate a decrease in the effectiveness of Bryant's traction for Graciela?

Graciela’s buttocks are resting on the bed Signup and view all the answers

Which action is the highest priority regarding Rudy's external shunt?

Avoid taking BP or blood sample from the arm with the shunt Signup and view all the answers

What dietary recommendation is appropriate for Rudy with acute renal failure?

Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes Signup and view all the answers

Which organism is the most common causative agent of Pyelonephritis in hospitalized patients due to prolonged catheterization?

E. Coli Signup and view all the answers

What should be instructed to increase the chance of passing renal stones for Fe?

Strain all urine Signup and view all the answers

What does superficial partial thickness burns of the skin indicate in Sergio's condition?

Dermis is partially damaged Signup and view all the answers

In the first 24 hours after Sergio's thermal injury, which electrolyte abnormalities should be assessed?

Hyperkalemia and hyponatremia Signup and view all the answers

Which feeding method should the family adopt to minimize discomfort for Rudy?

Offer soft foods for a week Signup and view all the answers

What is the best approach to avoid irritation in Rudy's condition?

Offer clear liquid for 3 days Signup and view all the answers

Study Notes

Airway Clearance and Nursing Interventions

Richard has a nursing diagnosis of ineffective airway clearance due to excessive secretions and risk of infection.
Appropriate positioning for percussion involves placing the client lying flat on his back and then on his abdomen.
Documentation of treatment outcomes should exclude fluid intake measurements before and after the procedure.
Key assessment focuses include respiratory rate, breath sounds, location of congestion, and ensuring client comfort regarding procedure tolerances.
Special considerations for postural drainage involve checking the client's ability to tolerate various positions.
Chest percussion involves delivering blows with cupped palms; vibration involves gentle shaking during exhalation.

Urine Specimen Collection and Community Health

For urine specimen collection, it is correct to alcoholize the self-sealing port and draw from it using a sterile syringe.
Secondary prevention includes activities like screening for hypertension.
Primary prevention examples include immunizations.

Patient Assessments and Psychosocial Considerations

Orthopnea describes a condition where a person must sit or use multiple pillows to breathe comfortably.
Highest priority in geriatric care is ensuring client safety, especially for those at risk of falls.
Before a physical examination, psychological preparation of the client holds the highest priority.
Patient charts are legally owned by the hospital and controlled by healthcare professionals, not the patient.

Chronic Renal Failure and Dialysis Care

For patients with an A-V shunt, the highest priority is to avoid taking BP or blood samples from the shunt arm.
Diet therapy for acute renal failure should focus on low-protein, low-potassium, and low-sodium foods.
E. coli is identified as the most common causative agent of pyelonephritis from catheterization.

Burn Care and Management

Superficial partial thickness burns involve damage to the dermis but not deeper structures.
Within the first 24 hours post-burn, focus on intake and output monitoring and strict aseptic technique.
Post-burn, the priority nursing intervention during the acute phase is infection prevention.
The most dangerous electrolyte imbalance in burn patients is hyperkalemia during the emergent phase.
Hypokalemia is identifiable on an ECG by the presence of a U wave.
Pain medications are best administered intravenously for burn patients.
Topical antimicrobial frequently used in burn care includes silver sulfadiazine.

Therapeutic Relationships and Interventions

Hypertrophic burn scars result from exaggerated contraction processes following burns.
The role of the nurse includes being a counselor, especially for mental health patients requiring supportive relationships.
Understanding the impact of personal values and beliefs on therapeutic relationships is crucial for effective care.

Additional Nursing Considerations

Telephonic orders from physicians must be documented and signed within 24 hours to ensure legality.
In cases of suspected child abuse, prioritizing a safe environment for the child and siblings is crucial.
Cocaine is categorized as a stimulant, affecting both mental and physical states.
In older adulthood, individuals are encouraged to reflect on their lives and feel satisfaction.
Effective traction management includes ensuring that weights are appropriately positioned for treatment.

Monitoring Symptoms and Patient Safety

Observations for increased intracranial pressure following potential head injuries include specific signs such as altered consciousness and headache.

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Description

This practice exam focuses on nursing concepts related to airway management and patient care. It includes scenarios like assessing lung sounds and developing care plans for effective clearance of secretions. Ideal for nursing students preparing for the NLE.