Therapeutic Nursing Care | Care of Patient with respiratory problem | Altered Body Temperature | Mock Test | Staff Nurse | Guides Academy

Therapeutic nursing care-Care of patient with respiratory problem, altered body temperature, fluid electrolyte imbalance, body elimination deviation, care of unconscious patient, bed ridden patient and care of patients with pain.

Time: 15:00

A patient is experiencing acute dyspnea (difficulty breathing). Which position should the nurse place the patient in to maximize lung expansion?

[a] Supine

[b] Trendelenburg

[c] High-Fowler's

[d] Prone

A patient has a body temperature of 102.6°F (39.2°C). Which nursing intervention is most appropriate to manage this hyperthermia?

[a] Applying multiple heavy blankets to prevent shivering.

[b] Restricting fluid intake to prevent fluid overload.

[c] Administering a prescribed antipyretic and applying a cool compress.

[d] Encouraging strenuous physical activity to promote heat loss.

What is the most reliable indicator for monitoring a patient's fluid volume status on a daily basis?

[a] Measuring urine specific gravity.

[b] Assessing for skin turgor.

[c] Checking for peripheral edema.

[d] Obtaining the patient's weight at the same time each day.

The primary reason for performing frequent oral hygiene on an unconscious patient is to:

[a] Assess the patient's gag reflex.

[b] Improve the patient's appetite.

[c] Prevent aspiration pneumonia from oral bacteria.

[d] Keep the patient's lips from chapping.

A nurse is assessing a patient's pain. The patient describes the pain as a "sharp, stabbing feeling." This information would be documented under which letter of the PQRST pain assessment model?

[a] P (Provocation)

[b] Q (Quality)

[c] R (Region)

[d] S (Severity)

To prevent the formation of pressure injuries in a bed-ridden patient, the nurse should reposition the patient at least:

[a] Every 8 hours.

[b] Once per shift.

[c] Every 4 hours.

[d] Every 2 hours.

Pursed-lip breathing is taught to patients with COPD to help:

[a] Increase the respiratory rate.

[b] Prolong exhalation and keep airways open.

[c] Strengthen the diaphragm.

[d] Decrease the amount of oxygen needed.

A patient's lab results show a serum potassium level of 2.9 mEq/L. The nurse should prioritize monitoring for which of the following?

[a] Seizures

[b] Respiratory depression

[c] Cardiac dysrhythmias

[d] Muscle rigidity

When caring for a patient with an indwelling urinary catheter, which action is essential to prevent a catheter-associated urinary tract infection (CAUTI)?

[a] Keeping the drainage bag on the patient's lap during transport.

[b] Irrigating the catheter with sterile saline daily.

[c] Changing the catheter every 24 hours.

[d] Maintaining a closed drainage system with the bag kept below the bladder level.

Which of the following is an example of a non-pharmacological intervention for pain management?

[a] Administering an NSAID.

[b] Giving a patient-controlled analgesia (PCA) pump.

[c] Applying a cold pack and using distraction techniques.

[d] Administering a prescribed opioid medication.

What is the priority nursing assessment for an unconscious patient?

[a] Nutritional status

[b] Skin integrity

[c] Airway patency

[d] Fluid balance

A post-operative patient is reluctant to use their incentive spirometer. The nurse explains that its primary purpose is to prevent:

[a] Deep vein thrombosis (DVT).

[b] Atelectasis and pneumonia.

[c] A surgical site infection.

[d] Post-operative pain.

A patient with heart failure exhibits distended neck veins, bibasilar crackles, and 3+ pitting edema in the legs. These signs are indicative of:

[a] Dehydration (Hypovolemia)

[b] Fluid volume excess (Hypervolemia)

[c] Hyponatremia

[d] Hyperkalemia

The purpose of applying Sequential Compression Devices (SCDs) to the legs of a bed-ridden patient is to:

[a] Prevent skin breakdown.

[b] Keep the patient's legs warm.

[c] Prevent muscular contractures.

[d] Promote venous return and prevent deep vein thrombosis (DVT).

What is the most important action a nurse should take after administering an analgesic for pain?

[a] Document the administration immediately.

[b] Offer the patient a glass of water.

[c] Reassess the patient's pain level within an appropriate timeframe.

[d] Encourage the patient to sleep.

A patient is found unresponsive with a core body temperature of 93°F (33.9°C). What is the priority nursing intervention for this hypothermia?

[a] Administer a cool bath to prevent a rapid temperature rise.

[b] Vigorously massage the patient's extremities to increase circulation.

[c] Provide a hot beverage like coffee or tea.

[d] Remove any wet clothing and apply warm blankets.

When suctioning a patient's airway, the nurse should:

[a] Apply continuous suction while inserting the catheter.

[b] Apply intermittent suction while withdrawing the catheter.

[c] Suction for at least 30 seconds to ensure the airway is clear.

[d] Use the same catheter to suction the mouth and then the trachea.

A patient reports constipation. Which dietary modification should the nurse recommend?

[a] Decrease fluid intake and eat more cheese.

[b] A low-residue, low-fiber diet.

[c] Increase intake of white rice and bananas.

[d] Increase intake of fiber, such as fruits and vegetables, and drink more water.

A nurse is caring for an unconscious patient. To prevent foot drop and contractures, the nurse should use:

[a] A bed cradle.

[b] High-top sneakers or footboards and perform passive range-of-motion.

[c] Sequential compression devices (SCDs).

[d] Extra pillows under the patient's knees.

A patient with chronic pain due to arthritis tells the nurse they are in pain but appears calm and is watching television. The nurse's best interpretation is that:

[a] The patient is not truly in pain and is seeking medication.

[b] The patient has adapted to the pain, and their behavior may not reflect the pain's intensity.

[c] The television is an effective replacement for all pain medication.

[d] The patient's vital signs must be elevated for pain to be present.

A patient has a new colostomy. When assessing the stoma, which finding would be considered normal and healthy?

[a] A pale, dusky stoma.

[b] A stoma that is flush with the skin.

[c] A stoma that is beefy red and moist.

[d] A dark, bluish stoma.

A patient receiving continuous enteral feedings through a nasogastric tube is at high risk for aspiration. The nurse should always keep the head of the bed elevated to at least:

[a] 10 degrees.

[b] 15 degrees.

[c] 30 degrees.

[d] 90 degrees.

Which patient is at highest risk for developing fluid volume deficit (dehydration)?

[a] A patient with congestive heart failure.

[b] A patient with renal failure.

[c] An elderly patient with gastroenteritis (vomiting and diarrhea).

[d] A patient receiving IV fluids at 125 mL/hr.

When providing care for a patient with fecal incontinence, the nurse's priority is:

[a] Establishing a regular toileting schedule.

[b] Limiting the patient's fluid intake.

[c] Applying a large, absorbent diaper.

[d] Maintaining skin integrity through prompt cleaning and application of a moisture barrier.

A patient is reluctant to request pain medication for fear of developing an addiction. What is the nurse's most therapeutic response?

[a] "You should try to tolerate the pain for as long as you can."

[b] "Addiction is rare when opioids are used for short-term, acute pain. Proper pain control will help you heal faster."

[c] "Don't worry, we can switch you to a non-addictive medication later."

[d] "Your doctor ordered the medication, so you should take it."