Medical-Surgical Nursing Exam 14

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1. Which of the following procedures most specifically describes splitting or separating fused cardiac valve leaflets?

  1. Commisurotomy
    Commisurotomy is frequently used for mitral stenosis.
  2. Annuloplasty
    Annuloplasty refers to repair of a cardiac valve’s outer ring.
  3. Chordoplasty
    Chordoplasty refers to repair of the chordae tendonae of atroventricular valve leaflets.
  4. Valvuloplasty
    Valvuloplasty is a general term that refers to repair of a stenosed or regurgitant cardiac valve by commisurotomy, annuloplasty, leaflet repair, and/or chordoplasty.

2. Which of the following mitral valve conditions generally produces no symptoms?

  1. Prolapse
    Mitral valve prolpase is a deformity that usually produces no symptoms and has been diagnosed more frequently in recent years, probably as a result of improved diagnostic methods.
  2. Stenosis
    Mitral valve stenosis usually causes progressive fatigue.
  3. Regurgitation
    Mitral valve regurgitation, in its acute stage, usually presents as severe heart failure.
  4. Infection
    Mitral valve infection, when acute, will produce symptoms typical of infective endocarditis.

3. In which type of cardiomyopathy does the heart muscle actually increase in size and mass weight, especially along the septum?

  1. Hypertrophic
    Because of the structural changes, hypertrophic cardiomyopathy had also been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy (ASH).
  2. Dilated
    Because of the structural changes, hypertrophic cardiomyopathy had also been called idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy (ASH).
  3. Restrictive
    Restrictive cardiomyopathy is characterized by diastolic dysfunction caused by rigid ventricular walls that impair ventricular stretch and diastolic filling
  4. Arrhythmogenic right ventricular cardiomyopathy
    Arrhythmogenic right ventricular cardiomyopathy (ARVC) occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue

4. Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased?

  1. Answers questions regarding status with no problem.
    Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.
  2. Discusses prognosis freely.
    Open discussion generally indicates some degree of comfort with prognosis.
  3. Verbalizes fears and concerns.
    Verbalization of fears and concerns indicates some degree of comfort with prognosis.
  4. Participates in support groups.
    Participation in support groups indicates some degree of comfort with prognosis.

5. The patient with which of the follow characteristics is considered high risk for the development of infective endocarditis?

  1. Complex cyanotic congenital malformations                                                                                            The patient who has complex cyanotic congenital malformations is at high risk for the development of infective endocarditis.
  2. Mitral valve prolapse with valvular regurgitation
    The patient with mitral valve prolapse with valvular regurgitation is at moderate risk for the development of infective endocarditis.
  3. Hypertrophic cardiomyopathy
    The patient with hypertrophic cardiomyopathy is at moderate risk for the development of infective endocarditis.
  4. Acquired valvular dysfunction
    The patient with acquired valvular dysfunction is at moderate risk for the development of infective endocarditis.

6. Which of the following terms indicates the amount of blood pumped out of the ventricle with each contraction of the heart?

  1. Stroke volume
    Stroke volume is the amount of blood pumped out (ejected) with each contraction of the heart (heart beat). Stroke volume times heart rate equals cardiac output.
  2. Afterload
    Afterload is the amount of resistance to ejection of blood from a ventricle.
  3. Cardiac output
    Cardiac output is the amount of blood pumped out of the heart in one minute.
  4. Preload
    Preload is the pressure created by a volume of blood within a ventricle before contraction.

7. When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as the

  1. pulmonary artery wedge pressure.
    When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary arty until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure.
  2. central venous pressure.
    Central venous pressure is measured in the right atrium.
  3. pulmonary artery pressure.
    Pulmonary artery pressure is measured when the balloon tip is not inflated.
  4. cardiac output.
    Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

8. Which of the following medications is categorized as a loop diuretic?

  1. Furosemide (Lasix)
    Lasix is commonly used in the treatment of cardiac failure.
  2. Chlorothiazide (Diuril)
    Chlorothiazide is categorized as a thiazide diuretic.
  3. Chlorthalidone (Hygroton)
    Chlorothalidone is categorized as a thiazide diuretic.
  4. Spironolactone (Aldactone)
    Spironolactone is categorized as a potassium-sparing diuretic.

9. When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating

  1. Orthopnea
    Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position
  2. Dyspnea on exertion.
    Dyspnea on exertion refers to difficulty breathing with activity.
  3. Hyperpnea.
    Hyperpnea refers to increased rate and depth of respiration.
  4. Paroxysmal nocturnal dyspnea.
    Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

10. The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately?

  1. Persistent cough
    Persistent cough may indicate an onset of left-heart failure.
  2. Increased appetite
    Loss of appetite should be reported immediately.
  3. Weight loss
    Weight gain should be reported immediately.
  4. Ability to sleep through the night
    Frequent urination, causing interruption of sleep, should be reported immediately.

11. A classic sign of cardiogenic shock is

  1. Tissue hypoperfusion
    Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).
  2. High blood pressure
    Low blood pressure is a classic sign of cardiogenic shock.
  3. Hyperactive bowel sounds
    Hypoactive bowel sounds are classic signs of cardiogenic shock.
  4. Increased urinary output
    Decreased urinary output is a classic sign of cardiogenic shock.

12. Vasoactive drugs which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload include agents such as

  1. Sodium nitroprusside (Nipride)
    Sodium nitroprusside is used in the treatment of cardiogenic shock.
  2. Norepinephrine (Levophed)
    Norepinephrine (Levophed) is a vasopressor that is used to promote perfusion to the heart and brain.
  3. Dopamine (Inotropin)
    Dopamine (Inotropin) tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock.
  4. Furosemide (Lasix)
    Furosemide (Lasix) is a loop diuretic that reduces intravascular fluid volume.

13. Which of the following terms refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest?

  1. Intermittent claudication
    Intermittent claudication is a sign of peripheral arterial insufficiency.
  2. Aneurysm
    An aneurysm is a localized sac of an artery wall formed at a weak point in the vessel.
  3. Bruit
    A bruit is the sound produced by turbulent blood flow through an irregular, tortuous, stenotic, or dilated vessel.
  4. Ischemia
    Ischemia is a term used to denote deficient blood supply.

14. Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency?

  1. The border of the ulcer is irregular.
    The border of an ulcer caused by arterial insufficiency is circular.
  2. The ulcer is very painful to the patient, even though superficial.
    Superficial venous insufficiency ulcers cause minimal pain.
  3. The ulcer base is pale to black.
    The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color.
  4. The ulcer is deep, involving the joint space.
    Venous insufficiency ulcers are usually superficial.

15. A diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is termed

  1. contrast phlebography.
    When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein.
  2. air plethysmography
    Air plethysmography quantifies venous reflux and calf muscle pump ejection.
  3. lymphangiography.
    In lymphangiography, contrast media are injected into the lymph system.
  4. lymphoscintigraphy.
    In lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

16. The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes

  1. vasospasm.
    Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities.
  2. slowed heart rate.
    Nicotine has stimulant effects.
  3. depression of the cough reflex.
    Nicotine does not suppress cough. Smoking irritates the bronchial tree, causing coughing.
  4. diuresis.
    Nicotine does not cause diuresis.

17. Which of the following types of aneurysms results in bleeding into the layers of the arterial wall?

  1. Dissecting
    Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall.
  2. Saccular
    Saccular aneurysms collect blood in the weakened outpouching.
  3. False
    In a false aneurysm, the mass is actually a pulsating hematoma.
  4. Anastomotic
    An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites.

18. Which of the following terms refers to enlarged, red, and tender lymph nodes?

  1. Lymphadenitis
    Acute lymphadenitis is demonstrated by enlarged, red and tender lymph nodes.
  2. Lymphangitis
    Lymphangitis is an acute inflammation of the lymphatic channels.
  3. Lymphedema
    Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels.
  4. Elephantiasis
    Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.

19. Which of the following terms is given to hypertension in which the blood pressure, which is controlled with therapy, becomes uncontrolled (abnormally high) with the discontinuation of therapy?

  1. Rebound
    Rebound hypertension may precipitate a hypertensive crisis.
  2. Essential
    Essential or primary hypertension denotes high blood pressure from an unidentified source.
  3. Primary
    Essential or primary hypertension denotes high blood pressure from an unidentified source.
  4. Secondary
    Secondary hypertension denotes high blood pressure from an identified cause, such as renal disease.

20. Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period.

  1. 140, 90
    According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140–159 or a diastolic pressure of 90–99.
  2. 130, 80
    Pressure of 130 systolic and 80 diastolic falls within the normal range for an adult.
  3. 110, 60
    Pressure of 110 systolic and 60 diastolic falls within the normal range for an adult.
  4. 120, 70
    Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult.

21. The nurse teaches the patient which of the following guidelines regarding lifestyle modifications for hypertension?

  1. Maintain adequate dietary intake of potassium
    In general, one serving of a potassium-rich food such as banana, kale, broccoli, or orange juice will meet the daily need for potassium.
  2. Reduce smoking to no more than four cigarettes per day
    The patient should be guided to stop smoking.
  3. Limit aerobic physical activity to 15 minutes, three times per week
    The general guideline is to advise the patient to increase aerobic activity to 30 to 45 minutes most days of the week.
  4. Stop alcohol intake
    In general, alcohol intake should be limited to no more than 1 oz of ethanol per day.

22. Of the following diuretic medications, which conserves potassium?

  1. Spironolactone (Aldactone)
    Aldactone is known as a potassium-sparing diuretic.
  2. Furosemide (Lasix)
    Lasix causes loss of potassium from the body.
  3. Chlorothiazide (Diuril)
    Diuril causes mild hypokalemia.
  4. Chlorthalidone (Hygroton)
    Hygroton causes mild hypokalemia.

23. Which of the following adrenergic inhibitors acts directly on the blood vessels, producing vasodilation?

  1. Prazosin hydrochloride (Minipress)
    Minipress is a peripheral vasodilator acting directly on the blood vessel. It is not used in angina and coronary artery disease, however, because it induces tachycardia if not preceded by administration of propranolol and a diuretic.
  2. Reserpine (Serpasil)
    Serpasil impairs synthesis and reuptake of norepinephrine.
  3. Propranolol (Inderal)
    Inderal blocks the beta-adrenergic receptors of the sympathetic nervous system, especially the sympathetics to the heart, producing a slower heart reate and lowered blood pressure.
  4. Clonidine hydrochloride (Catapres)
    Catapres acts through the central nervous system, apparently through centrally mediated alpha-adrenergic stimulation in the brain, producing blood pressure reduction.

24. Which of the following terms refers to an abnormal decrease in white blood cells, red blood cells, and platelets?

  1. Pancytopenia
    Pancytopenia may be congenital or acquired.
  2. Anemia
    Anemia refers to decreased red cell mass.
  3. Leukopenia
    Leukopenia refers to a less-than-normal amount of WBCs in circulation.
  4. Thrombocytopenia
    Thrombocytopenia refers to a lower-than-normal platelet count.

25. Which of the following terms refers to a form of white blood cell involved in immune response?

  1. Lymphocyte
    Both B and T lymphocytes respond to exposure to antigens.
  2. Granulocyte
    Granulocytes include basophils, neutrophils, and eosinophils.
  3. Spherocyte
    A spherocyte is a red blood cell without central pallor, seen with hemolysis.
  4. Thrombocyte
    A thombocyte is a platelet.

26. The term that is used to refer to a primitive cell, capable of self-replication and differentiation, is

  1. stem cell.
    Stem cells may differentiate into myeloid or lymphoid stem cells.
  2. band cell.
    A band cell is a slightly immature neutrophil.
  3. spherocyte.
    A spherocyte is a red blood cell without central pallor.
  4. reticulocyte.
    A reticulocyte is a slightly immature red blood cell.

27. Of the following hemolytic anemias, which is categorized as inherited?

  1. Sickle cell anemia
    Glucose 6-phosphate dehydrogenase deficiency is an inherited abnormality resulting in hemolytic anemia.
  2. Autoimmune hemolytic anemia
    Autoimmune hemolytic anemia is an acquired anemia.
  3. Cold agglutinin disease
    Cold agglutinin disease is an acquired anemia.
  4. Hypersplenism
    Hypersplenism results in an acquired hemolytic anemia.

28. The antidote to heparin is

  1. protamine sulfate.
    Protamine sulfate, in the appropriate dosage, acts quickly to reverse the effects of heparin.
  2. vitamin K.
    Vitamin K is the antidote to warfarin (Coumadin).
  3. Narcan.
    Narcan is the drug used to reverse signs and symptoms of medication-induced narcosis.
  4. Ipecac.
    Ipecac is an emetic used to treat some poisonings.

29. Which of the following terms describes a gastric secretion that combines with vitamin B-12 so that it can be absorbed?

  1. Intrinsic factor
    Lack of intrinsic factor is a common finding in the aged patient.
  2. Amylase
    Amylase is an enzyme that aids in the digestion of starch.
  3. Pepsin
    Pepsin is a gastric enzyme important in protein digestion.
  4. Trypsin
    Trypsin is an enzyme that aids in the digestion of protein.

30. When bowel sounds are heard about every 15 seconds, the nurse would record that the bowel sounds are

  1. normal.
    Normal bowel sounds are heard every 5-20 seconds.
  2. hypoactive.
    Hypoactive bowel sounds is the description given to auscultation of one to two bowel sounds in 2 minutes.
  3. sluggish.
    Sluggish is not a term a nurse would use to accurately describe bowel sounds.
  4. absent.
    The nurse records that bowel sounds are absent when no sound is heard in 3-5 minutes.

31. When gastric analysis testing reveals excess secretion of gastric acid, which of the following diagnoses is supported?

  1. Duodenal ulcer
    Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid.
  2. Chronic atrophic gastritis
    Patients with chronic atrophic gastritis secrete little or no acid.
  3. Gastric cancer
    Patients with gastric cancer secrete little or no acid.
  4. Pernicious anemia
    Patients with pernicious anemia secrete no acid under basal conditions or after stimulation.

32. Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?

  1. Sialolithiasis
    Salivary stones are formed mainly from calcium phosphate.
  2. Parotitis
    Parotitis refers to inflammation of the parotid gland.
  3. Sialadenitis
    Sialadenitis refers to inflammation of the salivary glands.
  4. Stomatitis
    Stomatitis refers to inflammation of the oral mucosa.

33. Irritation of the lips associated with scaling, crust formation, and fissures is termed

  1. leukoplakia.
    Leukoplakia is characterized by white patches, usually on the buccal mucosa.
  2. lichen planus.
    Lichen planus refers to white papules at the intersection of a network of interlacing lesions.
  3. actinic cheilitis.
    Actinic cheilitis is the result of cumulative exposure to sun.
  4. chancre.
    A chancre is demonstrated as a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis.

34. Regarding oral cancer, the nurse provides health teaching to inform the patient that

  1. many oral cancers produce no symptoms in the early stages.
    As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.
  2. most oral cancers are painful at the outset.
    The most frequent symptom of oral cancer is a painless sore that will not heal.
  3. Blood testing is used to diagnose oral cancer.
    Biopsy is used to diagnose oral cancer.
  4. a typical lesion is soft and crater-like.
    A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

35. The most common symptom of esophageal disease is

  1. dysphagia.
    This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing.
  2. nausea.
    Nausea is the most common symptom of gastrointestinal problems in general.
  3. vomiting.
    Vomiting is a nonspecific symptom that may have a variety of causes.
  4. odynophagia.
    Odynophagia refers specifically to acute pain on swallowing.

36. Halitosis and a sour taste in the mouth are signs and symptoms associated most directly with

  1. esophageal diverticula.
    Because the diverticula may retain decomposed food, halitosis and a sour taste in the mouth are frequent complaints.
  2. achalasia.
    Achalasia presents as difficulty in swallowing both liquids and solids.
  3. gastroesophageal reflux.
    Gastroesophageal reflux presents as burning in the esophagus, indigestion, and difficulty in or pain upon swallowing.
  4. hiatal hernia.
    Hiatal hernia presents as heartburn, regurgitation, and dysphagia in many patients while at least 50% are asymptomatic.

37. Which of the following terms refers to the symptom of gastroesophageal reflux disease (GERD) which is characterized by a burning sensation in the esophagus?

  1. Pyrosis
    Pyrosis refers to a burning sensation in the esophagus and indicates GERD.
  2. Dyspepsia
    Indigestion is termed dyspepsia.
  3. Dysphagia
    Difficulty swallowing is termed dysphagia.
  4. Odynophagia
    Pain on swallowing is termed odynophagia.

38. The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease?

  1. Avoid eating or drinking 2 hours before bedtime.
    The patient should not recline with a full stomach.
  2. Minimize intake of caffeine, beer, milk, and foods containing peppermint and spearmint.
    The patient should be instructed to avoid the listed foods and food components.
  3. Elevate the foot of the bed on 6- to 8-inch blocks
    The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks.
  4. Eat a low carbohydrate diet
    The patient is instructed to eat a low-fat diet

39. Which of the following statements accurately describes cancer of the esophagus?

  1. Chronic irritation of the esophagus is a known risk factor.
    In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco.
  2. It is three times more common in women in the U.S. than men.
    In the United States, carcinoma of the esophagus occurs more than three times as often in men as in women.
  3. It is seen more frequently in Caucasians than in African Americans.
    It is seen more frequently in African Americans than in Caucasians.
  4. It usually occurs in the fourth decade of life.
    It usually occurs in the fifth decade of life.

40. Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition?

  1. Non-tunneled catheter
    The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.
  2. Peripherally-inserted central catheter (PICC)
    PICC lines may be used for intermediate terms (3-12 months).
  3. Tunneled catheters
    Tunneled central catheters are for long-term use and may remain in place for many years.
  4. Implanted ports
    Implanted ports are devices also used for long term home IV therapy (eg, Port A Cath, Mediport, Hickman Port, P.A.S. Port).

41. To ensure patency of central venous line ports, dilute heparin flushes are used in which of the following situations?

  1. Daily when not in use
    Daily instillation of dilute heparin flush when a port is not in use will maintain the port.
  2. With continuous infusions
    Continuous infusion maintains the patency of each port. Heparin flushes are used after each intermittent infusion.
  3. Before blood drawing
    Heparin flushes are used after blood drawing in order to prevent clotting of blood within the port.
  4. When the line is discontinued
    Heparin flush of ports is not necessary if a line is to be discontinued.

42. For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube?

  1. Enteric-coated tablets
    Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.
  2. Simple compressed tablets
    Simple compressed tablets may be crushed and dissolved in water for patient receiving oral medications by feeding tube.
  3. Buccal or sublingual tablets
    Buccal or sublingual tablets are absorbed by mucous membranes and may be given as intended to the patient undergoing tube feedings.
  4. Soft gelatin capsules filled with liquid
    The nurse may make an opening in the capsule and squeeze out contents for administration by feeding tube.

43. Medium -length nasoenteric tubes are used for:

  1. Feeding
    Placement of the tube must be verified prior to any feeding.
  2. Decompression
    A gastric sump and nasoenteric tube are used for gastrointestinal decompression.
  3. Aspiration
    Nasoenteric tubes are used for gastrointestinal aspiration.
  4. Emptying
    Gastric sump tubes are used to decompress the stomach and keep it empty.

44. Mercury is typically used in the placement of which of the following tubes?

  1. Miller-Abbott
    Most nasoenteric tubes use mercury to carry the tube by gravity to its desired location.
  2. Gastric sump
    A gastric sump is used to decompress and empty the stomach.
  3. Dobbhoff
    Dobbhoff tubes are used for enteric feeding.
  4. EnterafloW
    Enteraflow tubes are used for enteric feeding.

45. The most significant nursing problem related to continuous tube feedings is

  1. potential for aspiration
    Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings.
  2. interruption of GI integrity
    Tube feedings preserve GI integrity by intraluminal delivery of nutrients.
  3. disturbance in the sequence of intestinal and hepatic metabolism
    Tube feedings preserve the normal sequence of intestinal and hepatic metabolism.
  4. interruption in fat metabolism and lipoprotein synthesis
    Tube feedings maintain fat metabolism and lipoprotein synthesis.

46. When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to

  1. reassess the residual gastric content in 1 hour.
    If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.
  2. notify the physician.
    One observation of a residual gastric content over 100 cc does not have to be reported to the physician. If the observation occurs two times in succession, the physician should be notified.
  3. give the tube feeding.
    If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time.
  4. withhold the tube feeding indefinitely.
    If the amount of gastric residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely.

47. If tube feeding is continuous, the placement of the feeding tube should be checked

  1. every shift.
    Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.
  2. every hour.
    Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities.
  3. every 24 hours.
    Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings.
  4. when a tube feeding is continuous, it is unnecessary to check placement.
    Even though the feedings are continuous, the placement must be assessed.

48. Decrease in absorption of which of the following vitamins in the geriatric patient results in pernicious anemia?

  1. B12
    Vitamin B12 requires the intrinsic factor secreted by the gastric mucosa for absorption.
  2. C
    Lack of vitamin C may cause development of signs and symptoms of scurvy.
  3. D
    Vitamin D deficiency results in an inability to absorb calcium.
  4. B6
    Vitamin B6 affects neuromuscular function.

49. Which of the following terms refers to tarry, black stools?

  1. Melena
    Melena indicates blood in the stool.
  2. Hemarthrosis
    Hemarthrosis is bleeding into a joint.
  3. Hematemesis
    Hematemesis is vomiting blood.
  4. Pyrosis
    Pyrosis refers to heartburn.

50. Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance?

  1. Minimal intake of 1.5 liters per day
    If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.
  2. Minimal urine output of 50 milliliters per hour
    Minimal urine output may be less than 50 mL/hr.
  3. Minimal urine output of 10 milliliters per hour
    Minimal urine output must exceed 10 mL/hr.
  4. Minimal intake of 2 liters per day
    Minimal intake, as a rule of thumb, is less than 2 liters per day.