Chapter 42: Home Care Teaching Nursing School Test Banks

MULTIPLE CHOICE

1. Of the following types of thermometers available, which is not recommended for home use?

a.

Digital

b.

Tympanic

c.

Mercury

d.

Disposable single-use

ANS: C

If a mercury thermometer breaks, and it is not disposed of properly, the mercury gets into the air, posing a major health risk in the home (EPA, 2007). Educate patients about the environmental hazards associated with mercury in the home, and encourage patients to purchase mercury-free thermometers.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1017

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Mercury Thermometers

KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment

2. Which of the following is essential in teaching the patient how to use a thermometer?

a.

Reading a digital thermometer

b.

Shaking down the thermometer before use

c.

Using the axillary thermometer

d.

Selecting the most appropriate thermometer

ANS: D

Help a patient choose the most appropriate thermometer to use in the home based on the patients dexterity, vision, and financial resources. For example, a patient with visual changes from glaucoma or retinopathy is able to read more easily a thermometer with a large digital display. The need for an oral, rectal, or axillary temperature depends on the patients age and health status.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1017

OBJ: Identify factors that influence patients abilities to learn and care for themselves at home.

TOP: Choosing the Right Thermometer KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe and Effective Care Environment

3. What should the nurse first assess when preparing to teach a patient and/or family member how to read a thermometer?

a.

Patients actual temperature

b.

Patients ability to manipulate the thermometer

c.

Family members temperature

d.

Patients ability to take a pulse and respiratory rate as well

ANS: B

Assess the patients ability to manipulate and read the thermometer. Physical restrictions in handling or reading the thermometer prevent patients from being able to read the thermometer and often require instruction of a family member or significant other instead of the patient.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1017

OBJ: Identify factors that influence patients abilities to learn and care for themselves at home.

TOP: Choosing the Right Thermometer KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe and Effective Care Environment

4. Which of the following is an appropriate step when teaching temperature monitoring in the home?

a.

Suggest aspirin to decrease fevers.

b.

Recommend using only tympanic membrane sensors.

c.

Encourage the use of alcohol rubs to reduce fevers.

d.

Demonstrate the technique and have the client/caregiver perform it.

ANS: D

Demonstration is the best technique for teaching psychomotor skills. It allows for correction of errors in technique as they occur and for discussion of potential consequences of errors. Provide rationale for steps to the patient or caregiver. Use caution in recommending aspirin or any other over-the-counter drug or antipyretic medicine for patients whose conditions contraindicate their use. The type of thermometer needed is determined on the basis of the patients age and health status. Instruct the patient or caregiver to never use sponging with isopropyl alcohol to lower fever because of the neurotoxic effects that have been reported.

DIF: Cognitive Level: Application REF: Text reference: p. 1017

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Teaching How to Use the Thermometer

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

5. What should the nurse instruct the patient to do when teaching the patient how to take a temperature?

a.

Wait at least 30 minutes after smoking or ingesting hot or cold foods.

b.

Take the temperature immediately upon seeing chills or shivering.

c.

Wear sterile rubber gloves when taking a rectal temperature.

d.

Lubricate an oral thermometer with water-soluble lubricant only.

ANS: A

Instruct the patient to take the temperature at least 30 minutes after smoking or ingesting hot or cold liquids or foods. This improves the accuracy of temperature readings. To ensure accuracy, teach the patient to take the temperature after chills or shivering subsides. If taking rectal temperature, instruct the patient to lubricate the thermometer tip with water-soluble lubricant, to wear clean, disposable gloves, and to use only a rectal thermometer. Lubrication normally is not needed when one is taking an oral temperature.

DIF: Cognitive Level: Application REF: Text reference: p. 1018

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Teaching How to Use the Thermometer

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

6. What should the nurse instruct the parents to do when teaching them about temperature monitoring for a child?

a.

Use only a glass mercury thermometer.

b.

Take the temperature after shivering subsides.

c.

Avoid the use of tepid water sponging for fever.

d.

Take the temperature, but adjust the reading if the child has eaten a popsicle.

ANS: B

Teach the patient to take the temperature after chills or shivering subsides to obtain an accurate temperature. Nurses in home care need to encourage their patients to purchase mercury-free thermometers. Applying cool, moist compresses to the skin is a common therapy for temperature reduction that is safe to perform at home. Wait 30 minutes to take the temperature after the patient has ingested a popsicle.

DIF: Cognitive Level: Application REF: Text reference: p. 1018

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Utilizing the Thermometer

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

7. In teaching the patient how to take his own blood pressure, which of the following is true?

a.

Blood pressure cuffs that are too small will give a falsely low reading.

b.

Blood pressure cuffs that are too large will give a falsely high reading.

c.

Electronic blood pressure cuffs are just as accurate as other methods.

d.

The cuff should be placed directly over the skin and not over clothing.

ANS: D

Have clients place the cuff directly on the skin, not over clothing. Blood pressure cuffs that are too small tend to overestimate blood pressure, and cuffs that are too large tend to underestimate blood pressure. Although electronic monitors are easier to use, their accuracy is still a focus of debate.

DIF: Cognitive Level: Application REF: Text reference: p. 1020

OBJ: Choose appropriate teaching strategies to use in the home setting.

TOP: Blood Pressure Devices. KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

8. The patient is taking Synthroid (a thyroid medication) for hypothyroidism. What should the nurse instruct the patient to do when teaching the patient how to assess her own blood pressure and pulse?

a.

Withhold the medication if her blood pressure is above the normal range or if her pulse is over 100 beats per minute.

b.

Withhold the medication if her blood pressure is below the normal range or if her pulse is less than 60 beats per minute.

c.

Never withhold her medication. Have the patient take it and notify the physician at the next office visit.

d.

Withhold her medication only if both her blood pressure and pulse rate are too high.

ANS: A

Instruct patients taking thyroid medications to withhold medications when blood pressure is above the normal range or when pulse is above 100 beats per minute. Confirm with the prescriber specific guidelines for blood pressure and pulse, document information in the home care record, and provide clear, written instructions for the patient. Beta blockers (e.g., propranolol), calcium channel blockers (e.g., verapamil hydrochloride), or cardiac glycosides (e.g., digoxin) often are withheld if blood pressure is below normal range and/or pulse is below 60 beats per minute.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1024

OBJ: Choose appropriate teaching strategies to use in the home setting.

TOP: Teaching Considerations KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

9. In teaching the patient how to perform intermittent self-catheterization, the nurse instructs which of the following?

a.

Only strict aseptic technique should be used.

b.

All hospitals use strict aseptic technique.

c.

Clean intermittent self-catheterization increases the chance for infection.

d.

Clean intermittent self-catheterization is a safe and effective method.

ANS: D

Clean intermittent self-catheterization (CISC) is a safe and effective way to empty the bladder. Current practice supports CISC for use in the home to provide a means to completely empty the bladder, prevent urinary tract infection, and prevent further bladder and kidney damage. Today, some hospital policies recommend sterile technique; others recommend clean technique.

DIF: Cognitive Level: Application REF: Text reference: p. 1024

OBJ: Choose appropriate teaching strategies to use in the home setting.

TOP: Clean Intermittent Catheterization KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

10. When teaching the patient and family about CISC, why is it important for the nurse to teach about the signs and symptoms of complications?

a.

Although rare, complications are always severe.

b.

It is part of the process; complications almost never occur.

c.

Urinary complications are common with CISC.

d.

The only major complication is infection.

ANS: C

Urinary complications are common in patients who use CISC. Verbalization of signs and symptoms of complications helps patients identify potential problems early and seek appropriate care. Signs and symptoms of complications of CISC include urinary tract infection (UTI) and urethral trauma and bleeding.

DIF: Cognitive Level: Application REF: Text reference: p. 1025

OBJ: Choose appropriate teaching strategies to use in the home setting.

TOP: Clean Intermittent Catheterization KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

11. When being taught CISC, at what interval should the patient be taught to replace the catheter?

a.

With each use

b.

Daily

c.

Weekly

d.

Monthly

ANS: D

Teach the patient to replace the catheter every 2 to 4 weeks, or when it becomes cracked or brittle, has any buildup of sediment, or loses its form.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1026

OBJ: Choose appropriate teaching strategies to use in the home setting.

TOP: Replacing the Catheter KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

12. What is the principal difference in tracheostomy care between care given in the acute care setting and care given in the home care environment?

a.

In the acute care setting, the inner cannula is cleaned.

b.

In the home care setting, dressings are not necessary.

c.

In the acute care setting, hydrogen peroxide is used for cleaning.

d.

In the home care setting, the procedure may be done with clean technique.

ANS: D

The indications for performing tracheostomy care and suctioning in the home are similar to those for tracheostomy care and suctioning in the hospital, except for one key variable: the use of medical asepsis or clean technique. In the hospital, principles of surgical asepsis are used because the patient is more susceptible to infection, and because the hospital contains more virulent or pathogenic microorganisms than are usually present in the home setting. In the home setting, most patients use clean technique. Inner cannula care is performed both at home and in the acute care setting. The inner cannula is available in both disposable and nondisposable forms. Fresh trach dressings protect the skin around the stoma from pressure breakdown and collect secretions; they are necessary in both acute care and home care settings. Hydrogen peroxide may be used in both home care and acute care settings.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1034

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance.

TOP: Differences in Trach Care Between Home Care and Acute Care Settings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. What is an expected outcome after tracheostomy care is successfully performed?

a.

A stoma site that is hard to the touch

b.

An inner cannula that is free of secretions

c.

Copious secretions obtained from suctioning

d.

Bloody secretions that have been suctioned

ANS: B

A stoma site that is clean and free of infection and transesophageal fistula and an inner cannula that is free of secretions indicate that tracheostomy care is successful. If the stoma site is reddened or hard, with or without drainage, evaluate the cleaning regimen for continued use of clean technique, and increase tracheostomy care frequency. This is an unexpected outcome. Copious colored secretions present around the stoma or when the patient is suctioned are an unexpected outcome. Bloody secretions are an unexpected outcome and require evaluation of suctioning technique and frequency and size of the catheter.

DIF: Cognitive Level: Application REF: Text reference: p. 1035

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Unexpected and Expected Outcomes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. The nurse is teaching the patient and family how to perform tracheal suctioning. What does proper technique include?

a.

Teaching how to instill normal saline before suctioning

b.

Suctioning the nasal and oral pharynx before the trachea

c.

Encouraging daily brushing of the teeth and oral hygiene

d.

Having the patient take two to three deep breaths after the procedure

ANS: D

At the conclusion of the procedure, have the patient take two to three deep breaths, and determine whether symptoms that necessitated suctioning are no longer present. Deep breathing reduces oxygen loss and prevents hypoxia. Expect the patients respiratory status to improve after suctioning. Use of normal saline adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies; therefore, this can contribute to lower airway contamination. After suctioning the patient, teach him to suction the nasal and oral pharynx, and give mouth care. Encourage the patient or family member to brush the teeth with a small, soft toothbrush 2 times a day, and to use mouth moisturizer and moisturize the lips every 2 to 4 hours.

DIF: Cognitive Level: Application REF: Text reference: p. 1036

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Suctioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

15. When teaching the patient about performing trach care, which of the following is an acceptable technique?

a.

Remove the old ties before applying the new.

b.

Keep two trach tubes of the same size at the bedside.

c.

Place the new trach tie, then remove the old tie.

d.

Dispose of all old supplies and replace with new.

ANS: C

During tracheostomy care, the patient is at risk for the trach tube coming out. Never remove the old tracheostomy tube ties until the new ties have been secured properly. Keep two tracheostomy tubes, one the same size as the patients and one a size smaller, at the patients bedside, so you can insert a new tube if the tube comes out. Clean reusable supplies in warm, soapy water. Rinse thoroughly, and dry between two layers of clean paper towels. Store supplies in a loosely closed clear plastic bag.

DIF: Cognitive Level: Application REF: Text reference: p. 1036

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Trach Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

16. What is an appropriate technique to use when teaching an older patient about self-medication in the home?

a.

Speak very loudly.

b.

Teach the family separately.

c.

Provide frequent pauses.

d.

Provide fewer but longer teaching sessions.

ANS: C

Provide frequent pauses so the patient can ask questions and express understanding of content. Use short sentences and speak in a slow, low-pitched voice. Effective teaching strategies for older adults may include involvement of a family member or caregiver. Provide frequent, short teaching sessions.

DIF: Cognitive Level: Application REF: Text reference: p. 1041

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Teaching Older Patients

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

17. The patients caregiver is checking the patients nasogastric (NG) tube for gastric residual before proceeding with the patients next feeding. The patient aspirates 250 mL of residual for the second hour in a row. The caregiver held the tube feeding within the last hour. What should the caregiver do now?

a.

Hold the feeding again.

b.

Contact the health care provider.

c.

Proceed with the feeding.

d.

Give half of the feeding and see how the patient tolerates it.

ANS: B

If aspirates remain at more than 200 mL after an hour, instruct the patient or caregiver to contact the home care nurse or health care provider.

DIF: Cognitive Level: Application REF: Text reference: p. 1045

OBJ: Implement and evaluate appropriate learning strategies that support positive patient outcomes.

TOP: Gastric Residual KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18. What does the nurse teach the patient and caregiver to do when setting up and changing administration sets for continuous tube feedings to preserve medical asepsis?

a.

Add formula to formula already hung to prevent waste.

b.

Store unused formula at room temperature to prevent spasm.

c.

Hang only enough formula that will be infused in a 4- to 6-hour period.

d.

Change the administration set every 48 hours.

ANS: C

Limit the amount of formula hung at one time to an amount that can be infused in a 4- to 6-hour period (less time in warmer weather to minimize risk for microorganism contamination). Do not add formula to a hanging bag. Using refrigeration and limiting hang time reduce microorganisms. Changing administration sets every 24 hours reduces microorganism growth.

DIF: Cognitive Level: Application REF: Text reference: p. 1045

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Asepsis With Tube Feedings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

19. Information that should be provided to the caregiver of a patient with a nasogastric (NG) tube includes:

a.

keeping the head of the bed lowered for feedings.

b.

keeping unused formula at room temperature.

c.

aspirating every 4 hours when receiving continuous drip feedings.

d.

providing half of the feeding if the residual exceeds 250 mL.

ANS: C

Patients and caregivers need to document intake and output (I&O), daily weights, amount of gastric fluid aspirated before each feeding (or every 4 hours if receiving continuous feeding), date and time of feedings, amount and type of formula, any additives, and date and time administration sets are changed. Instruct the patient or caregiver that the patient should sit up in a chair or have the head of the bed elevated at least 30 to 45 degrees while receiving feedings or medications, or when the tube is flushed. Refrigerate unused formula. If gastric aspirates are greater than or equal to 200 mL, instruct the patient or caregiver to return gastric contents and delay tube feeding for 1 hour. If aspirates remain greater than or equal to 200 mL after an hour, instruct the patient or caregiver to contact the home health nurse or health care provider.

DIF: Cognitive Level: Application REF: Text reference: p. 1046

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Management of Tube Feedings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

20. A patient is discharged and is sent home with enteral feedings. What instructions should the nurse give to the caregiver?

a.

Flush the tube out after administering medications.

b.

Keep the tube loose to allow for patient movement.

c.

Use sterile technique when preparing and administering feedings.

d.

Hang enough formula each time to cover 8 to 12 hours of feeding.

ANS: A

Discuss flushing of the tube after administration of feedings or medications to prevent clogging. Discuss measures to stabilize the feeding tube in patients with abdominal tubes and to protect skin integrity. Perform hand hygiene to reduce the transfer of microorganisms. Sterile technique is not needed. Limiting the amount of formula hung at one time to an amount that can be infused in a 4- to 6-hour period will help limit bacterial growth.

DIF: Cognitive Level: Application REF: Text reference: p. 1045

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Management of Tube Feedings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

21. What instructions should the nurse provide when teaching the patient and the patients caregiver how to administer parenteral nutrition (PN)?

a.

PN solution should be kept refrigerated until time of administration.

b.

Remixing separated mixture components by shaking the bag is common.

c.

PN is compatible with most intravenous (IV) medications.

d.

Blood glucose monitoring will be necessary.

ANS: D

PN increases blood glucose levels, which negatively affects patient outcomes. Frequent monitoring of glucose helps the caregiver to detect problems early. Expect testing frequency to decrease as the patients condition and response to PN stabilize. Suggest taking PN solution out of the refrigerator for 30 to 60 minutes before scheduled infusion time. Chilled solution often causes discomfort; allowing the solution to warm enhances comfort during infusion. If a precipitate appears, if components of the mixture are separated, or if the color changes, explain that the solution needs to be discarded. Explain that PN is incompatible with most medications; do not add medications to the PN that are not ordered to be added.

DIF: Cognitive Level: Application REF: Text reference: p. 1048

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Glucose Monitoring With PN

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

MULTIPLE RESPONSE

1. Expected outcomes for patients who are being taught how to use a thermometer include which of the following? (Select all that apply.)

a.

Ability to correctly measure temperature

b.

Ability to properly clean and store the thermometer

c.

Knowledge of normal temperature ranges

d.

Knowledge of signs and symptoms of fever

ANS: A, B, C, D

Expected outcomes after completion of the procedure include that the patient is able to correctly measure temperature, demonstrate proper cleaning and storage of equipment, and state normal temperature range and factors that affect temperature, signs and symptoms of fever and hypothermia, and measures to take with abnormal temperatures.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1018

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home.

TOP: Expected Outcomes of Teaching How to Use the Thermometer

KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment

2. Which of the following are signs of hyperthermia? (Select all that apply.)

a.

Dry, warm, flushed skin

b.

Chills and piloerection

c.

Uncontrolled shivering

d.

Loss of memory

ANS: A, B

Symptoms of fever: warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize the onset of fever in self or family member for early detection and intervention. Symptoms of hypothermia: cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1018

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Signs of Hyperthermia

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse is teaching the patient about the signs of hypothermia. She teaches that signs of hypothermia include which of the following? (Select all that apply.)

a.

Piloerection

b.

Restlessness

c.

Cool skin

d.

Uncontrolled shivering

ANS: C, D

Symptoms of hypothermia: cool skin, uncontrolled shivering, loss of memory, and signs of poor judgment. Symptoms of fever: warm, dry, flushed skin; feeling warm; chills; piloerection; malaise; and restlessness. The patient needs to recognize onset of fever in self or family member for early detection and intervention.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1018

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Signs of Hypothermia

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. In teaching the patient how to take his own blood pressure, the nurse instructs the patient to avoid which of the following 30 minutes before taking blood pressure (BP)? (Select all that apply.)

a.

Exercise

b.

Caffeine

c.

Smoking

d.

Resting

ANS: A, B, C

Encourage the patient to avoid exercise, caffeine, and smoking for 30 minutes before assessment to avoid an inaccurate reading. These factors cause elevations in BP and pulse.

Have the patient rest at least 5 minutes before measurement to reduce anxiety that can falsely elevate readings.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1022

OBJ: Choose appropriate teaching strategies to use in the home setting.

TOP: Factors That Affect Blood Pressure

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

5. In teaching the patient the best sites for assessing BP, which of the following should the patient be taught to avoid? (Select all that apply.)

a.

Sites with intravenous catheters

b.

Arms with arteriovenous shunts

c.

Arms on the side of mastectomy

d.

The left arm after a heart attack

ANS: A, B, C

The patient should be taught to avoid applying the cuff to an arm with an IV catheter with or without fluids infusing, an arteriovenous shunt, breast or axillary surgery, trauma, inflammation, disease, or a cast or bulky bandage. Application of pressure from an inflated bladder temporarily impairs blood flow and compromises circulation in the extremity that already has impaired circulation. There is no restriction on the BP cuff site in a heart attack patient unless he or she has one of the above conditions.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1022

OBJ: Choose appropriate teaching strategies to use in the home setting.

TOP: Factors That Affect Blood Pressure Site Selection

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

6. The patient needs to be taught the signs of hypoxia. Which of the following are causes of hypoxia? (Select all that apply.)

a.

Incorrect flow rate

b.

Poor tubing connection

c.

Use of long oxygen tubing

d.

Airway plugging

ANS: A, B, C, D

Hypoxia sometimes occurs at home when a patient uses oxygen. Possible causes of hypoxia include poor tubing connections, use of long oxygen tubing, and worsening of the patients physical problem with changes in respiratory status. Assess the patient for changes in respiratory status, such as airway plugging, respiratory tract infection, or bronchospasm.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1030

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Causes of Hypoxia.

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. The nurse will train the tracheostomy patient and caregiver that reusable supplies need to be disinfected at least weekly. Which of the following methods is recommended for cleaning tracheostomy supplies at home? (Select all that apply.)

a.

Boil reusable (boilable) supplies for 5 minutes. Allow to cool and dry.

b.

Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry.

c.

Soak reusable supplies in equal parts of vinegar and water for 30 minutes. Remove, rinse thoroughly, and dry.

d.

Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturers instructions. Rinse and dry.

ANS: B, C, D

To disinfect supplies, use one of these methods as described: (1) Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry. (2) Soak reusable supplies in equal parts of vinegar and water for 30 minutes. Remove, rinse thoroughly, and dry. (3) Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturers instructions. Rinse and dry.

DIF: Cognitive Level: Application REF: Text reference: p. 1036

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Tracheostomy Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

8. In preparing to teach a patient how to self-administer mediation, the nurse realizes that 80% of patients who are instructed to self-medicate for preventative care fail to do so. Reasons for this include which of the following?(Select all that apply.)

a.

Fear of adverse events

b.

Inconvenient medication regimens

c.

Costly prescriptions

d.

Forgetfulness

ANS: A, B, C, D

Some barriers to medication adherence include fear of adverse reactions from medications, belief that a medication does not help, inconvenience of taking medication, cost of medication, inadequate knowledge, forgetfulness, and lack of social support.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1039

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Failure to Self-Medicate

KEY: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment

COMPLETION

1. Temperatures in the older adult are different from those in the younger adult. The mean oral temperature for older adults often ranges from ____________.

ANS:

35 C to 36.1 C (95 F to 97 F)

Mean oral temperature for older adults often ranges from 35 C to 36.1 C (95 F to 97 F); therefore, temperatures considered within the normal range sometimes reflect a fever in the older adult.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1020

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Temperature of Older Adults

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

2. Oxygen-conserving devices (OCDs) reduce the amount of oxygen the patient uses, resulting in an overall cost reduction to the patient. The type of OCD that stores oxygen in a chamber during the expiratory phase of respirations is known as the _______________.

ANS:

reservoir nasal cannula

The reservoir nasal cannula stores oxygen in a chamber during the expiratory phase of respirations.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1027

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

3. OCDs reduce the amount of oxygen the patient uses, resulting in an overall cost reduction to the patient. The type of OCD that delivers oxygen only during inspiration is called a _______________.

ANS:

demand oxygen delivery system

Demand oxygen delivery systems deliver a burst of oxygen only during inspiration.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1027

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. A ___________________ delivers oxygen through a catheter permanently inserted into the trachea, thus allowing the patient to speak and bypassing anatomical dead space.

ANS:

transtracheal oxygen catheter

A transtracheal oxygen catheter delivers oxygen through a catheter permanently inserted into the trachea, thus allowing the patient to speak and bypassing anatomical dead space.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1027

OBJ: Discuss situations and conditions that require the patient and/or family to learn skills that support and achieve health maintenance. TOP: Reservoir Nasal Cannula

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. While teaching how to check for gastric residual, the nurse instructs the caregiver to delay the tube feeding if he or she obtains more than _________ mL of gastric aspirate.

ANS:

250

If gastric aspirates are greater than 250 mL, instruct the patient or caregiver to return gastric contents and delay tube feeding for 1 hour. If aspirates remain greater than 250 mL after an hour, instruct the patient or caregiver to contact the home care nurse or health care provider.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1045

OBJ: Implement and evaluate appropriate learning strategies that support clients ability to care for themselves in the home. TOP: Gastric Residual

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

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