Exam (elaborations)
Chapter 22 Care of Patients with Alterations in Health
- Course
- Nursing
- Institution
- Western Piedmont Community College
Chapter 22 Care of Patients with Alterations in Health
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Chapter 22: Care of Patients with Alterations in HealthMULTIPLE CHOICE
1. Why should the nurse instill eye irrigation from the inner to the outer canthus?
a. To avoid harming the sclera
b. To include the conjunctiva in the irrigation
c. To keep the pupil constricted
d. To protect the nasolacrimal ducts
ANS: D
The irrigation flow is directed to the outer canthus to protect the nasolacrimal ducts from
contaminants.
PTS: 1 DIF: Cognitive Level: Application REF: Page 615
OBJ: 1 TOP: Eye irrigation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. When an order for eye irrigation is received, to whom can the nurse delegate the procedure to?
a. The patient
b. Another nurse
c. A nursing assistant
d. A family member
ANS: B
Performing eye irrigation requires the skills of a licensed nurse.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 615
OBJ: 1 TOP: Delegation KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
3. To what temperature should water for eye compress be heated?
a. 95° F
b. 110° F
c. 115° F
d. 120° F
ANS: D
Water for an eye compress may be heated to no more than 120° F.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 618, Skill 22-2
OBJ: 2 TOP: Eye compress
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
4. When a patient complains of progressive hearing loss, crackling and ringing noises in his ear,
and progressive ear pain, what should the nurse assess for?
a. A dead battery in the patient‘s hearing aid
b. Cerumen impaction
, c. Sinus congestion
d. A middle ear infection
ANS: B
Symptoms of cerumen impaction are progressive hearing loss, bothersome noises in the ear,
and progressive ear pain.
PTS: 1 DIF: Cognitive Level: Application REF: Page 617
OBJ: 1 TOP: Cerumen impaction
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. When a patient asks if he can keep the heating pack on his leg all the time, the nurse reminds
him of which of the following complication of long-term heat application?
a. The heat can cause extreme vasoconstriction.
b. The heat can increase the possibility of infection.
c. The heat can cause the blood pressure to increase.
d. The heat can damage epithelial cells.
ANS: D
Prolonged contact with heat can cause damage to the epithelial cells.
PTS: 1 DIF: Cognitive Level: Application REF: Page 622
OBJ: 2 TOP: Heat applications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
6. How does an Aquathermia pad differ from a traditional heating pad?
a. The Aquathermia pad can be folded to fit the anatomic location snugly.
b. The Aquathermia pad can be placed under the patient.
c. The Aquathermia pad has circulating water for temperature control.
d. The Aquathermia pad can be left on for as long as 2 hours.
ANS: C
The Aquathermia pad should not be folded or placed under the patient, nor should it be left on
for longer than 20 minutes. The Aquathermia pad has water that circulates and stays warm for
the entire time of the treatment with no need to reheat the compress.
PTS: 1 DIF: Cognitive Level: Application REF: Page 626
OBJ: 2 TOP: Aquathermia pad
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. What gauge needle should be selected by the nurse when preparing to administer blood?
a. 25
b. 22
c. 21
d. 18
ANS: D
A large-bore needle will allow blood flow without clogging.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 632
OBJ: 6 TOP: Blood administration
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