Chapter 20 Selected Nursing Skills

Chapter 20  Selected Nursing Skills

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. A nurse should instill eye irrigation from the inner to the outer canthus to:
a.
avoid harming the sclera.
b.
include the conjunctiva in the irrigation.
c.
keep the pupil constricted.
d.
protect the nasolacrimal ducts.

ANS: D
The irrigation flow is directed to the outer canthus to protect the nasolacrimal ducts from contaminants.

DIF: Cognitive Level: Application REF: Page 525 OBJ: 1
TOP: Eye irrigation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

2. When an order for eye irrigation is received, the nurse can 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.

DIF: Cognitive Level: Application REF: Page 525 OBJ: 1
TOP: Delegation KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment

3. The nurse should heat the water for an eye compress to a temperature of no more than:
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.

DIF: Cognitive Level: Application REF: Page 527, Skill 20-2
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, the nurse should 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.

DIF: Cognitive Level: Application REF: Page 529 OBJ: 1
TOP: Cerumen impaction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

5. When a patient asks if he can keep the hot application on his leg all the time, the nurse reminds him that long-term heat can:
a.
cause extreme vasoconstriction.
b.
increase possibility of infection.
c.
cause the blood pressure to increase.
d.
damage epithelial cells.

ANS: D
Prolonged contact with heat can cause damage to the epithelial cells.

DIF: Cognitive Level: Application REF: Page 531 OBJ: 2
TOP: Heat applications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment