ATI Pre Exam 3 Quiz

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? Apply a moisture barrier ointment to the clients skin Clean the client's skin and perineum with hot water after each episode of incontinence Check the client's skin every 8 hrs for signs of breakdown Request a prescription for the insertion of an indwelling urinary catheter

Apply a moisture barrier ointment to the clients skin (Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.)

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? Steatorrhea Blood Bacteria Parasites

Blood (A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers)

A nurse is reinforcing teaching to a client who is experiencing constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply) Excessive laxative use Ignoring the urge to defecate Inadequate fluid intake Increased fiber in the diet. Increased activity

Excessive laxative use, Ignoring the urge to defecate, Inadequate fluid intake

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? Bear down hard when defecating Drink four glasses of water daily Increase intake of raw vegetables and fruit Limit activity

Increase intake of raw vegetables and fruit (The client should increase dietary intake of raw vegetables and fruit to help provide fiber in the diet, which will increase stool bulk and move the stool through the colon to prevent constipation.)

A nurse is reviewing the provider's prescription for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take? Administer an oral antacid Provide a bulk-forming agents such as metamucil for the client to take Insert nasogastric tube Apply an abdominal binder

Insert nasogastric tube (The nurse should expect to insert a nasogastric tube for the client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus.)

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every two hours. which of the following actions should the nurse take as directed by the plan of care? Ask the client to move her arms and legs while applying slight resistance Move the client's limbs through their complete range of motion Have the client move each limb independently through its complete range of motion Instruct the client to tighten muscle groups for a short period, and then relax

Instruct the client to tighten muscle groups for a short period, and then relax (Isometric exercises involves static (no movement) contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.)

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? Increase fluids Perform a bladder scan Insert a straight catheter Provide assistance to bathroom

Perform a bladder scan (The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.)

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.). Report of feeling pressure Dysuria Distended bladder Voiding 30 mL frequently

Report of feeling pressure, Distended bladder, Voiding 30 mL frequently

A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following is an appropriate nursing action? Discontinue the enema Slow the flow of enema solution briefly Continue the enema and reassure the client Pause the enema and administer oral pain medication

Slow the flow of enema solution briefly. (Slowing the enema solution flow temporarily prevents cramping.)

A nurse is caring for a client who has a hip fracture that requires surgical repair. The nurse should identify which of the following health care professionals as responsible for obtaining informed consent from the client for the procedure? Nurse Anesthesiologist Surgeon Surgical site nurse

Surgeon (The health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client. The surgeon who is performing the surgical repair of the fracture would be responsible for obtaining informed consent.)

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? Remind the client to tell the nurse when he has to urinate Use adult diapers to prevent frequent clothing changes Take the client to the bathroom every 2 hrs Request a prescription for an indwelling urinary catheter

Take the client to the bathroom every 2 hrs (By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.)

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? Temporary urinary retention Urinary frequency for several days Blood-tinged urined Highly concentrated urine

Temporary urinary retention (Until the bladder regains its full tone, it is common for clients to develop urinary retention, If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary)

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? The client who has a tracheostomy tube attached to humidified oxygen The client who has an indwelling catheter to gravity drainage The client who has a chest tube to water seal The client who has a nasogastric (NG) tube to suction

The client who has a nasogastric (NG) tube to suction. (Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for electrolyte imbalances.)

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? Vital sign measurement The client's self report of pain severity Visual observations for nonverbal signs of pain The nature and invasiveness of the surgical procedure

The client's self-report of pain severity (Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly.)

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching? "I will empty my pouch when it becomes 1/3 full." "I will be certain to take enteric-coated medications." "I will change my entire pouch-system at least weekly." " I will use caution when eating high fiber foods."

"I will be certain to take enteric-coated medications." (Enteric-coated or extended-release medications should be avoided by those with an ileostomy because the medication is absorbed or partially absorbed in the colon and should be avoided to reduce the risk of blockage caused by the coating.)

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. which of the following client statements indicates an understanding of pain control? "I will call for pain medication before the previous dose wears off." "I will call for pain medication as my pain starts to increase again." "I will wait for you to evaluate my pain before asking for more medication." "I will ask for less medication to avoid addiction."

"I will call for pain medication before the previous dose wears off." (The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe.)

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? "I will allow him to be in the position where he is most comfortable during the feeding." "I will elevate the head of the bed 10 degrees during the feeding." "I will turn him on his left side during the feeding." "I will have him sit in his chair during the feeding."

"I will have him sit in his chair during the feeding." (The client should be placed in a Fowler's position or in a sitting position in a chair, which is the normal position for eating. This is the position that will prevent aspiration of fluid into the lungs and promote a gravitational flow.)

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will walk briskly for 30 minutes before bedtime." "I will no longer have a glass of wine before bedtime." "I will have a cup of hot cocoa immediately before bedtime." "I will do my muscle relaxation techniques each afternoon."

"I will no longer have a glass of wine before bedtime." (The client should limit or avoid alcohol consumption in the late afternoon and evening. Alcohol can act as a diuretic and cause the client to wake during sleeping hours to urinate. Alcohol also interrupts the sleep cycle and can make it difficult to stay asleep or return to sleep after awakening.)

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? "I'Il pee in the container when I begin to urinate" "I'Il use 3 cleansing wipes from front to back. One on each side then the middle" "I'Ill clean the inside of the container with a wipe." "I'll use each cleansing wipe twice."

"I'Il use 3 cleansing wipes from front to back. One on each side then the middle" (The client should cleanse the perineal area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus.)

A nurse is teaching a client who is preoperative for a colectomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make? "The tube is a routine standard following this type of surgery." "The tube will allow us to provide you with nutrition." "The tube will remove gas and fluid from your stomach." "The tube can be explained to you once you are stable after surgery."

"The tube will remove gas and fluid from your stomach." (The nurse should inform the client that the NG tube will decompress the stomach of gas and fluid in order to allow the bowel to rest.)

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? "You can expect fecal output within 24 hours." "You will need to increase your dietary intake of raw vegetables." "You can expect the stoma to be purplisj in color for the first week." "You may experience a small amount of bleeding around the stoma."

"You may experience a small amount of bleeding around the stoma."

A nurse in the emergency department is preparing to administer naloxone 0.4 mg IV bolus to a client who has opioid induced respiratory depression. Available is naloxone injection 0.2 mg/mL. How many mL should the nurse administer per dose?

2 mL

A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse schedule a colonoscopy? 56 year old who had a colonoscopy 6 years ago 34 year old who reports a new onset of constipation 32 year old who is 6 months pregnant with frequent constipation 51 year old who is being seen for a annual physical examination

51 year old who is being seen for a annual physical examination. (Colorectal cancer (CRC) is not common prior to the age of 40 years. When an adult turns 40, the provider should begin screening the client for risk factors of CRC (e.g., family history, inflammatory bowel disease, tobacco and alcohol use, high-fat and low-fiber diet, diet high in animal fats and red meat, sedentary lifestyle). The provider also may begin fecal occult blood testing depending on the client's risk. Screening colonoscopies are recommended starting at age 50 for those clients considered to be at normal risk with no family history and repeated every 10 years. It may begin earlier and performed more often for clients at high risk.)

A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention? A client who has an elevated BUN A client who reports painful urination and large output A client who reports urinary frequency with small amounts A client who has protein and glucose in his urine

A client who reports urinary frequency with small amounts (Voiding a small amount of urine (less than 100 mL) frequently (2 to 3 times per hr), and dribbling of urine are manifestations of urinary retention.)

A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? Remind the client that a signed informed consent form is a legally binding document. Notify the surgeon that the client wishes to withdraw informed consent for the procedure. Inform the surgical team to cancel the client's surgery. Proceed with preparation of the patient for the surgical procedure.

Notify the surgeon that the client wishes to withdraw informed consent for the procedure. (The client has the right to withdraw informed consent; therefore, the surgeon who is the one to obtain the informed consent should be notified of the request.)

A charge nurse is observing a nurse auscultating a client's bowel sounds. which of the following actions requires intervention by the charge nurse? Clamps the NG tube during auscultation Performs auscultation between meals Auscultates bowel sounds for 3 to 5 mind Palpates the abdomen prior to performing auscultation

Palpates the abdomen prior to performing auscultation (The nurse should auscultate the abdomen prior to palpating it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.)

A nurse is caring for a client who needs a stool specimen collected. Which action should the nurse take when obtaining the specimen? Use a sterile swab to obtain the specimen Place the specimen in a sterile container Label the paper bag in which the specimen container is placed Send specimen container immediately to the lab

Send specimen container immediately to the lab (The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings.)

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? Urinary tract infection Urinary retention Urinary incontinence. Urinary frequency

Urinary tract infection (A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCs, RBCs and bacteria. The urine often has an unpleasant odor.)

For which of the following findings should the nurse notify the provider? Urine output of 600 mL in the past 24 hr Urine output of 2,200 mL in the past 24 hr First-voided urine in the morning has a strong odor Urine is cloudy after sitting in the urinal for 6 hr

Urine output of 600 mL in the past 24 hr (The nurse should notify the provider if the client's urinary output is less than 30 mL/hr. This finding indicates a fluid imbalance, decreased circulating fluid volume, and possibly inadequate renal perfusion.)

A nurse is implementing a bowel training program for a client. For the program to be effective the client should be taken to the bathroom at which of the following times? When the client has the urge to defecate Every 2 hr while the client is awake Immediately before the client has a meal After the client feels abdominal cramping

When the client has the urge to defecate (When on a bowel training program, the nurse should take the client to the toilet when the client recognizes the urge to defecate. A bowel training program focuses on identifying times in the client's bowel pattern to promote self-control of defecation.)

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? Insert the needle into the needleless port at a 60° angle Withdraw 3 to 5 mL of urine from the port Wiped the area of the needleless port with sterile water Don sterile gloves

Withdraw 3 to 5 mL of urine from the port

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing? Measuring Vital Signs Removing the abdominal dressing Helping the client into the shower Ambulating the client in the hallway

removing the abdominal dressing