EAQ practice questions

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? - A column of water 20 cm high in the suction control chamber - 75 mL of bright red blood in the drainage collection chamber - An intact occlusive dressing at the insertion site - Constant bubbling in the water seal chamber

Constant bubbling in the water seal chamber

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? - Pregnancy - Inactivity - Aerobic exercise - Tight clothing

Inactivity

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? - Oxygen Saturation: 89% - Body temperature: 101°F - Blood Pressure: 130/80 mmHg - Respiratory rate: 26 beats/minute

Oxygen Saturation: 89%

The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? - Stimulate continuous formation of urine. - Facilitate the measurement of urinary output. - Prevent the development of clots in the bladder. - Provide continuous pressure on the prostatic fossa.

Prevent the development of clots in the bladder.

While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. The client also complains of urinary incontinence. Which nursing intervention is beneficial for the client? - Providing thorough perineal care after each voiding - Encouraging the client to use the toilet or bedpan every 2 hours - Responding quickly to the client's indication of the need to void - Providing privacy, assistance, and voiding stimulants over the perineum

Providing thorough perineal care after each voiding

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? - Pulse rate - Tissue turgor - Specific gravity - Body temperature

Tissue turgor

A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? - Infection caused by the excretion of feces - Injury caused by exposed intestinal mucosa - Altered bowel elimination caused by the ostomy - Limited water reabsorption caused by removal of intestine

Limited water reabsorption caused by removal of intestine

A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. On physical examination, the nurse finds a smooth, firm, and enlarged prostate. The digital rectal examination report indicates enlargement of prostate tissue surrounding the urethra. Which condition does the nurse suspect in the client? - Prostatitis - Paraphimosis - Prostate cancer - Benign prostatic hyperplasia (BPH)

Benign prostatic hyperplasia (BPH)

A client with colitis has had a hemicolectomy. Three days after surgery the nurse identifies that the client has abdominal distention and absent bowel sounds, and has vomited 300 mL of dark green viscous fluid. The nurse contacts the primary healthcare provider and recommends which intervention? - Nasogastric tube for decompression - Antiemetic for nausea/vomiting - Intravenous (IV) lactated Ringer for fluid replacement - Stat electrolytes to assess for probable electrolyte imbalance

Nasogastric tube for decompression

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents? - Colitis - Stomatitis - Paralytic ileus - Gastrocolic reflux

Paralytic ileus

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? - Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. - After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. - Clean the insertion site daily using a solution of one part vinegar to two parts water. - Replace the drainage bag with a new bag once a week.

Replace the drainage bag with a new bag once a week.

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site? - Tubing injection port - Distal end of the tubing - Urinary drainage bag - Catheter insertion site

Tubing injection port

A nurse is providing care to a client 8 hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? - Incisional pain - Absent bowel sounds - Urine output of 20 mL/hr - Serosanguineous drainage on the dressing

Urine output of 20 mL/hr

A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? - Vitamins - Whole bran - Cod liver oil - Amino acids

Whole bran

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? - "Inhale completely and exhale in short, rapid breaths." - "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." - "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." - "Exhale halfway, then inhale a rapid, small breath; repeat several times."

"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale."

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections? - "Wear cotton underpants." - "Void at least every 6 hours." - "Increase foods containing alkaline ash in the diet." - "Wipe from back to front after toileting."

"Wear cotton underpants."

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? - "I will avoid the pooling of urine in the tubing." - "I will avoid prolonged clamping of the tubing." - "I will avoid draining urine from the tubing before ambulation." - "I will avoid raising the drainage tube above the level of the bladder."

"I will avoid draining urine from the tubing before ambulation."

A nurse is assessing several clients. Which client will require parenteral nutrition? - A client with brain neoplasm - A client with anorexia nervosa - A client with inflammatory bowel disease - A client with severe malabsorption disorder

A client with severe malabsorption disorder

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? - Skin breakdown - Aspiration pneumonia - Retention ileus - Profuse diarrhea

Aspiration pneumonia

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? - Have the prescription renewed every 48 hours. - Assess the client's condition every hour. - Provide range of motion to the client's elbows every shift. - Document output from the tube and catheter every 2 hours.

Assess the client's condition every hour.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? - Radial pulse: 70 - Temperature: 37 °C - Respiratory rate: 14 - Blood pressure: 110/70 - Oxygen saturation: 92%

C,D,E

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? - Instruct the client to call for help with elimination needs; answer the client's call light immediately to prevent incontinence. - Place a waterproof pad under the client to prevent incontinence and soiling the linens. - Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence. - Offer toileting to the client every 2 hours to prevent incontinence.

Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? - Elevate the head of the bed between 30 and 45 degrees. - Decrease flow rate at night. - Check for residual daily. - Irrigate regularly with warm tap water

Elevate the head of the bed between 30 and 45 degrees.

A client has a permanent sigmoid colostomy as a result of cancer of the rectum. The primary healthcare provider prescribes daily colostomy irrigations. What does the nurse explain is the primary purpose of these irrigations? - Prevent straining at passage of stool - Establish a regular elimination schedule - Decrease the amount of flatus in the bowel - Limit the amount of fluid lost from the intestine

Establish a regular elimination schedule

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? - Libel - Slander - Negligence - Invasion of privacy

Invasion of privacy

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? - Immediately stop the infusion. - Lower the height of the enema bag. - Advance the enema tubing 2 to 3 inches (5 to 7.5 cm). - Clamp the tube for 2 minutes and then restart the infusion.

Lower the height of the enema bag.

A client suspected to have a prostate disorder is encouraged to have a rectal examination. What position of the client will facilitate a rectal examination by the registered nurse (RN)? - Sims position - Prone position - Dorsal recumbent position - Lateral recumbent position

Sims position

A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. What does the nurse include when teaching the client about the purpose of the antibiotics? - They prevent incisional infection. - Antibiotics prevent postoperative pneumonia. - These drugs limit the risk of a urinary tract infection. - They are given to eliminate bacteria from the gastrointestinal (GI) tract.

They are given to eliminate bacteria from the gastrointestinal (GI) tract.

A client has undergone pelvic surgery and the nurse removes the catheter in a week according to instructions. In the follow up within several hours, which finding in the client indicates a need for reinsertion of catheter? - Anuria - Polyuria - Retention - Incontinence

retention