Exam 3 (35-37)

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which of the following would she document? A) "Ileostomy bag half filled with liquid feces." B) "Ileostomy bag half filled with hard, formed feces." C) "Colostomy bag intact without feces." D) "Colostomy bag filled with flatus and feces."

A) "Ileostomy bag half filled with liquid feces."

Which of the following nutritional guidelines should a nurse provide to a client who is entering the second trimester of her pregnancy? A) "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." B) "Try to eat your normal number of calories, but aim to eat a diet that's higher in fruits and vegetables." C) "The more food energy you consume, the greater the chances that you will have a healthy pregnancy." D) "Maintain your regular calorie intake, but take some supplements and emphasize organic foods."

A) "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients."

A nurse performing a nutritional assessment determines that the BMI of a 5'11" (1.8 meters) male client who weighs 81 kilograms is which of the following? A) 25.1 B) 18.5 C) 20.3 D) 28.6

A) 25.1

A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing one pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response? A) 500 calories/day B) 200 calories/day C) 300 calories/day D) 400 calories/day

A) 500 calories/day

For which of the following clients should the nurse anticipate the need for a pureed diet? A) A man whose stroke has resulted in difficulty swallowing B) A woman who has required gallbladder surgery C) A man with dementia who is unable to follow instructions D) An obese woman after bariatric surgery

A) A man whose stroke has resulted in difficulty swallowing

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following? A) An increase in the client's blood pressure B) A decrease in the client's blood pressure C) An increase in the client's respiratory rate D) A decrease in the client's respiratory rate

A) An increase in the client's blood pressure

A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding? A) Assist him to a standing position. B) Tell him he has to void to be discharged. C) Pour cold water over his genitalia. D) Ask his wife to assist with the urinal.

A) Assist him to a standing position

After surgery, a postoperative client has not voided for eight hours. Where would the nurse assess the bladder for distention? A) Between the symphysis pubis and the umbilicus B) Over the costovertebral region of the flank C) In the left lower quadrant of the abdomen D) Between ribs 11 and 12 and the umbilicus

A) Between the symphysis pubis and the umbilicus

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, she informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy? A) Carbohydrates, protein, and lipids B) Vitamins, minerals, and water C) Carbohydrates, protein, and water D) Lipids, vitamins, and minerals

A) Carbohydrates, protein, and lipids

The nurse is testing the blood glucose levels of a client with a history of diabetes. The nurse has performed hand hygiene, checked the order, informed the client and turned on the monitor. After removing a test strip from the vial, the nurse should do which of the following? A) Confirm that the strip and the meter share the same code. B) Massage the client's finger toward the selected puncture site. C) Cleanse the client's finger with alcohol. D) Pierce the client's skin with the lancet

A) Confirm that the strip and the meter share the same code.

The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client? A) Constipation B) Diarrhea C) Deficient fluid volume D) Excessive fluid volume

A) Constipation

The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason? A) Detect abdominal masses B) Determine abdominal firmness C) Assess softness of abdominal muscles D) Assess degree of abdominal distention

A) Detect abdominal masses

An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging? A) Diminished kidney ability to concentrate urine B) Increased bladder muscle tone causing urinary frequency C) Increased bladder contractility causing urinary stasis D) Decreased intake of fluids during daytime hours

A) Diminished kidney ability to concentrate urine

Which of the following describes the term micturition? A) Emptying the bladder B) Catheterizing the bladder C) Collecting a urine specimen D) Experiencing total incontinence

A) Emptying the bladder

The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake? A) Encourage his daughter to prepare food at home and bring it to the client. B) Serve large meals and encourage the client to eat as much as possible. C) Provide distractions while the client is fed so that he will eat more. D) Provide bland meals.

A) Encourage his daughter to prepare food at home and bring it to the client.

A nurse is scheduling diagnostic studies for client. Which test would be performed first? A) Fecal occult blood test B) Barium study C) Endoscopic exam D) Upper gastrointestinal series

A) Fecal occult blood test

Which of the following are signs and symptoms of poor nutritional status? A) Flaky facial skin, facial edema, pale skin color B) Tongue is a deep red in color with surface papillae present. C) Firm, pink nail beds D) Firm hair that is resistant to plucking

A) Flaky facial skin, facial edema, pale skin color

While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. What stool characteristics are expected in breast-fed infants? A) Golden yellow and loose B) Dark brown and firm C) Y ellow-brown and pasty D) Green and mucusy

A) Golden yellow and loose

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on: A) Habitual laxative use is the most common cause of chronic constipation. B) If laxatives are not effective, the client should begin to use enemas. C) A laxative that works by a different method should be used. D) Chronic constipation is nothing to be concerned about

A) Habitual laxative use is the most common cause of chronic constipation.

What are two essential techniques when collecting a stool specimen? A) Hand hygiene and wearing gloves B) Following policies and selecting containers C) Wearing goggles and an isolation gown D) Using a no-touch method and toilet paper

A) Hand hygiene and wearing gloves

Which is an expected outcome for a client undergoing a bowel training program? A) Have a soft, formed stool at regular intervals without a laxative. B) Continue to use laxatives, but use one less irritating to the rectum. C) Use oil-retention enemas on a regular basis for elimination. D) Have a formed stool at least twice a day for two weeks.

A) Have a soft, formed stool at regular intervals without a laxative.

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? A) Increased bowel sounds B) Abdominal tenderness C) Areas of distention D) Muscular resistance

A) Increased bowel sounds

A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate? A) Increased output of dilute urine B) Increased urine concentration C) A risk of urinary tract infections D) Transient incontinence and increased urine production

A) Increased output of dilute urine

Most nutritionists recommend increasing fiber in the diet. In addition to other benefits, how does fiber affect cholesterol? A) Increases fecal excretion of cholesterol B) Decreases fecal excretion of cholesterol C) Facilitates intake and use of trans fat D) Raises blood cholesterol levels

A) Increases fecal excretion of cholesterol

What information do anthropometric measurements provide in adults? A) Indirect measure of protein and fat stores B) Direct measure of degree of obesity C) Indication of degree of growth rate D) Reflection of social interaction with others

A) Indirect measure of protein and fat stores

In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? A) Infection B) Advanced age C) Prolonged fasting D) Long periods of sleep

A) Infection

A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions should the nurse perform to determine the presence of fecal impaction? A) Inserted a lubricated, gloved finger into the rectum. B) Obtain a sharp intestinal x-ray. C) Insert a lubricated rectal tube into the rectum. D) Administer an oil retention enema into the rectum.

A) Inserted a lubricated, gloved finger into the rectum.

A nurse is caring for a young adult female client who has a folic acid deficiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following? A) Neural tube deficits in the fetus B) Inadequate absorption of calcium and phosphorus C) Hemolysis of red blood cells D) Impaired neuromuscular functioning

A) Neural tube deficits in the fetus

Which of the following laboratory results indicates the presence of malnutrition? A) Serum albumin 2.8 g/dL B) Hemoglobin (Hgb) 11.3 g/dL C) Creatinine 1.9 mg/dL D) Hematocrit (Hct) 56%

A) Serum albumin 2.8 g/dL

An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses? A) Social Isolation B) Impaired Adjustment C) Defensive Coping D) Impaired Memory

A) Social Isolation

A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which of the following positions would the nurse place the client? A) Supine B) Sims' C) High Fowler's D) Dorsal recumbent

A) Supine

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A) Suprapubic catheter B) Indwelling urethral catheter C) Intermittent urethral catheter D) Straight catheter

A) Suprapubic catheter

A nurse is assessing the urine output of a client with Parkinson's disease who is on levodopa. Which of the following is a common finding for a client on this medication? A) The urine may be brown or black. B) The urine may be blood-tinged. C) The urine may be green or blue-green. D) The urine may be orange or orange-red.

A) The urine may be brown or black

A nurse is caring for a client with a history of cardiac and vascular disease. Which of the following fats should the nurse allow in the client's diet for his condition? A) Unsaturated fats B) Trans fats C) Saturated fats D) Hydrogenated fats

A) Unsaturated fats

A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? A) Urinary incontinence B) Urinary incompetence C) Normal micturition D) Uncontrolled voiding

A) Urinary incontinence

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection? A) Void and discard the urine. B) Begin the collection at a specific time. C) Add the first voiding to the specimen. D) Keep the urine warm during collection.

A) Void and discard the urine.

A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this baby? A) Yellow, loose, odorless B) Brown, paste-like, some odor C) Brown, formed, strong odor D) Black, semiformed, no odor

A) Yellow, loose, odorless

During a visit to the pediatrician's office, a parent inquires about toilet training her daughter age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when ... A) the child can recognize bladder fullness. B) the child can hold the urine for four to five hours. C) The child cannot control urination until seated on the toilet. D) The child ignores the desire to void.

A) the child can recognize bladder fullness.

Which of the following factors increase BMR? Select all that apply. A) Growth B) Infections C) Fever D) Emotional tension E) Aging

A, B, C, D

A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following? A) "I should take frequent bubble baths." B) "I need to void after sexual intercourse." C) "I should wipe from back to front after going to the bathroom." D) "I need to wear pants that are snug fitting."

B) "I need to void after sexual intercourse."

The nurse prepares to administer an intermittent feeding to a client who has a nasogastric feeding tube. Arrange the following steps in the correct order 1. Verify correct tube placement. 2. Position client with head of bed elevated 30 to 45° degrees 3. Aspirate all gastric contents. 4. Flush tube with 30 mL water. 5. Verify that residual volume is less than 400 mL. 6. Administer the feeding A) 1, 2, 3, 4, 5, 6 B) 2, 1, 3, 5, 4, 6 C) 2, 3, 1, 4, 6, 5 D) 1, 3, 2, 4, 5, 6 E) 1, 4, 2, 3, 5, 6

B) 2, 1, 3, 5, 4, 6

A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A) A clean catheter and rubber gloves B) A sterile catheterization kit or tray C) Solutions to sterilize the urethra D) Solutions to sterilize the vagina

B) A sterile catheterization kit or tray

A client has had frequent watery stools (diarrhea) for an extended period of time. The client also has decreased skin turgor and dark urine. Based on these data, which nursing diagnosis would be appropriate? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Fluid Volume C) Impaired Tissue Integrity D) Impaired Urinary Elimination

B) Deficient Fluid Volume

A nurse is providing discharge instructions for a client with a new colostomy. Which of the following is a recommended guideline for long-term ostomy care? A) During the first six to eight weeks after surgery, eat foods high in fiber. B) Drink at least two quarts of fluids, preferably water, daily. C) Use enteric-coated or sustained-release medications if needed. D) Use a mild laxative if needed.

B) Drink at least two quarts of fluids, preferably water, daily.

A client is admitted to the health care facility with complaints of pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as which of the following? A) Polyuria B) Dysuria C) Nocturia D) Hematuria

B) Dysuria

To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to do which of the following? A) Eliminate high-fiber foods B) Eat foods high in folic acid C) Consume saturated fats D) Consume milk products in the last trimester

B) Eat foods high in folic acid

A nurse has documented that a client has anorexia. What does this term mean? A) Eating more than daily requirements B) Lack of appetite C) Vitamin C deficiency D) Fluid deficit

B) Lack of appetite

A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is ... A) Allergic to sugar B) Lactose intolerant C) Experiencing infectious diarrhea D) Deficient in fiber

B) Lactose intolerant

During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify? A) Constipation B) Perceived constipation C) Risk of constipation D) Bowel incontinence

B) Perceived constipation

A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition? A) Fever, joint pain, dehydration B) Poor wound healing, apathy, edema C) Sleep disturbances, anger, increased output D) Weight gain, visual deficits, erythema of skin

B) Poor wound healing, apathy, edema

The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for this client? A) Risk for activity intolerance B) Risk for impaired skin integrity C) Risk for infection D) Risk for falls

B) Risk for impaired skin integrity

A client is on bedrest, and an enema has been ordered. In what position should the nurse position the client? A) Fowler's B) Sims' C) Prone D) Sitting

B) Sims'

A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client? A) Public embarrassment B) Skin breakdown and UTI C) Inability to control urine D) Odor and leakage

B) Skin breakdown and UTI

A nurse is caring for a client with complaints of chest pain. Which of the following test results would indicate whether the client is at risk for cardiac disease? A) Test results of levels of unsaturated fats B) Test results for dyslipidemia C) Test results of levels of balanced proteins D) Test results of levels of calories in each food intake

B) Test results for dyslipidemia

What is the micturition reflex? A) The process of filtration beginning with the glomerulus B) The act of bladder contraction and perceived need to void C) The reabsorption of the substances the body wants to retain D) The secretion of electrolytes that are harmful to the body

B) The act of bladder contraction and perceived need to void

A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem? A) It is painful to sit on a bedpan. B) The position does not facilitate downward pressure. C) The position encourages the Valsalva maneuver. D) The cause is unknown and requires further study

B) The position does not facilitate downward pressure.

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? A) Urinary incontinence B) Urinary retention C) Involuntary voiding D) Urinary frequency

B) Urinary retention

A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply. A) Vitamins B) Proteins C) Fats D) Minerals E) Carbohydrates

B, C, E

A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching? A) "I need to tell you that I am having my menstrual period." B) "I will void into the specimen bottle you gave me." C) "I will keep the toilet paper in the specimen." D) "I will be sure that no stool is included in my urine."

C) "I will keep the toilet paper in the specimen."

A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior? A) "When he does this, scold him and he will quit." B) "I don't understand why this child is losing control." C) "This is normal when a child this age is hospitalized." D) "I will have to call the doctor and report this behavior."

C) "This is normal when a child this age is hospitalized."

A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? A) "Just give it a few more days and you should be fine." B) "Well, that shouldn't happen. Let me recommend a good laxative for you." C) "When you increase fiber in your diet, you also need to increase liquids." D) "I will tell the doctor you are having problems; maybe he can help."

C) "When you increase fiber in your diet, you also need to increase liquids."

A nurse is helping a client design a weight-loss diet. To lose one pound of fat (3,500 calories) per week, how many calories should be decreased each day? A) 100 B) 250 C) 500 D) 1,000

C) 500

A nurse is educating a client on the amount of water to drink each day. What is the recommended daily fluid intake for adults? A) 1 to 2 (4-oz) glasses per day B) 5 to 6 (6-oz) glasses per day C) 8 to 10 (8-oz) glasses per day D) 16 to 20 (12-oz) glasses per day

C) 8 to 10 (8-oz) glasses per day

Which client will have an increased metabolic rate and require nutritional interventions? A) A healthy young adult who works in an office B) A retired person living in a temperate climate C) A person with a serious infection and fever D) An older, sedentary adult with painful joints

C) A person with a serious infection and fever

A client visits a health care facility with complaints of loss of appetite following a prolonged illness. How should the nurse document the client's condition? A) Emaciation B) Cachexia C) Anorexia D) Nausea

C) Anorexia

A nurse is caring for a client with excessive abdominal fat. Which of the following is a risk associated with excessive abdominal fat about which the nurse should inform the client? A) Emaciation B) Cachexia C) Cardiovascular disease D) Anorexia

C) Cardiovascular disease

A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. B) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. D) Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence.

C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection

A nurse has catheterized a client to obtain urine for measuring post void residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next? A) Report this abnormal finding to the physician. B) Perform another catheterization to verify the amount. C) Document this normal finding for post void residual. D) Palpate the abdomen for a distended bladder.

C) Document this normal finding for post void residual.

What independent nursing intervention can be implemented to stimulate appetite? A) Administer prescribed medications. B) Recommend dietary supplements. C) Encourage or provide oral care. D) Assess manifestations of malnutrition.

C) Encourage or provide oral care.

A nurse is assessing the urine on a newborn's diaper. What would be a normal assessment finding? A) Scanty to no urine B) Highly concentrated urine C) Light in color and odorless D) Dark in color and odorous

C) Light in color and odorless

A nurse is providing care to a client who has undergone a colonoscopy. Which of the following would be most appropriate for the nurse to do after the procedure? A) Avoid giving solid food B) Administer a laxative to the client C) Monitor for rectal bleeding D) Limit oral fluid intake

C) Monitor for rectal bleeding

A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse assesses no feces in the collection bag. What should the nurse do next? A) Notify the physician immediately. B) Ask another nurse to check her findings. C) Nothing; this is normal. D) Recheck the bag in two hours.

C) Nothing; this is normal.

A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? A) Milk B) Eggs C) Oatmeal D) Nuts

C) Oatmeal

A nurse calculates the BMI of a client during a general survey as Under which of the following categories would this 30. client fall? A) Underweight B) Normal C) Overweight D) Obesity Class I

C) Overweight

A nurse is preparing to catheterize a female client. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra? A) Has different innervation B) No connection with bladder C) Shorter in length D) Longer in length

C) Shorter in length

An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea? A) Heart tones B) Lung sounds C) Skin turgor D) Activity level

C) Skin turgor

Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly? A) Hard, formed B) Black, tarry C) Soft, watery D) Dry, odorous

C) Soft, watery

A young woman comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis? A) Routine urinalysis B) Chest x-ray C) Stool sample D) Sputum sample

C) Stool sample

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? A) Condom catheter B) Urinary bag C) Straight catheter D) Retention catheter

C) Straight catheter

A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. Which is a recommended guideline for initiating this training? A) The child should be able to hold urine for four hours. B) The child should be between 18 and 24 months old. C) The child should be able to communicate the need to void. D) The child does not need the desire to gain control of voiding.

C) The child should be able to communicate the need to void.

A client is taking diuretics. What should the nurse teach the client about his urine? A) Urinary output will be decreased. B) Urinary output will be increased. C) Urine will be a pale yellow color. D) Urine may be brown or black.

C) Urine will be a pale yellow color.

A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information? A) "I understand these will help me control stress incontinence." B) "I know this is also called pelvic floor muscle training." C) "I will do these 30 to 80 times a day for two months." D) "I will contract the muscles in my abdomen and thighs."

D) "I will contract the muscles in my abdomen and thighs."

A school nurse is educating a class of middle-school girls on how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information? A) "I will take showers rather than baths." B) "I will wear underpants with cotton crotches." C) "I will tell my parents if I have burning or pain." D) "I will wipe back to front after going to the toilet."

D) "I will wipe back to front after going to the toilet."

A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client's anxiety? A) "We do these procedures every day, so you don't need to worry." B) "I have had this done to me, and it only hurt for a little while." C) "Why are you so worried? Do you think you have a tumor?" D) "Let me explain to you what they do during this procedure."

D) "Let me explain to you what they do during this procedure."

A client is discussing weight loss with a nurse. The patient says, "I will not eat for two weeks, then I will lose at least 10 pounds." What should the nurse tell the client? A) "What a good idea. Go ahead. That will jump start your weight loss!" B) "Many people find that to be an ideal way to lose weight quickly and easily." C) "That will increase your metabolic rate and help you lose weight." D) "That will decrease your metabolic rate and make weight loss more difficult."

D) "That will decrease your metabolic rate and make weight loss more difficult."

A nurse is feeding a client. Which of the following statements would help a person maintain dignity while being fed? A) "I am going to feed you your cereal first, and then your eggs." B) "I wish I had more time so I could feed you all of your meal." C) "I know you don't like me to feed you, but you need to eat." D) "What part of your dinner would you like to eat first?"

D) "What part of your dinner would you like to eat first?"

A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen? A) Pour urine from the collecting bag. B) Remove the catheter and ask the client to void. C) Aspirate urine from the collecting bag. D) Aspirate urine from the collection port.

D) Aspirate urine from the collection port.

What is occult blood? A) Bright red visible blood B) Dark black visible blood C) Blood that contains mucus D) Blood that cannot be seen

D) Blood that cannot be seen

A nurse is discussing infant care with a woman who just had a baby girl. What type of nutrition would the nurse recommend for the infant? A) Solid foods after the first month B) No solid foods until age 1 year C) Bottle feeding with cow's milk D) Breast-feeding or formula with iron

D) Breast-feeding or formula with iron

While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information? A) Change the plan of care to include forcing fluids. B) Ask the client to drink more water during the day. C) Post a sign limiting fluids to 1,000 mL every 24 hours. D) Continue with care; this is a normal fluid intake.

D) Continue with care; this is a normal fluid intake.

A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma? A) Pallor B) Purple-blue C) Irritation and bleeding D) Dark red and moist

D) Dark red and moist

A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? A) Anuria B) Oliguria C) Polyuria D) Dysuria

D) Dysuria

A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora? A) Stool-softening laxatives, such as Colace B) Increasing fluid intake to 3,000 mL/day C) Drinking fluids with a high sugar content D) Eating fermented products, such as yogurt

D) Eating fermented products, such as yogurt

How often would a nurse recommend a client eat or drink a source of vitamin C? A) Once a week B) Once a month C) Three times a week D) Every day

D) Every day

What is the route of administration for TPN? A) Oral B) Subcutaneous C) Intramuscular D) Intravenous

D) Intravenous

A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last in the sequence when conducting an abdominal assessment? A) It is the most painful assessment method B) It is the most embarrassing assessment method C) To allow time for the examiner's hands to warm D) It disturbs normal peristalsis and bowel motility

D) It disturbs normal peristalsis and bowel motility

A client has been prescribed a clear liquid diet. What food or fluids will be served? A) Milk, frozen dessert, egg substitutes B) High-calorie, high-protein supplements C) Hot cereals, ice cream, chocolate milk D) Jell-O, carbonated beverages, apple juice

D) Jell-O, carbonated beverages, apple juice

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client to change? A) Decrease high-fiber foods B) Decrease amount of fluids C) Omit fruits if eating vegetables D) Nothing; this is a good diet

D) Nothing; this is a good diet

nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill? A) Deflate the balloon by aspirating the fluid. B) Ask the client to take several deep breaths. C) Tell the client burning may initially occur. D) Wash hands and put on gloves.

D) Wash hands and put on gloves.

A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine? A) Compare the amount of output with intake. B) Use a clean measuring cup for each voiding. C) Tell the client to wash the urethra before voiding. D) Wear gloves when handling a client's urine.

D) Wear gloves when handling a client's urine.