Foundations Exam 2 Practice Questions

A 72-year-old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to help her get to sleep. What is the nurse's best response?

"Antihistamines should not be used because they can cause confusion and increase your risk of falls."

Which skills can the nurse delegate to assistive personnel (AP)?

- Assist with care of an established tracheostomy tube. - Reposition a patient with a chest tube.

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection?

- Change the dressing using sterile technique. - Change the TPN tubing every 24 hours.

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence?

- Frequent position changes - Using an incontinence cleaner - Applying a moisture barrier ointment

The nurse has just witnessed her patient go into cardiac arrest. The family is in the patient's room at the time the cardiac arrest occurs. What priority interventions should the nurse perform at this time?

- Perform chest compressions. - Ask someone to bring the automatic external defibrillator (AED) to the room for immediate defibrillation. - Place the patient supine.

interventions that may prevent pressure-related injury

- limiting head of bed elevation - repositioning - ROM exercises

The nurse is preparing to perform a blood glucose monitoring test on a patient. Place the steps for performing the procedure in the correct sequence.

1. Instruct patient to perform hand hygiene with soap and water. 2. Check code on test strip vial. 3. Press button on meter to confirm match codes. 4. Perform hand hygiene and put on clean gloves. 5. Clean patient finger with antiseptic swab. 6. Holding lancet to finger, press release button on machine. 7. Bringing meter to test strip, allow blood drop to wick onto test strip. 8. Interpret results and document.

Place the steps when performing wound irrigation of a large open wound in the correct sequence.

1. Place biohazard bag near bed. 2. Fill syringe with irrigation fluid. 3. Attach 19-gauge angiocatheter to syringe. 4. Position angiocatheter over wound. 5.Use slow, continuous pressure to irrigate wound.

prediabetes fasting glucose range

100-125 mg/dL

A client's fasting plasma glucose levels are being evaluated. The nurse identifies that the client is considered to be a diabetic if the results are within which range?

126 to 140 mg/dL (7.0-7.8 mmol/L)

normal fasting glucose range

70-99 mg/dL

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen?

Collect one fecal smear from three separate bowel movements.

What is the removal of devitalized tissue from a wound called?

Debridement

hesitancy

Delay in start of urinary stream when voiding - Causes: anxiety, bladder outlet obstruction

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing:

Depression.

oliguria

Diminished urinary output in relation to fluid intake - Causes: Fluid and electrolyte imbalance (e.g., dehydration), Kidney dysfunction or failure, Increased secretion of antidiuretic hormone (ADH), Urinary tract obstruction

Which nursing intervention decreases the risk for CAUTI?

Hanging the urinary drainage bag below the level of the bladder

The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect?

Lactose intolerance

dysuria

Pain or discomfort associated with voiding - Causes: Urinary tract infection, Inflammation of the prostate, Urethritis, Trauma to the lower urinary tract, Urinary tract tumors

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged?

Patient speaking to nurse

The nurse is caring for a patient with dysphagia and is feeding her a pureed chicken diet. Suddenly the patient begins to choke. What is the priority nursing intervention?

Stop feeding her.

causes of hematuria

Tumors (e.g., kidney, bladder), Infection (e.g., glomerular nephritis, cystitis), Urinary tract calculi, Trauma to the urinary tract

polyuria

Voiding excessive amounts of urine - Causes: High volumes of fluid intake, Uncontrolled diabetes mellitus, Diabetes insipidus, Diuretic therapy

good skin turgor is an indicator of

adequate hydration

when caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration?

elevate the head of the bed between 30 and 45 degrees

hypoglycemia fasting glucose range

less than 70 mg/dL - 40 to 60 mg/dL

normal bowel sounds indicate

peristalsis

which statement by an older adult client about skincare to prevent pressure ulcers indicates a need for further teaching?

"I should apply powders or talc on a perineum wound" - they should NOT do this They SHOULD: - gently pat skin - use mild, heavily fatted soap - wash skin with tepid water, rather than hot water

The nurse recognizes that which statement made by the patient indicates an understanding of sleep-hygiene practices?

"I usually drink a cup of warm milk in the evening to help me sleep."

Which statement made by the parents of a 2-month-old infant requires further education by the nurse?

"I'm going to alternate formula with whole milk, starting next month."

A nurse is taking a sleep history from a patient. The nurse recognizes that which statement made by the patient needs further follow-up?

"It takes me about 45 to 60 minutes to fall asleep."

A mother brings her 4-year-old son into the health clinic for a checkup and tells the nurse practitioner that he is having sleep problems. The nurse practitioner provides teaching on sleep hygiene for toddlers. Which statement made by the mother indicates a need for further teaching?

"We will play hide and seek just before bed to wear him out."

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching?

"When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus."

Which instruction is important for the nurse to include in discharge teaching for a client who has to perform intermittent urinary self-catheterization?

"wash your hands before performing the procedure"

A nurse is teaching a patient about the warning signs of possible colorectal cancer according to the American Cancer Society guidelines. Which statements reflect that the patient understands the teaching?

- "I need to let my doctor know if my bowel habits start to change." - "Blood in the stool is one warning sign I need to look for." - "Some people with colorectal cancer have unexplained abdominal or back pain."

The nurse recognizes that which statements made by a patient indicate an understanding of behaviors that will promote sleep?

- "I will not watch television in bed." - "I will not drink caffeine later in the day." - "I will start to exercise regularly during the day."

retention

- Acute retention: Suddenly unable to void when bladder is adequately full or overfull - Chronic retention: Bladder does not empty completely during voiding, and urine is retained in the bladder

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center?

- Adequate staffing is available on all shifts. - Social activities are available for all residents. - Staff encourage family involvement in care planning and assisting with physical care.

Which nursing actions does the nurse take when placing a bedpan under a patient who is immobilized?

- After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. - Make sure the patient has a nurse call system in reach to notify the nurse when ready to have the bedpan removed.

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient?

- Allow the balloon to drain into the syringe by gravity. - Initiate a voiding record/bladder diary.

A patient is scheduled to have an intravenous pyelogram (IVP) tomorrow morning. Which nursing measures should be implemented before the test?

- Ask the patient about any allergies and reactions. - Ensure that informed consent has been obtained. - Instruct the patient that facial flushing can occur when the contrast medium is given.

A patient with a three-way indwelling urinary catheter and CBI complains of lower abdominal pain and distention after surgery. What should be the nurse's initial intervention(s)?

- Assess the patency of the drainage system. - Measure urine output.

After abdominal surgery, the patient is on the surgical unit with an indwelling urinary catheter placed. What aspects of care for this patient can be delegated to the assistive personnel (AP)?

- Assisting the nurse with patient positioning and maintaining privacy during catheter care - Reporting to the nurse any patient discomfort or fever - Reporting any abnormal color, odor, or amount of urine in the drainage bag

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention?

- Chest retractions - Respiratory rate of 28 breaths per minute - Nasal flaring

Which of the following nursing activities apply to an MDRPI?

- Cushion at risk areas (e.g., ears, nose with foam or protective dressing). - Choose correct size of device. - Observe for erythema or irritation that conforms to pattern or shape of device. - Observe under casts and splints.

A nurse is participating in a health and wellness event at the local community center. A woman approaches with her father and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse asks about his ability to complete activities of daily living (ADLs) by asking which of the following questions?

- Describe any problems you have in sitting or getting up from your toilet. - Tell me how often you take a bath during the week and how you bathe.

Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which of the following interventions reduce the risk for MARSI?

- Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. - Apply adhesive remover. - Use Montgomery ties to secure the dressing.

Which sleep-hygiene actions at bedtime can the nurse delegate to assistive personnel?

- Giving the patient a back rub - Turning on quiet music - Dimming the lights in the patient's room

Which skills does the nurse teach a patient with a new colostomy before discharge from the health care agency?

- How to change the pouch - How to empty the pouch - How to open and close the pouch - How to determine whether the ostomy is healing appropriately

Which instructions does the nurse include when educating a person with chronic constipation?

- Increase fiber and fluids in the diet. - Exercise for 30 minutes every day. - Schedule time to use the toilet at the same time every day.

Which nursing interventions best promote effective sleep in an older adult?

- Limit fluids 2 to 4 hours before sleep. - Ensure that the room temperature is comfortably cool. - Provide warm covers.

What should the nurse teach a young woman with a history of UTIs about UTI prevention?

- Maintain regular bowel elimination. - Wear cotton underwear. - Cleanse the perineum from front to back.

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions?

- Notify the health care provider. - Cover the area with sterile, saline-soaked towels immediately.

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized?

- Plan vital signs to be taken before the patients are asleep. - Have patients follow at-home bedtime schedule. - Close the door to patients' rooms at bedtime.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

- Provision of support to abdominal tissues when coughing or walking - Reduction of stress on the abdominal incision

A nurse sees a 76-year-old woman in the outpatient clinic. The patient states that she recently started to notice a glare in the lights at home. Her vision is blurred, and she is unable to play cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate?

- Refer her to an ophthalmologist. - Suggest large-print books and playing cards. - Assess her home environment for safety.

A daughter is beginning to assume caregiver responsibility for her 90-year-old widowed father. Her father has hypertension, coronary artery disease, and type 2 diabetes mellitus. Home health services are set for once a week. During the first visit, the daughter expresses concern about all the medications that her father has been prescribed by different doctors and that he has obtained from different pharmacies. The daughter states that her father cannot really tell her what each medication is for or when he should take them. From this initial information the nurse suspects polypharmacy. What medication assessment data are needed?

- Review all medication prescriptions - Match medication prescriptions with the patient's medication bottles or unit-dose blister packs - Identify involvement of the caregiver in helping with medication administration - Obtain a listing of any over-the-counter medications

The nurse is caring for a patient with pneumonia, who has severe malnutrition. The patient's condition places her at risk for which of the following life-threatening complications during hospitalization?

- Sepsis - Hemorrhage - Skin breakdown

A nurse is developing a plan for a patient who was diagnosed with narcolepsy. Which interventions should the nurse include on the plan?

- Take brief naps, no longer than 20 minutes, no more than twice a day. - Establish a regular exercise program. - Teach the patient about the side effects of modafinil.

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for their grandchildren as needed, and belongs to numerous church committees. What are the major psychosocial concerns for this patient?

- The loss of his work role - How the wife may now expect assistance with household tasks and with babysitting the grandchildren

A nurse is caring for a 76-year-old female patient in the home setting. She just lost her husband from COVID-19 and has four children who live nearby. The patient was an educator and retired only 2 years ago. The nurse applies knowledge of developmental changes and the nature of loss in older adults when assessing which of the following situations?

- The nature of her relationships with her adult children - The patient's perception of the need for caregiving assistance from the family with activities her husband performed - The impact of her husband's death on her monthly income - The patient's current physical functional status

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient?

- The patient has visible secretions in the airway. - There is a sawtooth pattern on the patient's EtCO2 monitor. - The patient has excessive coughing.

Which of the following are measures to reduce tissue damage from shear?

- Use a transfer device (e.g., transfer board). - Have head of bed flat when repositioning patient. - Raise head of bed 30 degrees when patient is positioned supine.

A 78-year-old male is going through preoperative screening and preparation for his surgery in 1 week. His wife is with him, and initially they both appear anxious. He will be undergoing a colon resection for colon cancer and will have a permanent colostomy. The nurse knows the patient's age and developmental status will affect how the assessment is conducted. The nurse wants to provide a database that will be useful to the nurses in the hospital and therefore applies clinical judgment appropriately through which of the following:

- When the patient has difficult remembering current medications, the nurse asks the wife to supplement information. - The nurse anticipates the effect of the colostomy on functioning and asks the patient how he perceives life with a colostomy.

which nursing interventions require the nurse to wear gloves?

- cleaning a newborn immediately after delivery - emptying a portable wound drainage system

Self-catheterization

- client is taught to wash hands thoroughly with soap and water before inserting a clean catheter - sterile gloves are not required in home care setting - pt should be taught to recognize when self-catheterization is needed and develop a 2-3 hr cath schedule - home care setting may require pt to clean and reuse caths

which factor would the nurse assess for a client reporting constipation?

- diet - fluid intake - use of laxatives - date of last bowel movement - use of opioid pain medications

the nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. Which interventions would the nurse include to decrease the risk of complications?

- examine the feet daily - wear well-fitting shoes - perform regular exercise

which infection prevention technique would be appropriate for the nurse to include when teaching a client being discharged with an indwelling catheter?

- keep the drainage bag below waist level - once a day, the client would wash the first inches of the catheter, starting at the insertion site and moving outward - the foreskin would be replaced as soon as the foreskin has been cleaned and dried - the drainage bag would be cleaned with the vinegar (1) and water (2) solution

the nurse who is working during the 8AM to 4PM shift must document a client's fluid intake and output. An intravenous drip is infusing at 50 mL per hour. The client drinks 4 oz of OJ and 6 oz of tea at 8:30AM and vomits 200 mL at 9AM. At 10AM the client drinks 60 mL of water with medications; the client voids 550 mL of urine at 11AM. At 12:30PM, 3 oz of soup and 4 oz of icecream are ingested. The client voids 450 mL at 2PM. Calculate the total intake for the 8AM-4PM shift

1 oz= 30mL total Intake= 970 mL - vomit and urine output would NOT be included in the client's intake

The nurse is contacting the health care provider about a patient's sleep problem. Place the steps of the SBAR (situation, background, assessment, recommendation) in the correct order.

1. "Dr. Smithson, this is Pam, the nurse caring for Mrs. Dodd. I'm calling because Mrs. Dodd is having difficulty sleeping." 2. Mrs. Dodd, 46 years old, was admitted 3 days ago following a motor vehicle accident. She is in balanced skeletal traction for a fractured left femur. She is having difficulty falling asleep. 3. Mrs. Dodd is taking her pain medication every 4 hours as ordered and rates her pain as 2 out of 10. Last night she was still awake at 0100. She states that she is comfortable but just can't fall asleep. Her vital signs are BP 124/76, P 78, R 12 and T 37.1°C (98.8°F). 4. "I'm calling to ask if you would order a hypnotic such as zolpidem to use on a prn basis."

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.

1. Drape patient with the sterile square and fenestrated drapes. 2. Prepare sterile field and supplies. 3. Lubricate catheter. 4. Cleanse urethral meatus with antiseptic solution. 5. Insert and advance catheter. 6. When urine appears, advance another 2.5 to 5 cm. 7. Inflate catheter balloon. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order.

1. Perform hand hygiene 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 3. Apply sterile gloves 4. Have patient take deep breaths 5. Lubricate catheter with water-soluble lubricant. 6. Advance catheter through nares and into trachea. 7. Apply suction. 8. Withdraw catheter.

Place the steps for an ileostomy pouch change in the correct order.

1. Remove the old pouch. 2. Cleanse and dry the peristomal skin. 3. Assess the stoma and the skin around it. 4. Measure the stoma. 5. Trace the correct measurement onto the back of the wafer. 6. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 7. Press the pouch in place over the stoma. 8. Close the end of the pouch.

What is a critical step when inserting an indwelling catheter into a male patient?

Advance the catheter to the bifurcation of the drainage and balloon ports.

urgency

An immediate and strong desire to void that is not easily deferred - Causes: Full bladder, Urinary tract infection, Inflammation or irritation of the bladder, Overactive bladder

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. The patient lives with her son, is very thin and unkempt, has a Stage 3 pressure injury on her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son, who accompanied her to the hospital. What is the nurse's next step?

Ask the son to step out of the room so that she can complete her assessment.

nocturia

Awakened from sleep because of the urge to void - Causes: Excess intake of fluids (especially coffee or alcohol before bedtime), Bladder outlet obstruction (e.g., prostate enlargement), Overactive bladder, Medications (e.g., diuretic taken in the evening), Cardiovascular disease (e.g., hypertension), Urinary tract infection

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

A patient is receiving an enteral feeding at 65 mL/h. The GRV in 4 hours was 125 mL. What is the priority nursing intervention?

Continue the feedings; this is normal gastric residual for this feeding.

A nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing:

Delirium.

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first?

Elevate the head of the bed to 45 degrees.

Unstageable pressure injury

Full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact, without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Stage 3

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable pressure injury.

Stage 4

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable pressure injury.

The nurse is changing the PN tubing. What action should the nurse take to prevent an air embolus?

Have the patient turn on the left side and perform a Valsalva maneuver

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment?

Initiate a bowel or habit training program to promote continence.

Stage 1

Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep-tissue pressure injury.

dribbling

Leakage of small amounts of urine despite voluntary control of micturition - Causes: Bladder outlet obstruction (e.g., prostatic enlargement), Incomplete bladder emptying, Stress incontinence

The nurse is inserting a urinary catheter for a female patient, and after the catheter has been inserted 3 inches, no urine is returned. What should the nurse do next?

Leave the catheter there and start over with a new catheter.

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider?

New, vigorous bubbling in the water-seal chamber.

Stage 2

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Adipose tissue (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Which action can a nurse delegate to AP?

Performing glucose monitoring every 6 hours on a stable patient

A nurse sees an AP perform the following interventions for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse?

Placing patient supine while giving a bath

hematuria

Presence of blood in urine - Gross hematuria (blood is easily seen in urine) - Microscopic hematuria (blood not visualized but measured on urinalysis)

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day?

Report the time and amount of first voiding.

During the administration of a warm tap-water enema, a patient starts to have cramping abdominal pain that he rates a 6 out of 10. What nursing action should the nurse take first?

Stop the instillation.

frequency

Voiding more than 8 times during waking hours and/or at decreased intervals, such as less than every 2 hour - Causes: high volumes of fluid intake, bladder irritants, UTI, increased pressure on bladder, bladder outlet obstruction, overactive bladder

A patient is receiving both PN and EN. When would the nurse collaborate with the health care provider and request a discontinuation of PN?

When 75% of the patient's nutritional needs are met by the tube feedings

which finding would the nurse identify as normal inflammation versus an infection when assessing a pt's wound that was sutured 72 hrs ago?

a slight red border around the wound is normal inflammation during the first few days - increased temp above 101 F, purulent drainage, and increased pain are all signs of infection

a client reports sleeping until noon every day and taking frequent naps during the rest of the day. Initially, which action would the nurse take?

arrange a referral for a thorough medical evaluation - this is a sign of hypersomnia

the nurse is providing care to a client who is receiving enteral feedings via nasogastric (NG) tube. Which serious complication would the nurse take measures to prevent?

aspiration pneumonia - care should be taken to prevent dislodging of the tube or vomiting - proper positioning of the client with an NG tube would include supine or side-lying, semi-fowler, or higher

which action would the nurse take when observing that a postsurgical client has a urine output of 800 m: total in the first 24 hours after surgery?

document the normal finding - urine output of 800 mL is normal postoperative output since it is more than 30 mL/hour

intravenous fluids are a better source of fluid than

enteral feedings

to prevent an adverse outcome while providing care for a client experiencing diarrhea, which client data would the nurse closely monitor?

fluid and electrolyte balance

when a client's total parenteral nutrition (TPN) bag is empty, which action is appropriate for the nurse to take?

hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag

which intervention would prevent urinary stasis and formation of renal calculi in an immobile client?

increasing oral fluid intake to 2-3 L/day

a 15 yr old adolescent is found to have type 1 diabetes. Which would the nurse include when teaching the adolescent about type 1 diabetes?

it has a more rapid onset than does type 2 diabetes - type 1 diabetes is often first diagnosed during an episode of acute ketoacidosis - type 1 diabetes are insulin dependent

A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. Which action would the nurse take first?

obtain an x-ray to verify that the tube is in the stomach

the nurse is caring for an older adult client who has constipation. Which independent nursing intervention best helps reestablish a normal bowel pattern?

offer a cup of prune juice

when monitoring a client 24 to 48 hours after abdominal surgery, the nurse would assess for which problem associated with anesthetic agents?

paralytic ileus - the nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery

an older adult is returned to the surgical unit after having a subtotal gastrectomy. The nurse anticipates that which dietary modification will be prescribed?

resume small, easily digested feedings gradually

which eye problem is the leading cause of blindness in clients with diabetes?

retinopathy

which statement describes the primary reason why the nurse raises 3 of the 4 side rails on the bed of an 83 yr old client who is postanesthesia for a fractured hip?

the action is a safety measure because of the client's age

an emaciated older adult with dementia develops a large pressure injury after refusing to change position for extended periods. The family blames the nurses and threatens to sue. Which factor is considered when determining the source of blame for the pressure injury?

the client should have been turned regularly (every 2 hrs)

the nurse is preparing discharge instructions for a client who acquired a nosocomial Clostridium difficile infection. Which would the nurse include in the instructions?

the infection causes diarrhea accompanied by flatus and abdominal discomfort - spores are relatively resistant, so cleaning and disinfection of home items is important to prevent spread

normal appearing stools indicate

the intestinal tract is functioning normally

when providing care for a client with diarrhea, in which clinical indicator would the nurse anticipate a decrease?

tissue turgor - skin elasticity will decrease because of a decrease in interstitial fluid

at which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter?

tubing injection port

a client has a stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force?

use lift sheets to pull up, transfer, and position the pt

where would you assess for an air leak in the patient with a chest tube?

water seal chamber

which finding would indicate that the prescribed enteral feeding has been effective in a malnourished client who had head and neck surgery for pharyngeal cancer?

well-healed incisions