funds exam 3 study questions

Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter? 1. Empty the drainage bag at least every 8 hours. 2. Clean up the length of the catheter to the perineum. 3. Use clean technique to obtain a specimen for culture and sensitivity. 4. Place the drainage bag on the client's lap while transporting the client to testing.

ANS: 1 The urinary drainage bag should be emptied at least every 8 hours. If large outputs are noted, more frequent emptying will be required. The perineum should be cleansed and then down the catheter for a length of approximately 10 cm (4 inches). Only use sterile technique to collect specimens from a closed drainage system. Avoid raising the drainage bag above the level of the bladder. If it becomes necessary to raise the bag during transfer of the client to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first. The drainage bag can be attached to the wheelchair below the level of the client's bladder for transport. It should not be placed on the client's lap.

The nurse is caring for a 23-year-old male client who is in the ICU with second and third degree burns over 40 percent of his body. One of the first symptoms that the client is having organ failure is that the urine output is less than: 1. 30 mL/hour 2. 40 mL/hour 3. 50 mL/hour 4. 60 mL/hour

ANS: 1 An output of less than 30 mL/hr indicates possible renal alterations

The nurse is assessing a client admitted with complaints related to chronic kidney dysfunction. The nurse recognizes that this client is most likely to present with which of the resulting symptoms? 1. Anemia 2. Hypotension 3. Diabetes mellitus 4. Clinical depression

ANS: 1 Clients with chronic alterations in kidney function cannot produce sufficient quantities of the hormone erythropoietin; therefore they are prone to anemia. Diabetes mellitus may be a cause of the renal dysfunction, and the client may or may not be depressed. Hypertension, not hypotension, is a typical outcome of kidney dysfunction

A 33-year-old female client in her first trimester of pregnancy complains to the nurse on her prenatal visit that she is needs to urinate more frequently and is concerned about having a urinary tract infection. Which of the following statements would be most appropriate for the nurse to make? 1. Are you having any burning or pain when you urinate? 2. Your uterus is pushing up against your bladder which causes you to have to go more frequently 3. Later in your pregnancy as the baby gets bigger it will be a lot worse 4. It is normal for you to have to urinate more frequently because you are eliminating for two now

ANS: 1 In a pregnant woman the developing fetus pushes against the bladder, reducing the bladder's capacity and causing a feeling of fullness. This effect is more likely to occur in the first and third trimesters. Since the client expressed concern regarding a UTI, the nurse should make further assessments to explore that possibility

A timed urine specimen collection is ordered. The test will need to be restarted if which of the following occurs? 1. The client voids in the toilet. 2. The urine specimen is kept cold . 3. The first voided urine is discarded. 4. The preservative is placed in the collection container

ANS: 1 Missed specimens make the whole collection inaccurate, causing the test to need to be restarted. The urine specimen is kept in a collection container, which may contain preservatives, or the urine may be kept in a collection container on ice. The timed period begins after the client urinates. The first voided urine is discarded, and then the time for collection begins

The nurse caring for a client who is receiving closed catheter irrigation instills 950 mL of normal saline irrigant during the shift. There is a total of 1725 mL in the drainage bag. The nurse calculates the client's urinary output for the shift to be: 1. 775 mL 2. 950 mL 3. 1725 mL 4. 2675 mL

ANS: 1 The amount of fluid used to irrigate the bladder and catheter should be subtracted from the total output to determine an accurate urinary output. 1725 mL 950 mL = 775 mL.

The nurse is discussing signs and symptoms of both upper and lower urinary tract infections with a client who has a history of both. Which of the following statements by the client reflects the best understanding of the differing symptomatology? 1. "When I get cloudy urine, I figure I have an infection." 2. "Burning when I urinate is usually the first symptom I notice." 3. "I have a big problem when I feel like I have the flu but with back pain too." 4. "When I see blood in my urine, I know I need to call my health care provider.

ANS: 3 Clients with lower UTIs have pain or burning during urination (dysuria) as urine flows over inflamed tissues. Fever, chills, nausea, vomiting, and malaise develop as the infection worsens. An irritated bladder (cystitis) causes a frequent and urgent sensation of the need to void. Irritation to bladder and urethral mucosa results in blood-tinged urine (hematuria). The urine appears concentrated and cloudy because of the presence of WBCs or bacteria. If infection spreads to the upper urinary tract (kidneys— pyelonephritis, a serious renal condition), flank pain, tenderness, fever, and chills are common. The remaining options identify general symptoms that are not condition specific.

Which of the following symptomatology is reflective of a lower urinary tract infection? (Select all that apply.) 1. Chills and fever 2. Nausea and vomiting 3. Frequency or urgency 4. Cloudy or blood-tinged urine 5. Pelvic tenderness or flank pain 6. Burning or pain when voiding

ANS: 1, 2, 3, 4, 6 Clients with lower UTIs have pain or burning during urination (dysuria) as urine flows over inflamed tissues. Fever, chills, nausea, vomiting, and malaise develop as the infection worsens. An irritated bladder (cystitis) causes a frequent and urgent sensation of the need to void. Irritation to bladder and urethral mucosa results in blood-tinged urine (hematuria). The urine appears concentrated and cloudy because of the presence of white blood cells (WBCs) or bacteria. If infection spreads to the upper urinary tract (kidneys— pyelonephritis, a serious renal condition), flank pain, tenderness, fever, and chills are common.

The nurse is discussing a middle-age adult male client's report of nocturia. The client has diabetes that is managed with diet and exercise as well as hypertension that is currently well-controlled with medication. The nurse should include which of the following as possible causes for his frequent urination at night? (Select all that apply.) 1. An enlarged prostate gland 2. Poorly controlled blood glucose 3. Drinking a cup of tea before bed 4. Possible side effect of his medication 5. Taking his diuretic too close to bedtime 6. Consuming too many liquids during the day

ANS: 1, 2, 3, 5 Excessive fluid intake before bed (especially coffee or alcohol), renal disease, the aging process, prostate enlargement, poorly controlled diabetes, and diuretic medication therapy scheduled late in the day can cause nocturia. If taken appropriately, his medications are not likely a cause.

The nurse is caring for a client with type 1 diabetes who has been diagnosed with end-stage renal disease (ESRD). The nurse regularly assesses the client for which of the following? (Select all that apply.) 1. Nausea 2. Polyuria 3. Lethargy 4. Vomiting 5. Confusion 6. Headache

ANS: 1, 3, 4, 5, 6 Diseases that cause irreversible damage to kidney tissue result in end-stage renal disease (ESRD). Eventually the client has symptoms resulting from uremic syndrome. An increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, oliguria, nausea, vomiting, headache, drowsiness, coma, and convulsions characterize this syndrome

Which of the following clients presents with an increased risk for urinary incontinence? (Select all that apply.) 1. The 74-year-old diagnosed with parkinsonism 5 years ago 2. The 25-year-old with Crohn's disease diagnosed 4 years ago 3. The 62-year-old Alzheimer's disease client diagnosed 8 years ago 4. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago 5. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago 6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago

ANS: 1, 3, 4, 5, 6 Many diseases and conditions affect the ability to micturate. Diabetes mellitus and multiple sclerosis cause changes in nerve functions that can lead to possible loss of bladder tone, reduced sensation of bladder fullness, or inability to inhibit bladder contractions. Older men often suffer from BPH, which makes them prone to urinary retention and incontinence. Some clients with cognitive impairments, such as Alzheimer's disease, lose the ability to sense a full bladder or are unable to recall the procedure for voiding. Diseases that slow or hinder physical activity interfere with the ability to void. Degenerative joint disease and parkinsonism are examples of conditions that make it difficult to reach and use toilet facilities. Crohn's disease is gastrointestinal in nature and does not directly affect micturition.

The nurse suspects that the client has a bladder infection based on the client's exhibiting an early sign or symptom such as: 1. Chills 2. Hematuria 3. Flank pain 4. Incontinence

ANS: 2 Irritation to the bladder and urethral mucosa results in blood-tinged urine (hematuria). Hematuria is a sign of a bladder infection. Chills are a more systemic symptom associated with pyelonephritis. Flank pain is a more systemic symptom associated with pyelonephritis. Incontinence is not a symptom of a bladder infection

The nurse is caring for a 56-year-old female client with renal failure who regularly undergoes peritoneal dialysis. The nurse understands that this client is most at risk for: 1. Pulmonary embolism 2. Electrolyte imbalances 3. Polyuria 4. Urinary incontinence

ANS: 2 Peritoneal dialysis is an indirect method of cleansing the blood of waste products using osmosis and diffusion with the peritoneum functioning as a semipermeable membrane. This method removes excess fluid and waste products from the bloodstream when a sterile electrolyte solution (dialysate) is instilled into the peritoneal cavity by gravity via a surgically placed catheter. The dialysate remains in the cavity for a prescribed time interval and then is drained out by gravity, taking accumulated wastes and excess fluid and electrolytes with it. This places the client at risk for electrolyte imbalances.

The nurse is aware that clients with chronic alterations in kidney function suffer from insufficient amounts of: 1. Vitamin A 2. Vitamin D 3. Vitamin E 4. Vitamin K

ANS: 2 The kidneys play a role in calcium and phosphate regulation by producing a substance that converts vitamin D into its active form. Clients with chronic alterations in kidney function do not make sufficient amounts of the active vitamin D. Clients with chronic alterations in kidney function do not suffer from an insufficient amount of vitamin A, vitamin E, or vitamin K.

A client with an excessive alcohol intake has a reduced amount of antidiuretic hormone (ADH). The nurse anticipates the client will exhibit: 1. Hematuria 2. An increased blood pressure 3. Dry mucous membranes 4. A low serum sodium level

ANS: 3

A condom catheter is to be used for an adult male client in the extended care facility. In the application of the condom catheter, the nurse employs appropriate technique when: 1. Using sterile gloves 2. Wrapping the adhesive tape securely around the base of the penis 3. Leaving a 1- to 2-inch space between the tip of the penis and the end of the catheter 4. Taping the tubing tightly to the thigh and attaching the drainage bag to the bed frame

ANS: 3 A 1- to 2-inch space should be left between the tip of the penis and the end of the catheter. Nonsterile gloves are worn to apply a condom catheter. Standard adhesive tape should never be used to secure a condom catheter because it does not expand with change in penis size and is painful to remove. The tubing of a condom catheter is not taped tightly to the thigh. The drainage bag is attached to the lower bed frame

The nurse caring for a client in an extended care facility should provide which intervention in a bladder retraining program? 1. Providing negative reinforcement when the client is incontinent 2. Having the client wear adult diapers as a preventative measure 3. Putting the client on a q2h toilet schedule during the day 4. Promoting the intake of caffeine to stimulate voiding

ANS: 3 A bladder retraining program includes initiating a toileting schedule on awakening, at least every 2 hours during the day and evening, before getting into bed, and every 4 hours at night. Negative reinforcement should not be used when the client is incontinent. However, positive reinforcement should be provided when continence is maintained. The client should be offered protective undergarments to contain urine and reduce the client's embarrassment (not diapers). Tea, coffee, other caffeine drinks, and alcohol should be minimized.

The nurse is discussing urinary elimination alterations with a group of middle-age adults. The nurse appropriately shares with the group that whereas men experience urinary frequency as a result of prostate enlargement, the female: 1. Is more affected if she has experienced multiple pregnancies 2. Does not usually experience urinary problems until much later in life 3. Experiences an increased risk for urinary tract infections related to menopause 4. Appears to have less risk for kidney infections because of gradually declining estrogen levels

ANS: 3 Aging often impairs micturition. In the male, prostate enlargement usually begins during the 40s and continues throughout life, resulting in urinary frequency and possible urinary retention. In women, changes in the urethral mucosa associated with loss of estrogen during and after menopause contribute to increased susceptibility to UTIs. Although pregnancies may affect urinary continence, decreased estrogen levels do not protect against kidney infections.

When calculating the daily intake and output, the nurse anticipates that the urinary output for an average adult should be: 1. 800 to 1000 mL/day 2. 1000 to 1200 mL/day 3. 1500 to 1600 mL/day 4. 2000 to 2300 mL/day

ANS: 3 Although output does depend on intake, the normal adult urine output is 1500 to 1600 mL/day

Which of the following clients will most benefit from client/parent education regarding the prevention of renal infections via proper hygiene habits? 1. Males ages 35 to 65 2. Males ages 3 to 16 3. Females ages 3 to 12 4. Females ages 20 to 50

ANS: 3 The 3- to 12-year-old female has the shortest urethra and so has the greatest need. The short length of the urethra predisposes women and girls to infection. It is easy for bacteria to enter the urethra from the perineal area.

A postpartum client has been unable to void since her delivery of her baby this morning. Which of the following nursing measures would be beneficial for the client initially? 1. Increase fluid intake to 3500 mL. 2. Insert indwelling Foley catheter. 3. Rinse the perineum with warm water. 4. Apply firm pressure over the bladder.

ANS: 3 The nurse can pour warm water over the client's perineum and create the sensation to urinate. A client with normal renal function who does not have heart or kidney disease should drink 2000 to 2500 mL of fluid daily. Increasing the client's fluid intake to 3500 mL is excessive. Because bladder catheterization carries the risk for UTI, it should be avoided if possible. The nurse should try other noninvasive measures to promote urination before calling the health care provider for an order to insert a Foley catheter. The nurse should not apply firm pressure over the bladder of a postpartum woman with an intact nervous system. The nurse could create more damage by exerting force on the client's uterus at this time

In an assessment of a client with reflex incontinence the nurse expects to find that the client has: 1. A constant dribbling of urine 2. An uncontrollable loss of urine when coughing or sneezing 3. No urge to void and an unawareness of bladder filling 4. An immediate urge to void but not enough time to reach the bathroom

ANS: 3 The nurse expects to find the client with reflex incontinence to have no urge to void and an unawareness of bladder filling. A constant dribbling of urine may be seen with overflow incontinence. With stress incontinence the client is unable to control loss of urine when coughing or sneezing. Functional incontinence is seen when there is an immediate urge to void but not enough time to get to the bathroom

Which of the following actions by the nurse would indicate the need for remedial education in the removal of an indwelling catheter? 1. Draping the female client between the thighs 2. Obtaining a specimen before removal 3. Cutting the catheter to deflate the balloon 4. Checking the client's output for 24 hours after removal

ANS: 3 The nurse should not cut the catheter to deflate the balloon. The nurse inserts an empty, sterile syringe into the injection port. The nurse slowly withdraws all of the solution to deflate the balloon totally. The nurse then pulls the catheter out smoothly and slowly. The nurse positions the client in the same position as during catheterization. The nurse places a towel between a female client's thighs or over a male client's thighs. Some institutions recommend collecting a sterile urine specimen before removal of the catheter or sending the catheter tip for culture and sensitivity tests. The nurse should assess the client's urinary function by noting the first voiding after catheter removal and documenting the time

The nurse is caring for an older adult who is recovering from hip replacement surgery. The client shares with the nurse that he has been using the urinal "a lot but I feel like my bladder isn't empty." Which of the following statements by the nurse shows the best understanding of the appropriate initial intervention for this particular client? 1. "I'll call your primary care provider and let her know you are having this problem." 2. "I have the ancillary personnel measure your output, so please don't empty your urinal yourself." 3. "I'm going to ask that you please use your call bell and notify me or the ancillary staff each time you void." 4. "I suggest that we try limiting the amount of fluids you are drinking for a few hours and see if that helps."

ANS: 3 With retention the client may void small amounts of urine 2 or 3 times an hour with no real relief of discomfort or may continually dribble urine. Be aware of the volume and frequency of voiding to assess this condition in the client. The alert, oriented client can be asked to notify the nurse each time micturition occurs. The notification of the primary care provider is not the initial intervention. Although measuring the urine output is not inappropriate, it is not specific to this client's complaint. Restricting fluids is neither appropriate nor likely to affect the problem

The nurse is working with a client who has a urinary diversion. Included in the plan of care for this client is instruction that: 1. Special clothing will need to be ordered in order to fit around the diversion 2. A stomal bag will only need to be worn at night 3. A reduction in physical activity will be planned 4. Special skin care is a priority

ANS: 4

Urinary elimination may be altered with different pathophysiological conditions. For the client with diabetes mellitus, the nurse anticipates that an initial urinary sign or symptom will be: 1. Urgency 2. Dysuria 3. Hematuria 4. Polyuria

ANS: 4

The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of: 1. The impaired cognitive state the client will experience as the effects of the anesthesia wear off 2. The decreased volume of orally ingested fluids before, during, and after the surgical procedure 3. The length of time the client was under the effects of general anesthesia required for the surgical procedure 4. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder

ANS: 4 Medications, including anesthesia, interfere with both the production and the characteristics of urine and affect the act of urination. The remaining options may affect urination but not to the extent of the anesthetic effects

The nurse determines that the nursing diagnosis stress urinary incontinence related to decreased pelvic muscle tone is the most appropriate for an oriented adult female client. A therapeutic nursing intervention based on this diagnosis is to: 1. Apply adult diapers 2. Catheterize the client 3. Administer Urecholine 4. Teach Kegel exercises

ANS: 4 Pelvic floor exercises, also known as Kegel exercises, improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups. These exercises have demonstrated effectiveness in treating stress incontinence, overactive bladders, and mixed causes of urinary continence. The client is oriented and therefore could be taught Kegel exercises to improve pelvic floor muscle tone. Applying adult diapers does not improve the client's problem of incontinence and places the client at risk for skin breakdown. Because bladder catheterization carries the risk for urinary tract infection (UTI), it is preferable to rely on other measures for management of incontinence. The nurse can support the use of Kegel exercises as an inexpensive nonpharmacological intervention to reduce the client's stress incontinence. Bethanechol (Urecholine) stimulates the parasympathetic nervous system to promote complete bladder emptying and is primarily used to treat urinary retention and possible overflow incontinence. Nonpharmacological approaches should be attempted before pharmacological approaches are taken

A 46-year-old male client with chronic renal problems is in the hospital for a nephrostomy. The nurse understands that this is the surgical insertion of a tube that will drain urine from the client's: 1. Bladder 2. Urethra 3. Ureters 4. Renal pelvis

ANS: 4 Some clients have a need for urinary drainage directly from one or both kidneys. In this case a tube placed directly into the renal pelvis. This procedure is called a nephrostomy

Which of the following nursing interventions is most specific for a client being monitored for possible urinary retention? 1. Measuring urine output with each urination 2. Monitoring the color and clarity of urine with each voiding 3. Collecting a urine sample for a culture and sensitivity test 4. Asking the cognizant client to report each time he or she urinates

ANS: 4 With retention the client may void small amounts of urine 2 or 3 times an hour with no real relief of discomfort or may continually dribble urine. Be aware of the volume and frequency of voiding to assess this condition in the client. The alert, oriented client can be asked to notify the nurse each time micturition occurs. The remaining options are more generalized or specific for a urinary tract infection

The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit: 1. Severe flank pain and hematuria 2. Pain and burning on urination 3. A loss of the urge to void 4. A feeling of pressure and voiding of small amounts

ANS: 4 With urinary retention, urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the symphysis pubis, restlessness, and diaphoresis. The sphincter temporarily opens to allow a small volume of urine (25 to 60 mL) to escape, with no real relief of discomfort. Severe flank pain and hematuria are supporting data for an upper urinary tract infection (pyelonephritis). Pain and burning on urination are symptoms of a lower urinary tract infection (such as a bladder infection). Supportive data for reflex incontinence would include a loss of the urge to void

A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. "If I get a blue color that means the test is negative." b. "I should not get any urine on the stool I am testing." c. "If I eat red meat before my test, it could give me false results." d. "I should check with my doctor to stop taking aspirin before the test."

ANS: A A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not contaminated with urine. The patient needs to avoid certain foods, like red meat, to rule out a false positive. While the health care provider should be consulted before asking a patient to stop any medication, if there are no contraindications, the patient should be instructed to stop taking aspirin, ibuprofen, naproxen, or other nonsteroidal antiinflammatory drugs for 7 days because these could cause a false-positive test result

A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected? a. Perceptual b. Cognitive c. Affective d. Social

ANS: A Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems include boredom and restlessness; the patient is participating in an activity. The patient is interacting with the home health nurse, so socialization is not a problem.

The nurse is describing the ChooseMyPlate program to a patient. Which statement from the patient indicates successful learning? a. "I can use this to make healthy lifestyle food choices." b. "I can use this to count specific calories of food." c. "I can use this for my baby girl." d. "I can use this when I am sick.

ANS: A ChooseMyPlate serves as a basic guide for making food choices for a healthy lifestyle. The ChooseMyPlate program was developed by the U.S. Department of Agriculture to replace the MyFoodPyramid program. It helps balance calories but does not provide specific calories of food. These guidelines are for Americans over the age of 2 years. These guidelines are provided for health, not sickness

A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take? a. Offer the patient a back rub. b. Hang a "Do not disturb" sign on patient's door. c. Ask the patient "Would you like a newspaper to read?" d. Place the patient in the room farthest from the nurses' station.

ANS: A Comfort measures such as washing the face and hands and providing back rubs improve the quality of stimulation and lessen the chance of sensory deprivation. The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage helps establish a humanistic relationship that the patient is missing. All of the other options do not promote patient-nurse interaction and promote further social isolation

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Lecture and discussion d. Reading assignment with a written summary

ANS: A Concept mapping challenges the student to synthesize data and identify relationships between nursing diagnoses. The primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data

A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by an assistive personnel (NAP) demonstrates understanding of the needs of this patient? a. Dressing the left side first b. Dressing the right side first c. Dressing the lower extremities first d. Dressing the upper extremities firs

ANS: A Dressing the left side first will be reinforced by the nurse. If a patient has partial paralysis and reduced sensation, the patient dresses the affected side first; in this case, the left. A stroke on the right hemisphere affects the left side of the body. The right side or upper and lower extremities are not as effective

A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment? a. Impaired night vision b. Difficulty hearing low pitch c. Heightened sense of smell d. Increased taste discrimination

ANS: A Night vision becomes impaired as physiological changes in the aging eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging

The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority? a. Hearing b. Vision c. Smell d. Taste

ANS: A Some antibiotics (e.g., streptomycin, gentamicin, and tobramycin) are ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Smell and taste are not as affected.

A patient is using laxatives 3 times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

ANS: A Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed

A nurse is assessing cognitive functioning of a patient. Which action will the nurse take? a. Administer a Mini-Mental State Examination (MMSE). b. Ask the patient to state name, location, and what month it is. c. Ask the patient's family if the patient is behaving normally. d. Administer the hearing handicap inventory for the elderly (HHIE-S)

ANS: A The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitive functioning. The Mini-Mental State Examination (MMSE) is a tool you can use to measure disorientation, change in problem-solving abilities, and altered conceptualization and abstract thinking. Asking the patient orientation questions evaluates only the patient's orientation to self and surroundings, not abstract reasoning or critical thinking ability. Family members are not the most reliable source of information about the patient, although information received from the family should be considered. The HHIE-S is a 5-minute, 10-item questionnaire that assesses how the individual perceives the social and emotional effects of hearing loss. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment.

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explore other options for pain relief. b. Discuss the surgical procedure and reason for the pain. c. Explain to the patient that nothing else has been ordered. d. Offer to notify the health care provider after morning rounds are completed.

ANS: A The critically thinking nurse should explore all options for pain relief first. The nurse should use critical thinking to determine the cause of the pain and determine various options for pain, not just ordered pain medications. The nurse can act independently to determine all options for pain relief and does not have to wait until after the health care provider rounds are completed. Explaining the cause of the pain does not address options for pain relief

A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion? a. Cecum, ascending, transverse, descending, sigmoid, and rectum b. Ascending, transverse, descending, sigmoid, rectum, and cecum c. Cecum, sigmoid, ascending, transverse, descending, and rectum d. Ascending, transverse, descending, rectum, sigmoid, and cecum

ANS: A The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination

Which patient is demonstrating a refractive error sensory problem? a. A patient who frequently reports the incorrect time from the clock across the room. b. A patient who is having difficulty remembering how to perform familiar tasks. c. A patient who turns the television up as loud as possible. d. A patient who has trouble saying words

ANS: A The most common visual problem is a refractive error such as nearsightedness. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental and cognitive status. Turning the television up louder indicates the need for a hearing assessment. For a patient having trouble saying words a picture board/chart may be used.

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding? a. Hypoactive bowel sounds b. Increased fluid intake c. Soft tender abdomen d. Jaundice in sclera

ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. Increased fluid intake would help the problem; a decreased intake can lead to constipation. Jaundice does not occur with constipation but can occur with liver disease

The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit? a. Xerostomia b. Dysequilibrium c. Diabetic retinopathy d. Peripheral neuropathy

ANS: A Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns. Dysequilibrium is balance. Diabetic retinopathy affects vision. Peripheral neuropathy includes numbness and tingling of the affected areas and stumbling gait

Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) a. Tense muscles b. Reactive responses c. Trouble concentrating d. Feeling very tired e. Managed emotions

ANS: A, B, C, D Learn to recognize when you are feeling stressed—your muscles will tense, you become reactive when others communicate with you, you have trouble concentrating, and you feel very tired. Emotions are not managed when stressed

To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select all that apply.) a. Allows fasting on Yom Kippur for a Jewish patient. b. Allows caffeine drinks for a Mormon patient. c. Serves no ham products to a Muslim patient. d. Serves kosher foods to a Christian patient. e. Serves no meat or fish to a Hindu patient.

ANS: A, C, E The Jewish religion fasts 24 hours on Yom Kippur and must adhere to kosher food preparation methods. Hinduism requires no meats or fish. Muslims do not eat pork. Mormons do not drink caffeinated or alcoholic drink

A nurse is working to prevent blindness. Which preventive action is a priority? a. Screen young adults early for visual impairments. b. Include rubella and syphilis screening in the preconception care plan. c. Instruct parents to report reduced eye contact from their child immediately. d. Administer eye prophylactic antibiotics to newborns within 24 hours after birth

ANS: B Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases such as rubella, syphilis, chlamydia, and gonorrhea that affect development of vision in the fetus is a preventative measure. Vision testing after birth is important to begin steps to correct or identify the problem early on so the child can develop as normally as possible; waiting until children are young adults is too late. Another technique is administering eye prophylaxis in the form of erythromycin ointment approximately 1 hour after an infant's birth. Reporting reduced eye contact is recommended but is not a preventative measure

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Malodorous stool d. Continuous output from the stoma

ANS: B Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous

A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? a. Position in semi-Fowler's. b. Flex head with chin down. c. Place food on left side. d. Offer fruit juice.

ANS: B Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the patient has unilateral weakness, teach him or her and the caregiver to place food in the stronger side of the mouth. Provide a 30-minute rest period before eating and position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. Thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated

A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? a. Refusing the assignment b. Asking for an orientation to the unit c. Admitting lack of knowledge and going home d. Assuming that patient care will be the same as on the other units

ANS: B Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility but going home does not illustrate an example of responsibility

The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning? a. Asks the nurse to test the temperature of the water before entering the bath. b. Places colored stickers on faucet handles to indicate temperature. c. Replaces all lace-up shoes with Velcro straps for ease. d. Uses a heating pad on a low setting to keep warm

ANS: B If a patient with tactile deficits also has a visual impairment, it is important to be sure that water faucets are clearly marked "hot" and "cold," or use color codes (i.e., red for hot and blue for cold). Discourage the use of heating pads in this population. Asking the nurse to test the water does not promote independence, although it does promote safety. Velcro is easier for a patient with a tactile deficit to manipulate and promotes self-care but not safety.

Before being administered a cleansing enema an 80-year-old patient says "I don't think I will be able to hold the enema." Which is the next priority nursing action? a. Rolling the patient into right-lying Sims' position b. Positioning the patient in the dorsal recumbent position on a bedpan c. Inserting a rectal plug to contain the enema solution after administering d. Assisting the patient to the bedside commode and administering the enema

ANS: B If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims' position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe

The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding? a. Nasogastric tube b. Jejunostomy tube c. Nasointestinal tube d. Percutaneous endoscopic gastrostomy (PEG) tube

ANS: B Patients with gastroparesis or esophageal reflux or with a history of aspiration pneumonia may require placement of tubes beyond the stomach into the intestine. The jejunostomy tube is the only tube in the list that is beyond the stomach and is not contraindicated by facial trauma. The nasogastric tube and the PEG tube are placed in the stomach, and placement could lead to aspiration. The nasointestinal tube and the nasogastric tube may be contraindicated by facial trauma and the broken nose

Which action indicates a registered nurse is being responsible for making clinical decisions? a. Applies clear textbook solutions to patients' problems. b. Takes immediate action when a patient's condition worsens. c. Uses only traditional methods of providing care to patients. d. Formulates standardized care plans solely for groups of patients

ANS: B Registered nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Most patients have health care problems for which there are no clear textbook solutions. Care plans should be individualized for each patient, not just for groups

The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift? a. Expressive b. Receptive c. Global d. Motor

ANS: B Sensory or receptive aphasia is the inability to understand written or spoken language. A patient is able to express words but is unable to understand questions or comments of others. Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. Global aphasia is the inability to understand language or communicate orally

A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What form of energy is the nurse discussing? a. Resting energy expenditure (REE) b. Basal metabolic rate (BMR) c. Nutrient density d. Nutrients

ANS: B The basal metabolic rate (BMR) is the energy needed at rest to maintain life-sustaining activities for a specific period of time. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High-nutrient density foods provide a large number of nutrients in relation to kilocalories.

In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient? a. Insulin is the only consideration that must be taken into account. b. Saturated fat should be limited to less than 7% of total calories. c. Nonnutritive sweeteners can be used without restriction. d. Cholesterol intake should be greater than 200 mg/day

ANS: B The diabetic patient should limit saturated fat to less than 7% of total calories and cholesterol intake to less than 200 mg/day. Type 1 diabetes requires both insulin and dietary restrictions for optimal control. Nonnutritive sweeteners can be eaten as long as the recommended daily intake levels are followed.

While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? a. Postpone catheter insertion until the next shift. b. Adapt the positioning technique to the situation. c. Notify the health care provider for a urologist consult. d. Follow textbook procedure with contraindicated position

ANS: B The nurse must use critical thinking skills in this situation to adapt positioning technique. In practice, patient procedures are not always presented as in a textbook, but they are individualized. A urologist consult is not warranted for positioning problems. Postponing insertion of the catheter is not an appropriate action

A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? a. Patient's outcomes for learning b. Nurse's assumptions about hospital discharge c. Identification of several actual health problems d. Documentation of patient's ability to meet the goa

ANS: B The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The purpose of the nursing process is to diagnose and treat human responses (e.g., patient symptoms, need for knowledge) to actual or potential health problems. Use of the process allows nurses to help patients meet agreed-on outcomes for better health. The patient's outcomes, having several actual health problems, and a description of the patient's abilities to meet the goal are all appropriate to document in the nursing plan of care

A nurse is caring for a group of patients. Which patient will the nurse see first? a. Patient receiving total parenteral nutrition of 2-in-1 for 50 hours b. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours c. Patient receiving continuous enteral feeding with same feeding bag for 12 hours d. Patient receiving continuous enteral feeding with same tubing for 24 hours

ANS: B The nurse should see the patient with total parenteral nutrition that has the same tubing for 26 hours. To prevent infection, change the TPN infusion tubing every 24 hours. Change the administration system every 72 hours when infusing a 2-in-1 solution and every 24 hours for a 3-in-1 solution. Change bag and use a new administration set every 24 hours for a continuous enteral feeding. While the patient with the continuous enteral feeding has the same tubing for 24 hours, it has not extended the time like the total parenteral nutrition has

A patient is having difficulty reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? a. Humility b. Creativity c. Risk taking d. Confidence

ANS: B The nurse uses creativity in this situation to figure out how the patient can safely get a drink of water. Humility is recognizing when more information is needed to make a decision. Confidence is being well prepared to perform nursing care safely. This question best illustrates the attitude of creativity. Risk taking is demonstrating the courage to speak out or to question orders based on the nurse's own knowledge base

A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested? a. Improperly home-canned food b. Undercooked ground beef c. Soft cheese d. Custard

ANS: B Undercooked ground beef is the usual food source for E. coli. Botulism is associated with improperly home-canned foods. Soft cheese is the usual food source for listeriosis. Custards are associated with salmonellosis and Staphylococcus

1. Which action should the nurse take when using critical thinking to make clinical decisions? a. Makes decisions based on intuition. b. Accepts one established way to provide care. c. Considers what is important in any given situation. d. Reads and follows the heath care provider's orders

ANS: C A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Patient care can be provided in many ways. The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Following health care provider's orders is not considered a critical thinking skill. If your knowledge causes you to question a health care provider's order, do so

A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A child about to receive a normal saline enema b. A teenager about to receive loperamide for diarrhea c. A dehydrated older patient about to receive a hypertonic enema d. A middle-aged patient with myocardial infarction about to receive docusate sodium

ANS: C A hypertonic enema is contradicted in a dehydrated patient since it will pull fluid out of the body; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for diarrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent straining

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is flush with the skin. c. Stoma is purple. d. Stoma is moist.

ANS: C A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude.

The nurse performing a fecal occult blood test should take what action? a. Test the quality control section before testing the stool specimens. b. Apply liberal amounts of stool to the guaiac paper. c. Report a positive finding to the provider. d. Don sterile disposable gloves

ANS: C Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative

The patient diagnosed with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful? a. Maintain a prescribed carbohydrate intake. b. Eat fish at least 5 times/week. c. Limit cholesterol to less than 300 mg/daily. d. Avoid high-fiber foods.

ANS: C American Heart Association guidelines recommend limiting cholesterol to less than 300 mg/day. Diet therapy includes eating fish at least 2 times per week and eating whole grain high-fiber foods. Maintaining a prescribed carbohydrate intake is necessary for diabetes mellitus

Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a. Administering pain-relief medication according to what was given last shift b. Offering pain-relief medication based on the health care provider's orders c. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past d. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed

ANS: C Asking the patient what pain-relief methods have worked in the past is an example of exploring many options for pain relief. Nonpharmacological pain-relief methods are available, as are medications for pain. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on assigned patients and intervene accordingly. Pain is subjective. The nurse should offer pain-relief methods based on the patient's reports without being judgmental

The nurse will anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Endoscopy d. Anorectal manometry

ANS: C Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization

A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool? a. Bright red blood b. Dark black blood c. Microscopic d. Mucoid

ANS: C Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic). This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood, dark black blood, and blood that contains mucus (mucoid) is not the purpose of a guaiac test

In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother? a. Calcium intake is especially important in the first trimester. b. Protein intake needs to decrease to preserve kidney function. c. Folic acid is needed to help prevent birth defects and anemia. d. Extra vitamins and minerals should be taken as much as possible

ANS: C Folic acid intake is particularly important for DNA synthesis and growth of red blood cells. Inadequate intake may lead to fetal neural tube defects, anencephaly, or maternal megaloblastic anemia. Protein intake throughout pregnancy needs to increase to 60 g daily. Calcium intake is especially critical in the third trimester, when fetal bones mineralize. Prenatal care usually includes vitamin and mineral supplementation to ensure daily intakes; however, pregnant women should not take additional supplements beyond prescribed amounts.

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea? a. Antibiotic therapy b. Clostridium difficile c. Formula intolerance d. Bacterial contamination

ANS: C Hyperosmolar formulas can cause diarrhea or formula intolerance. If that is the case, the solution is to lower the rate, dilute the formula, or change to an isotonic formula. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allowing for C. difficile toxin buildup. However, this takes time (more than 2 hours), and no indication suggests that this patient is on antibiotics. Bacterial contamination of the feeding usually occurs when feedings are left hanging for longer than 8 hours

In general, when a patient's energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? a. Weight increases. b. Weight decreases. c. Weight does not change. d. Weight fluctuates daily

ANS: C In general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change. When kilocalories ingested exceed a person's energy demands, the individual gains weight. If kilocalories ingested fail to meet a person's energy requirement, the individual loses weight. Fluid, not kilocalories, causes daily weight fluctuations

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? a. Evaluation b. Explanation c. Interpretation d. Self-regulation

ANS: C Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data. This nurse is clarifying the data in this situation. Evaluation involves determining the effectiveness of interventions or care provided. The nurse in this scenario is assessing the patient, not evaluating interventions. Self-regulation is reflecting on experiences. Explanation is supporting findings and conclusions. The nurse in this question is clarifying uncertain data (determining cause of the low pulse), not supporting the finding of a low pulse

A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for vision, beginning with the first structure? 1. Lens 2. Pupil 3. Retina 4. Cornea 5. Optic nerve a. 2, 1, 4, 5, 3 b. 1, 2, 4, 3, 5 c. 4, 2, 1, 3, 5 d. 5, 2, 4, 1, 3

ANS: C Light rays enter the convex cornea and begin to converge. An adjustment of light rays occurs as they pass through the pupil and lens. Change in the shape of the lens focuses light on the retina. The sensory retina contains the rods and cones (i.e., photoreceptor cells sensitive to stimulation from light). Photoreceptor cells send electrical potentials by way of the optic nerve to the brain

Which action should the nurse take to best develop critical thinking skills? a. Study 3 hours more each night. b. Attend all in-service opportunities. c. Actively participate in clinical experiences. d. Interview staff nurses about their nursing experiences.

ANS: C Nursing is a practice discipline. Clinical learning experiences are necessary to acquire clinical decision-making skills. Studying for longer hours, interviewing nurses, and attending in-services do not provide opportunities for clinical decision making, as do actual clinical experiences.

A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse "Should I stop driving?" Which response by the nurse is most therapeutic? a. "Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk." b. "Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident." c. "No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go." d. "No, instead you should see your ophthalmologist and get some glasses to help you see better.

ANS: C Part of the normal aging process is reduced ability to see colors. The nurse should teach the patient new ways to adapt to this deficit. This patient's accident was not due to impaired cognitive function or reflexes. Glasses will not assist the patient in color discrimination.

A nurse is caring for a patient diagnosed with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit? a. The patient frequently cleans out eyes with saline washes. b. The patient applies different spices during mealtime to food. c. The patient turns one ear toward the nurse during conversation. d. The patient isolates self from social situations with groups of people

ANS: C Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indicates that the patient alters behavior to accommodate for the sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive

Which action demonstrates a nurse utilizing reflection to improve clinical decision making? a. Obtains data in an orderly fashion. b. Uses an objective approach in patient situations. c. Improves a plan of care while thinking back on interventions effectiveness. d. Provides evidence-based explanations and research for care of assigned patients

ANS: C Reflection utilizes critical thinking when thinking back on the effectiveness of interventions and how they were performed. It involves purposeful thinking back or recalling a situation to discover its purpose or meaning. The other options are not examples of reflection but do represent good nursing practice. Using an objective approach and obtaining data in an orderly fashion do not involve purposefully thinking back to discover the meaning or purpose of a situation. Providing evidence-based explanations for nursing interventions does not always involve thinking back to discover the meaning of a situation

A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a. Examine the meaning of data. b. Support findings and conclusions. c. Review the effectiveness of nursing actions. d. Search for links between the data and the nurse's assumptions

ANS: C Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurse's assumptions describes analysis

Which assessment finding is consistent with the diagnosis of malnutrition? a. Moist lips b. Pink conjunctivae c. Spoon-shaped nails d. Not easily plucked hair

ANS: C Spoon-shaped nails, koilonychia, is an indication of poor nutrition. All the others are normal findings. Lips should be moist, conjunctivae should be pink, and hair should not be easily plucked

The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do? a. Increase the rate to get the volume caught up before discontinuing. b. Stop the infusion as ordered. c. Taper infusion gradually. d. Hang 5% dextrose

ANS: C Sudden discontinuation of PN can cause hypoglycemia. PN must be tapered off. Usually, 10% dextrose is infused when PN solution is suddenly discontinued. Too rapid administration of hypertonic dextrose (PN) can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? a. Sigmoid b. Transverse c. Ascending d. Descending

ANS: C The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool (very liquid) would be in the ascending

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)? a. Performing the first postoperative pouch change b. Maintaining a nasogastric tube c. Administering an enema d. Digitally removing stool

ANS: C The skill of administering an enema can be delegated to an AP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an AP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel

A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1. Elevate head of bed to at least 30 degrees. 2. Check for gastric residual volume. 3. Flush tubing with 30 mL of water. 4. Verify tube placement. 5. Initiate feeding a. 4, 2, 1, 5, 3 b. 2, 4, 1, 3, 5 c. 1, 4, 2, 3, 5 d. 2, 1, 4, 5, 3

ANS: C The steps for an enteral feeding are as follows: place patient in high-Fowler's position or elevate head of bed to at least 30 (preferably 45) degrees, verify tube placement, check for gastric residual volume, flush tubing with 30 mL of water, and initiate feeding.

A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" What conclusion about the child will the nurse come to when interpreting the child's response? a. Sensations are intact. b. Reception is intact. c. Perception is intact. d. Reaction is intact

ANS: C When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person's experiences. Sensation is a general term that refers to awareness of sensory stimuli through the body's sense mechanisms. Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, taste, or sound. Reaction is how a person responds to a perceived stimulus

A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority? a. Reduce dependent nitrogen balance. b. Maintain negative nitrogen balance. c. Promote positive nitrogen balance. d. Facilitate neutral nitrogen balance.

ANS: C When intake of nitrogen is greater than output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. Negative nitrogen balance occurs when the body loses more nitrogen than the body gains. Neutral nitrogen balance occurs when gain equals loss and is not optimal for tissue healing. There is no such term as dependent nitrogen balance

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? a. Provide privacy and check on the patient 30 minutes later. b. Set a box of tissues at the patient's bedside before leaving the room. c. Limit visitors while the patient is upset. d. Ask the patient what triggered the crying

ANS: D A clinical sign or symptom (crying) often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments. This is demonstrating curiosity, which is an attitude of critical thinking. Checking on the patient 30 minutes later, providing tissues, and limiting visitors may be appropriate actions but these actions do not address critical thinking

The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? a. Normal weight b. Underweight c. Overweight d. Obese

ANS: D BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI from 18.5 to 24.9 is normal. BMI under 18.5 is underweight

The nurse is assessing a patient for nutritional status. Which action will the nurse take? a. Forego the assessment in the presence of chronic disease. b. Use the Mini Nutritional Assessment for pediatric patients. c. Choose a single objective tool that fits the patient's condition. d. Combine multiple objective measures with subjective measures

ANS: D Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems. Using a single objective measure is ineffective in predicting risk of nutritional problems. Chronic disease and increased metabolic requirements are risk factors for the development of nutritional problems; these patients may be in critical need of this assessment. The Mini Nutritional Assessment is used for screening older adults in home care programs, nursing homes, and hospitals

The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? a. Run lipids for no longer than 24 hours. b. Take down a running bag of TPN after 36 hours. c. Clean injection port with alcohol 5 seconds before and after use. d. Wear a sterile mask when changing the central venous catheter dressing

ANS: D During central venous catheter dressing changes, always use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection. To avoid infection, change the TPN infusion tubing every 24 hours, and do not hang a single container of PN for longer than 24 hours or lipids longer than 12 hours

The nurse is caring for a patient diagnosed with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care? a. Patient will carry a pen and a pad of paper around for communication. b. Patient will recover full use of speech vocabulary in 1 day. c. Patient will thicken drinks to prevent aspiration. d. Patient will communicate nonverbally

ANS: D Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through means such as pointing and gestures. Goals and outcomes need to be realistic and measurable; recovery in 1 day is not realistic. A patient who has expressive aphasia may not be able to speak or write words with a pen and paper. Thickening drinks prevents aspiration risk and is not included in a plan of care for this patient

A nurse is asked how many kcal/g are provided by fats. How should the nurse answer? a. 3 b. 4 c. 6 d. 9

ANS: D Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Carbohydrates and protein provide 4 kcal/g

A patient recovering from a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? a. Preparing to administer a barium enema b. Withholding narcotic pain medication c. Administering laxatives to the patient d. Raising the head of the bed

ANS: D Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain-relief measures should be given; however, preventative action should be taken to prevent constipation.

A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene? a. Custard b. Frozen yogurt c. Pureed vegetables d. Mashed potatoes and gravy

ANS: D Mashed potatoes and gravy are on a dysphagia, mechanical soft, soft and regular diet but are not components of a full liquid diet. The nurse will need to provide teaching on what is allowed on the diet. Custard, frozen yogurt, and pureed vegetables are all on a full liquid diet.

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? a. From the tip of the nose to the earlobe b. From the tip of the earlobe to the xiphoid process c. From the tip of the earlobe to the nose to the xiphoid process d. From the tip of the nose to the earlobe to the xiphoid process

ANS: D Measure distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. This approximates the distance from the nose to the stomach in 98% of patients. For duodenal or jejunal placement, an additional 20 to 30 cm is required

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? a. Polyunsaturated fats should be less than 7% of the total calories. b. Trans fat should be less than 7% of the total calories. c. Unsaturated fats are found mostly in animal sources. d. Saturated fats are found mostly in animal sources.

ANS: D Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Diet recommendations include limiting saturated and trans fat to less than 10%

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? a. Establishes minimal passing standards for testing. b. Utilizes evidence-based practice based on nurses' needs. c. Bypasses the patient's feelings to promote ethical standards. d. Uses critical thinking for the highest level of quality nursing care.

ANS: D Professional standards promote the highest level of quality nursing care. Application of professional standards requires you to use critical thinking for the good of individuals or groups. Bypassing the patient's feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses' needs

Which patient diagnosis increases the risk for developing neurogenic dysphagia? a. Benign peptic stricture b. Muscular dystrophy c. Myasthenia gravis d. Stroke

ANS: D Stroke is the only cause of dysphagia in this list that is considered neurogenic. Myasthenia gravis and muscular dystrophy are considered myogenic in origin, whereas benign peptic stricture is considered obstructive.

The nurse is teaching a health class about the ChooseMyPlate program. Which guidelines will the nurse include in the teaching session? a. Balancing sodium and potassium b. Decreasing water consumption c. Increasing portion size d. Balancing calories

ANS: D The ChooseMyPlate program includes guidelines for balancing calories; decreasing portion size; increasing healthy foods; increasing water consumption; and decreasing fats, sodium, and sugars. It does not balance sodium and potassium.

A nurse is teaching a patient about proteins that must be obtained through the diet since they cannot be synthesized in the body. Which term used by the patient indicates teaching is successful? a. Amino acids b. Triglycerides c. Dispensable amino acids d. Indispensable amino acids

ANS: D The body does not synthesize indispensable amino acids, so these need to be provided in the diet. The simplest form of protein is the amino acid. The body synthesizes dispensable amino acids. Triglycerides are made up of three fatty acids attached to a glycerol

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? a. Making an ethical clinical decision b. Making an informed clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

ANS: D The charge nurse must intervene when the nurse is using previous shift assessments to plan; this is inappropriate. Nurses are responsible for assessing their own patients to make decisions. Making informed, ethical decisions in the patient's best interest is practicing responsibly and does not need follow-up from the charge nurse.

The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? a. Ileum b. Cecum c. Stomach d. Duodenum

ANS: D The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine.

A nurse is using a critical thinking model to provide care. Which component is first implemented when helping a nurse make clinical decisions? a. Attitude b. Experience c. Nursing process d. Specific knowledge base

ANS: D The first component of the critical thinking model is a nurse's specific knowledge base. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. Clinical learning experiences are necessary to acquire clinical decision-making skills. The nursing process competency is the third component of the critical thinking model. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process

ANS: D The nursing process competency is the third component of the critical thinking model. In your practice, you will apply critical thinking components during each step of the nursing process. Care plans should be individualized and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? a. Fairness b. Intellectual standards c. Independent reasoning d. Institutional practice guideline

ANS: D The standards of professional responsibility that a nurse tries to achieve are the standards cited in Nurse Practice Acts, institutional practice guidelines (hospital/facility policy), and professional organizations' standards of practice (e.g., The American Nurses Association Standards of Professional Performance). Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions

During an assessment, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further? a. Neurological deficit b. Visual deficit c. Hearing deficit d. Balance defici

ANS: D Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. Neurological deficits include peripheral neuropathy and stroke. Visual deficits include presbyopia, cataracts, glaucoma, and macular degeneration. Hearing deficits include presbycusis and cerumen accumulation

A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure? 1. Eardrum 2. Perilymph 3. Oval window 4. Bony ossicles 5. Eighth cranial nerve a. 1, 5, 2, 4, 3 b. 1, 3, 4, 2, 5 c. 1, 2, 4, 5, 3 d. 1, 4, 3, 2, 5

ANS: D Vibration of the eardrum transmits through the bony ossicles. Vibrations at the oval window transmit in perilymph within the inner ear to stimulate hair cells that send impulses along the eighth cranial nerve to the brain

Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old female with three final examinations on the same day c. A 40-year-old female with major depressive disorder d. An 80-year-old male in an assisted-living environment

environment ANS: B Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from slowed peristalsis.