NUR 19202 Exam 2

A female client tells the nurse, "I try to consume 2000 calories daily by eating a variety of proteins, carbohydrates, and fats." What is the appropriate nursing response?

"That is a healthy amount of daily caloric intake." Healthy adult women on average require 1800 to 2400 cal/day, with a mix of proteins, carbohydrates, and fats. The nurse should affirm the client's dietary choices. Other answers are incorrect and do not counsel the client appropriately.

A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply.

prune juice with breakfast hot tea with meals a turkey sandwich with whole-grain bread A glass of prune juice is equivalent to more than one serving of the dried fruit, has high magnesium content, and is an excellent source of fluid to promote bowel elimination. Hot fluids, such as coffee, tea, or hot water with lemon juice, may also increase intestinal motility. High fiber foods such as whole-grain bread provide bulk for the stool. Ice cream and diet soda do not provide any preventative measures for constipation.

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?

tracheostomy collar A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.

Use of an indwelling urinary catheter leads to the loss of bladder tone.

true People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds. Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires further nursing teaching?

"My husband and I are ordering a product that has megadoses of vitamins." Consuming megadoses (amounts exceeding those considered adequate for health) of vitamins and minerals can be dangerous. This statement requires further nursing teaching. The other statements do not require further teaching.

A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs?

Gastrostomy tube When enteral feeding is required for a long-term period, an enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy). NG, NI, and Salem Sump tubes will not meet a client's long-term nutritional needs.

The nurse is caring for a postoperative client just returning from surgical insertion of a peritoneal dialysis catheter. Which are the nurse's priority assessments of the peritoneal dialysis catheter insertion site? Select all that apply.

Odor Bleeding Drainage Pain The nurse would assess the new surgical dressing over the peritoneal dialysis catheter for odor and drainage that may indicate an infection, record and mark any bleeding on the dressing that may indicate postsurgical hemorrhage, and pain at and around the surgical site. The client may not have significant urinary output related to end-stage renal disease and decreased kidney function, resulting in the need for a dialysis catheter.

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options.

Place the client in high Fowler's position. Measure the intended length to insert the NG tube. Lubricate the tube tip with water-soluble lubricant. Direct the tube upward and backward along the floor of the nose. Instruct the client to place the chin onto the chest. Advance the tube while the client swallows. An upright position is more natural for swallowing and protects against bronchial intubation aspiration, if the client should vomit. Therefore, the high Fowler's position is recommended for the client. Measurement ensures that the tube will be long enough to enter the client's stomach. Lubrication reduces friction and facilitates passage of the tube into the stomach. Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likelihood of mucosal injury. Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube, causes the epiglottis to cover the opening of the trachea, and helps to eliminate gagging and coughing.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?

Unless contraindicated, nurses should encourage clients to stand to use a urinal. A standing position facilitates bladder emptying and decreases the likelihood of spillage of urine. Although female urinals exist, they are more difficult to use and are not commonly used in health care facilities. Replacing urinals every 24 hours is not necessary. A urinal should not be left in place for extended periods of time, because pressure and irritation to the client's skin can result.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?

Wearing gloves when handling the urine All of these interventions would be important to ensure safety in handling the client's urine and obtaining an accurate output. However, safety with handling body fluids would be a priority for the nurse to decrease risk of exposure to pathogens or blood that may be in the client's urine.

normal weight

a BMI of 19 to 24.5 indicates normal weight

overweight

a BMI of 25 to 29.9 indicates an overweight individual

obese

a BMI of 30 or greater indicates obesity

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure?

Position the client in a supine position. Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

rapid respirations Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

straight catheter Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. A suprapubic catheter is used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area.

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?

teenager who is in the second trimester of pregnancy Children, adolescents, pregnant women, and breast-feeding mothers require more servings per day of certain food groups, particularly the milk group. Therefore, the teen (adolescent) who is pregnant will require more milk servings. The other clients do not require more servings of milk.

Which nursing student statement regarding vegetarian diets requires further teaching from the nursing instructor?

"According to research, vegetarians have a higher incidence of obesity than others." Vegetarians have a lower incidence of colorectal cancer and fewer problems with obesity and diseases associated with a high-fat diet. Protein complementation helps a client get amino acids needed. Vegans rely solely on plant sources for protein; semi-vegetarians exclude only red meat from their diet.

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." Elimination patterns vary widely among individuals, and the expectation of a daily bowel movement is not realistic for many healthy people. This client may not require pharmacologic interventions.

A client with diabetes must monitor his intake of sugar. Which client statement requires nursing intervention?

"At every meal, I eat bread with honey." A client monitoring carbohydrate intake should be mindful of his intake of sugar, which is found in honey. All other dietary choices are acceptable.

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

The nurse is providing care for an older adult client who is recovering from pneumonia on the hospital's medical unit. The nurse sets up the client's dinner tray on his overbed table. The client then states, "I won't be having any of this." What is the nurse's most appropriate response?

"Can you tell me why you don't want to have dinner tonight?" If a client does not want to eat, the nurse should begin by assessing the reasons behind the client's decision. This should precede any health education that may be needed. It is appropriate to set aside the tray for later, but assessment should take place first.

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

"Discard your first urine and begin the collection after that." The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.

A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct?

"I will administer enemas until the enema return is without stool." "Enemas until clear" means that the nurse would administer enemas until no more stool is noted on output. A nurse would not be able to determine if the entire intestinal tract is clear. Administering three enemas is not what the prescriber ordered. Consuming clear liquids does not impact the use of enemas. The enema may not be part of the client's discharge instructions.

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

The nurse is caring for a client with a new sigmoid colostomy. The client expresses concern about how to anticipate when a bowel movement will pass into the bag. Which answer is most appropriate?

"Irrigating the colostomy can help establish an elimination routine." Irrigations are used to promote regular evacuation of some colostomies. Left-sided colostomies of the descending colon and sigmoid colon can be irrigated successfully for regulating bowel elimination. Telling the client that it is impossible to anticipate when a bowel movement will occur is appropriate for a client with an ileostomy, but not with a sigmoid colostomy. Increasing fiber in the diet will make the stool more solid, but it will not help establish an elimination pattern. Recovering from surgery does not help the bowel elimination pattern to become regular. Irrigating the colostomy is the best way to control when a bowel movement occurs.

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem?

"Let's explore structuring activities and toileting breaks." The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?

"Let's review the types of fluids that your child drinks in the morning." Bladder irritants such as caffeine can cause urge incontinence; it is appropriate to determine whether the child is consuming fluids that contain caffeine. The child's urge incontinence is not extremely abnormal, and this physiological response is not related to gender. It is too soon to refer the client to the health care provider without taking a history, and it is impractical to simply recommend incontinence undergarments.

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins." The nurse will caution the client that self-administration of mineral oil to relieve constipation can interfere with absorption of fat-soluble vitamins. The nurse can then further discuss the reason the client is performing this treatment and determine other appropriate interventions to relieve constipation.

A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention?

"My favorite drink is coffee with sugar." Foods containing added sugar as a major ingredient tend to supply calories but few, if any, other nutrients. A client monitoring carbohydrate intake should be mindful of the intake of extra sugar. The other answer choices are appropriate for a client diagnosed with diabetes mellitus who is monitoring carbohydrate intake.

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse?

"Only if the stool has not been contaminated by urine." Stool can be collected from a diaper for occult blood testing only if the stool has not been contaminated by urine. It does not matter whether the diaper is disposable or cloth. The type of developer does not make a difference as all are used to test for occult blood.

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply.

"Respirations of the client with emphysema can be compared to a balloon that has been blown up before." "Emphysema, like a new balloon, takes less effort to empty air out of the alveoli." The lungs in a client with emphysema are stiff and noncompliant. The lungs (alveoli) are compared to a new balloon that takes more effort to blow up and release air out. As in emphysema, a new balloon takes extra effort to blow up; the client with emphysema has to exert more effort to breathe in and out, leading to shortness of breath. The new balloon is difficult to expand, representing decreased elasticity and leading to decreased compliance.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?

"Small water droplets come from this, thus preventing dry mucous membranes." The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier." Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.

"The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care." With a diagnosis of altered body image, a nurse would create interventions for the client becoming more comfortable with the surgical change. When the client is willing to look at the stoma, makes neutral or positive statements about the ostomy, and begins to assist with their care demonstrates that the client is accepting of the body image change that occurred. If the client takes prescribed antidepressants and uses spray deodorant several times an hour means that the has not accepted the change in their body or rather is in denial of the surgical change.

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide?

"This test detects heme, a type of iron compound in blood in the stool." The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.

Which measures are used by the nurse to confirm the correct placement of a nasogastric feeding tube? Select all that apply.

-measuring the pH level of aspirated contents -monitoring carbon dioxide levels -obtain a chest x-ray after placement as ordered -measuring tube length Measuring pH and tube length as well as monitoring carbon dioxide are accurate ways to confirm placement. The gold standard is to obtain a chest x-ray immediately after insertion to determine placement. Fluid would never be instilled and auscultation of air is not considered to be reliable for tube placement.

The nurse is preparing to administer a client's ordered tube feeding and the client aspirates gastric contents. Testing of the pH yields a result of 5.3. What is the nurse's most appropriate action?

Proceed with the feeding as ordered. The pH of gastric contents is acidic (less than 5.5); a pH of 5.3 thus constitutes an expected finding. There is no need to delay the feeding or reconfirm tube placement.

The client is preparing to obtain a clean-catch midstream urine specimen. List in order the steps needed to complete the diagnostic test.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into stool. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional. A clean-catch urine specimen is used to obtain a specimen that is clean in nature. The procedure is not sterile. The process requires the nurse to provide the needed education to the client. The client will begin by cleaning the area surrounding the meatus with a provided wipe. The client will void into the stool and discard. The client will next void into the provided specimen container. Once the specimen container is filled the client may finish voiding in the stool and discard. The specimen will need to be secured and submitted to the health care professional.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145 lb/ 65.7 kg A general guideline, often called the rule-of-thumb method, determines ideal weight based on height. This formula is as follows: For adult females: 100 lb/45.3 kg (for height of 5 feet or 152 cm) + 5 lb / 2.2 kg for each additional inch (2.5 cm) over 5 feet. For adult males: 106 lb / 48 kg (for height of 5 feet) + 6 lb / 2.7 kg for each additional inch over 5 feet.

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (5,850 × 109/L) Cardiac output is determined by multiplying the stroke volume by the heart rate/min, which equals 5,850 mL (5,850 × 109/L). Cardiac output and peripheral resistance determine both systolic and diastolic pressures.

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening?

50-year-old client with a family history of polyps The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect.

The nurse is caring for four older adult clients. Which does the nurse identify as highest risk for cardiometabolic syndrome?

70-year old with a body mass index (BMI) of 34.8 Waist circumference and obesity are linked with cardiometabolic syndrome. Therefore, the client with a BMI of 34.8 is obese and is at highest risk for cardiometabolic syndrome. The other clients are not at as high of a risk.

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?

8 L/min oxygen via nasal cannula The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to for a client with chronic lung disease.

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood. What range is considered a normal value for SpO2?

95% to 100%

underweight

A person with a BMI below 18.5 is underweight

The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action?

A risk that the peristomal skin will become excoriated An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

ABG Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?

Administer the solution gradually over 5 to 10 minutes. Large-volume enemas should be given over a 5- to 10-minute time frame. The solution should be warm, but warming for a specific time period in a microwave could result in overheating. It is not always necessary or possible for the client to attempt a bowel movement prior to the procedure. If performed correctly, the procedure should not necessitate analgesia.

A nurse is discussing vitamin supplementation. Which groups are more prone to mild vitamin deficiencies? Select all that apply.

Adolescents Pregnant or lactating women Strict vegetarians Vitamin deficiencies are inherent with a few populations. Adolescents often eat fast food or skip breakfast and are prone to having vitamin deficiencies. Pregnant or lactating women have higher nutritional demands and may not consume enough vitamins to meet the demand. The vegan or total vegetarian diet includes only foods from plants: fruits, vegetables, legumes (dried beans and peas), grains, seeds and nuts and they lack protein vitamins. Middle aged adults and non-smokers are not at risk.

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

After the initial stream is initiated, collect the sample. A clean-catch specimen is collected in mid-stream. It is not reasonable, nor necessary, to collect the entire urinary output. It is not correct to collect the first urine expelled or to wait until the void is almost over.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel?

Antidiarrheal agent Antidiarrheal agents act directly on the intestine to slow bowel motility or to absorb excess fluid in the bowel. Antiflatulence agents are used to relieve gas. Laxatives promote evacuation of hardened stool from the bowel. Suppositories, when inserted into the rectum, melt and can be absorbed for systemic or local effects.

A nurse is caring for a client with a gastrostomy tube and observes that a large amount of drainage is leaking from the tube. Upon inspection the nurse finds a great deal of slack in the tube. Which action should the nurse take next?

Apply gentle pressure to the tube while pressing the external bumper closer to the skin. If there is a large amount of slack between the internal guard and the external bumper, drainage can leak out of the site. In this case, the nurse should apply gentle pressure to tube while pressing the external bumper closer to the skin. Although the nurse should gently rotate the external bumper 90 degrees at least once a day, this action would not address the leaking of the tube. Skin barrier should be applied to protect the skin from irritation by the tube; however, this action would not address the leaking, either. There is no need to notify the health care provider regarding this issue.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence. The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first?

Aspirate stomach contents and check pH. Nasogastric tube placement should be checked before flushing, giving medications, or feeding. After placement has been ensured, the gastric residual should be checked, the nasogastric tube should be flushed as ordered, and the tube feeding administered.

A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk?

Assess the client's level of consciousness

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client?

Assess the color of the stoma. A bluish or dark stoma indicates impaired circulation to the stoma. This requires intervention to improve circulation to avoid permanent damage to the stoma. Applying the device would be secondary after the assessment. A stoma irrigation is not a priority in the care of the client. Having the client perform self stoma care would be one of the last interventions provided prior to discharge from the hospital after assessing for readiness.

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

Assess when client generally eats meals There are many reasons a client may refuse food that is served. The nurse should assess for food preferences, when the client generally eats, whether the client has digestive concerns, and cultural beliefs about foods. Leaving the client alone to eat, or simply delegating feeding, does not encourage intake. The client does not need an appetite stimulant until a full assessment has been conducted and other interventions have been implemented.

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline. An NG tube that is not draining should normally be irrigated. Turning the suction off and on is less likely to be effective, and it may be unsafe to leave the suction turned off for half an hour. Digestive enzymes are not used on NG tubes that are used for suction. Removing the NG tube would be an action of last resort.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using it. A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication.

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?

Before removing the tube, discontinue suction and separate the tube from suction. When removing the tube, the nurse should discontinue the suction and separate the tube from suction to allow for its unrestricted removal. The client should be placed in a 30- to 45-degree position. The tube should be flushed with 10 mL of water or normal saline solution and should be removed as the client holds his or her breath.

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?

Blood from the fingertips shows changes in glucose more quickly than other testing sites. With glucose monitoring, blood from the fingertips shows changes in blood glucose more quickly than other testing sites. With signs and symptoms of hypoglycemia, a fingertip site should be used. Calibrate the glucose monitors at least every month. Glucose levels increase with illness and stress to the body.

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis?

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls.

Which guideline is recommended when obtaining a capillary blood sample for glucose testing

Calibrate the meter according to the manufacturer's recommendation and when a new bottle of test strips is opened. Meters require calibration at least monthly or according to the manufacturer's recommendation and when a new bottle of test strips is opened. The heel site should be used in infants and children; if the site is cool, a warm compress can be placed on it before testing. For a client with abnormal results, the nurse should check the medical record for ordered interventions and notify the primary care provider of assessments and results.

A nurse who is planning a diet for a client who has anorexia chooses nutrients that supply energy to the body. Which nutrients are these? Select all that apply.

Carbohydrates Protein Lipids Carbohydrates, protein, and lipids (fats) are the nutrients that supply energy. Vitamins, minerals, and water do not supply energy, but are necessary for balanced nutrition.

Which is true regarding the normal urination?

Catheterized clients should drain a minimum of 30 mL of urine per hour. Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.

The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?

Check the fit of the oxygen mask. The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

hich nursing action associated with successful tube feedings follows recommended guidelines?

Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. The nurse should check the residual before each feeding or every 4 to 8 hours during a continuous feeding. High gastric residual volumes (200 to 250 mL or greater) can be associated with high risk for aspiration and aspiration-related pneumonia. A closed system is the best way to prevent contamination during enteral feedings. The bowel sounds do not have to be assessed as often as 4 times per shift. Once a shift is sufficient. Food dye should not be added as a means to assess tube placement or potential aspiration of fluid.

A nurse is providing care for a diverse group of clients on a medical floor. Which tasks may the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Checking a client's capillary blood glucose level Obtaining a client's stool specimen for occult blood testing Collecting a midstream urine specimen from a client with flank pain

Urinalysis and urine culture testing have been ordered for a client who has an indwelling urinary catheter. The nurse observes that there is currently no urine in the client's catheter tube. What should the nurse do?

Clamp the tube below to access the port to allow urine to accumulate. If there is not sufficient urine for collection, the nurse should clamp the tubing below the access port for up to 30 minutes. Increased fluid intake will not cause urine to accumulate in the tubing. Similarly, repositioning is unlikely to resolve the problem. Aspirating from an air-filled catheter tube may draw a contaminated sample from tubing distal to the access port.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?

Collect 15 to 30 mL of the client's liquid stool. Usually, 1 in (2.5 cm) of formed stool or 15 to 30 mL of liquid stool is sufficient; this client is more likely to have liquid stool. If portions of the stool include visible blood, mucus, or pus, include these with the specimen. Also be sure that the specimen is free of any barium or enema solution. Because a fresh specimen produces the most accurate results, send the specimen to the laboratory immediately.

The nurse is caring for a client diagnosed with a urinary tract infection. The primary care provider orders include an antibiotic, an antipyretic, and a urine culture and sensitivity, and urine specimen for nitrates. Which actions should the nurse take? Select all that apply.

Collect the first void clean urine specimen since the client presented in the emergency department at 0500. Obtain the urine specimens before beginning the ordered antibiotic. Instruct the client on the midstream urine collection process. Place the collected specimen with proper label in a biohazard bag and send it to the lab after collection. Whenever possible, the best specimen is the first void urine specimen because it will be the most concentrated with any bacteria or nitrates. The nurse, if possible, should collect the urine culture and sensitivity before providing the first dose of the antibiotic so the culture truly reflects the microbes. Antipyretics are also administered after obtaining cultures. The nurse should instruct the client on the correct process to obtain the urine culture. The nurse should place the specimen in a biohazard bag and send it to the lab after collection.

The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action is correct?

Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. Most obstructions are caused by coagulation of formula. The nurse should try using warm water and gentle pressure to remove the clog. Carbonated sodas, such as Coca-Cola, and meat tenderizers have not been shown effective in removing clogs in feeding tubes. Never use a stylet to unclog tubes. Advancing the tube is not needed, as this will not address the clog.

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client?

Cough medicine with an antihistamine The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. The client with diabetes should avoid cough medicine with a high sugar content. The client with thyroid disorders should avoid cough medicine containing iodine. The client with hypertension should avoid cough medicine with decongestants.

A nurse is caring for a client who has been ordered a clear liquid diet. Which liquid can be included in the client's diet?

Cranberry juice A clear liquid diet is composed only of clear fluids or foods that become fluid at body temperature. This includes clear broth, coffee, tea, clear fruit juices (apple, cranberry, grape), gelatin, popsicles, and commercially prepared clear liquid supplements. A clear liquid diet requires minimal digestion and leaves minimal residue. Low-fat milk, fruit juices or soup, and juices with fruit pulp (orange and grapefruit) are considered full-liquid diet.

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation. The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.

A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client?

Drink juice for majority of fluid intake. Water should comprise the majority of fluid intake. The remainder should come from food sources such as fruit or 100% fruit juices.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein. The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.

Which skin disorder is associated with asthma?

Eczema The client with asthma often recalls childhood allergies and eczema

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

Ensure proper positioning of the scanner head and rescan The scanner head should be repositioned, and the bladder should be rescanned before assuming that the bladder is truly empty. Additional ultrasound gel may need to be added for the scanner to work properly. If the bladder is truly distended, the client may become more uncomfortable from drinking additional water. The best position for bladder scanning is supine.

A nurse is caring for a client with a nasogastric tube. The nurse enters the room to flush the nasogastric tube and check gastric residual. Which action should the nurse perform first?

Ensure the head of the bed is elevated. The head of the bed should be elevated before giving medications or performing a tube feeding. Following this, the placement of the tube should be checked, aspirate the gastric contents with a syringe, and then flush the tube with the ordered amount of water.

Which task may be safely delegated to unlicensed assistive personnel (UAP)?

Feeding a client who is at risk for aspiration Assisting clients to eat may be delegated to UAP. These care providers are normally educated in the risks posed by aspiration. UAP cannot insert or remove NG tubes and they cannot administer tube feedings.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this?

Having the client sign a consent form for the procedure The client would sign a consent form for the procedure since it is invasive. This would be completed after the procedural health care provider had explained the purpose, risks, and benefits of the procedure. The client would not be maintained NPO (nothing by mouth) or have a catheter inserted for this procedure. The procedure is usually painless, so the client would not be told to expect pain as a normal part of the procedure.

A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate?

Hindus: Vegetable plate Dietary restrictions associated with religions are extremely important to provide culturally competent nursing care. Hindus do not consume beef because cows are considered a sacred creature. They are typically vegetarians; therefore, a vegetable plate is appropriate for this client. Orthodox Jews must have kosher foods. Shrimp and pork are prohibited in this religion. Mormons do not drink coffee, tea, or alcohol and they limit their meat consumption.

The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take?

Hold the enteral nutrition and notify the primary care provider. When the residual is greater than 500 mL, the enteral feeding should be held and the primary care provider (PCP) needs to be called for further instructions. If there had been two consecutive residuals >250 mL, the PCP would consider ordering a promotility agent. The PCP will consider decreasing the rate of the tube feeding and may or may not want the residual returned since it is so large. The nurse would not discard or replace the residual and merely chart the amount of the residual and continue the tube feeding at the ordered current rate. The excessive large residuals will increase the client's risk for aspiration.

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?

Hyperactive bowel sounds Increased bowel motility, indicated by hyperactive bowel sounds, is commonly caused by diarrhea. Visible waves of abdominal peristalsis are commonly seen in intestinal obstruction. The anal area normally has increased pigmentation and some hair growth. Diarrhea stools are liquid in formation, whereas dry, hard stools are seen in constipation.

A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site?

If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site. If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage. If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement, except to clean the area.

A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client?

Imbalanced Nutrition, Less Than Body Requirements The correct nursing diagnosis is Imbalanced Nutrition, Less Than Body Requirement. A clear liquid diet for 5 days would not provide adequate nutrition. It does provide about 1,000 calories but it is below the recommended range from 1,600 to 2,400 calories per day for adult women and 2,000 to 3,000 calories per day for adult men. Risk of injury would be related to movement, thoughts, and/or medications. Fluid volume deficit would be inappropriate as the client is consuming a clear liquid diet and that would provide adequate fluid volume but not enough nutrition. Activity intolerance would also be related to movement by the client.

The nurse is reviewing a client's most recent laboratory results, which reveal increases in hematocrit, creatinine, and blood urea nitrogen (BUN). After collaborating with the interdisciplinary team, what intervention is most appropriate?

Increase the client's fluid intake. Dehydration can cause increases in hematocrit, BUN, and creatinine. Calorie restriction, increased protein intake, and TPN are not indicated by these laboratory data.

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter. Ineffective breathing pattern is the state in which a person's inspiration and/or expiration pattern does not provide adequate ventilation.

The nurse is preparing to remove stool digitally for a client who is constipated. Which steps are included in this process? Select all that apply.

Insert gloved finger gently into anal canal, pointing toward the umbilicus. Generously lubricate index finger of dominant hand with water-soluble lubricant. Instruct client to bear down, if possible, while extracting feces to ease in removal. Gently work the finger around and into the hardened mass to break it up and then remove Steps in the process of digitally removing stool include the following: generously lubricating index finger of dominant hand with water-soluble lubricant; inserting gloved finger gently into anal canal, pointing toward the umbilicus; gently working the finger around and into the hardened mass to break it up; removing pieces of it and instructing client to bear down, if possible, while extracting feces to ease in removal. It is not necessary to put on sterile gloves, because this is not a sterile procedure. Clean gloves are sufficient for this procedure, so use of sterile gloves is not indicated.

The nurse prepares to collect the client's stool for ova and parasites. Which actions should the nurse provide? Select all that apply.

Instruct client to call immediately after having the bowel movement. Teach client to not place toilet paper with stool. Transport specimen to the lab immediately. Use a biohazard bag for the specimen. The stool for ova and parasites is collected in a container with medium and it is not a sterile technique. The nurse should ask that the client does not put toilet paper with the specimen. The nurse needs to collect the specimen immediately after the void and take it to the lab in a biohazard bag with the proper requisition following the facility's policy and procedure.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough. The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action?

Lower solution container and check temperature and flow rate. The nurse's next action would be to lower the solution container and check the temperature and flow rate. Lowering the solution container decreases the pressure of the flow of the solution. The cramping could be related to the pressure of the flow, the temperature of the solution, or a high flow rate of the solution. The nurse would not place the client in a supine position, but in a low-Fowler's position or higher. The nurse would not remove the tube and check for any fecal contents. The nurse would not modify the amount and length of the administration, as this is not causing the severe cramping.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?

Maintain the client's oxygenation and alert the health care provider immediately. If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment?

Monitoring the characteristics of the urinary output The effectiveness of therapy is determined by the urine characteristics. On completion of the therapy with continuous bladder irrigation, the client should exhibit urine that is clear, without evidence of clots or debris. The client will have no PVR during therapy. Palpation of the bladder region and calculation of a particular outflow rate do not determine the success or failure of therapy.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which stucture is most likely involved?

Nephron The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman's capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman's capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.

During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her 6-month-old infant. What does the nurse inform the mother?

New foods should be introduced one at a time for a period of 5 to 7 days. Solid foods are generally introduced between 4 and 6 months of age. New foods should be introduced one at a time for a period of 5 to 7 days so that any allergic reaction can be identified. Iron-fortified foods are recommended.

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings. The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter. The health care provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Sitting the client up may aggravate the pain. The nurse should attempt to keep the client in the most comfortable position possible until a prescription is received from the health care provider.

A nurse is removing an NG tube and notes epistaxis. What nursing interventions would the nurse perform in this situation? Select all that apply.

Occlude both nares until bleeding has subsided. Ensure that client is in upright position. Document epistaxis in client's medical record. The nurse would occlude both nares until bleeding subsided. This would help to stop the nosebleed. The nurse would ensure that the client is in the upright position. This will help the client from swallowing blood, which could lead to nausea and emesis. The nurse would document the episode in the client's medical record. The nurse would not contact the primary care provider if the nurse is removing the tube. There would be no need to reinsert the tube if a nosebleed occurred when removing the tube. The nurse would not encourage the client to blow the nose, as this will not help the nosebleed to stop. There would not be blood in the suction container if the nurse is removing the NG tube and the nosebleed occurred.

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply.

Perform, or allow client to perform, perineal hygiene at least once daily. Contact the health care provider to ask for an order for catheter discontinuation. The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:

RDA level The RDA level is the average dietary intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding?

Reddened perineal skin The presence of reddened perineal skin is an abnormal finding. The healthy skin should be moist and noninflamed with no discharge present. Smegma (an accumulation of white, odorous secretions from sebaceous glands found under the labia minora in women and under the foreskin in men) is considered a normal finding.

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide?

Refrain from eating red meat 3 days before testing. The nurse will teach that the client should avoid eating red meat 3 days before testing, refrain from consuming citrus fruits or juices for 3 days before beginning the test, and to avoid certain raw vegetables 2-3 days prior to testing. Acetaminophen use is acceptable; nonsteroidal anti-inflammatory drugs (NSAIDs) must be avoided 7 days before self-collecting stool.

The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse?

Reinstruct the client on use of collection container for next bowel movement. Stool should not be collected from the toilet due to contamination. The nurse should reinstruct the client on the use of a collection container for the next bowel movement. There is nothing to indicate that the test should be cancelled nor that the client needs a laxative administered.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary. If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.

The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate?

Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. Talking during eating increases the risk of aspiration for a client who has dysphagia. Arranging food on the plate in a clock face pattern is a strategy appropriate for a client who is visually impaired. Clients who have dysphagia need to eat slowly and be continually observed for signs of aspiration. Allow enough time for the client to adequately chew and swallow the food. The client may need to rest for short periods during eating.

The student nurse is caring for a client with a colostomy. When changing the ostomy appliance, the nurse manager would intervene if which action by the student is observed?

Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate When removing the appliance, the nurse should start at the top, not bottom, to prevent spillage of intestinal content. The disposal pad protects the work surface. Emptying the appliance before removal prevents spillage of fecal material. The skin should dry completely to provide good adherence of the appliance; applying a protectant to a 2-in (5-cm) radius around the stoma provides protection to the skin and prevents breakdown

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure. When administering an enema, the client's vagus nerve may be stimulated, causing a decrease in the heart rate. The client will exhibit nausea, lightheadedness, dizziness, and clammy skin. The procedure should be stopped, heart rate and blood pressure monitored, and the health care provider notified. The other responses are not appropriate for a client exhibiting a vagal response.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway. The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

The birth can cause perineal swelling. Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions?

The client drinks two glasses of water before and after sexual intercourse Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?

The client returned from a foreign country 2 days ago. Eating native food and drinking water in a foreign country may cause problems with digestion and elimination, such as diarrhea. To promote normal bowel elimination, people should drink 2,000 to 3,000 mL of fluids daily. Ignoring the urge to defecate and consuming large quantities of fiber, such as fresh vegetables, may lead to constipation.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions?

The client should avoid wearing tight clothes or belts near the site. Clients should avoid baths and public pools as well as wearing tight clothes and belts around the exit site. Once the site is healed, some health care providers do not require clients to wear a dressing unless the site is leaking. Clean technique is sometimes allowed in the home.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

The client will have to wear an external appliance to collect urine. An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?

The graduate places the client in Fowler's position. Placing the client in Fowler's position during an enema will cause the solution to remain in the rectum; expulsion of the solution happens rapidly with minimal cleansing accomplished. The solution should be retained until the desired results are achieved. The solution should not be too hot or too cold, but administered at room temperature. Most people are uncomfortable about discussing the intestinal tract and bowel elimination, so this is an opportune time to discuss it.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?

The largest part of a regular bedpan should be placed under the client's buttocks. The rounded, smooth upper end of the regular bedpan is designed to be placed under the buttocks. Because a regular bedpan is much larger than a fracture bedpan, it is usually less comfortable. Choice of bedpan is based on client characteristics rather than type of elimination. A fracture bedpan can be used for any client.

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse?

The new nurse places the client in the left lateral recumbent position. The client's head should be elevated 30 to 45 degrees. All of the other actions are correct and would not require intervention by the charge nurse.

A nurse is assessing the bowel elimination of pediatric clients on the unit. Which developmental factors affecting elimination should the nurse consider? Select all that apply.

The number of stools that infants pass varies greatly. Some children have bowel movements only every 2 or 3 days. The nurse would note that the number of stools that infants pass varies greatly. The number of bowel movements is often related to the feeding the infant is receiving. Breastfed babies often have 2 to 10 stools a day, where formula-fed babies have 1 to 2 stools daily. The nurse would also note that some children have bowel movements only every 2 or 3 days. The nurse would note that constipation is often a chronic problem for older adults. The nurse knows that the voluntary control of defecation occurs between the ages of 18 to 24 months, not 12 to 18 months. A child is likely not constipated if they do not have a daily bowel movement. Children differ in their individual bowel patterns. Liquid stool does not always signify diarrhea in a child. Loose stools may be related to overfeeding.

A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply.

The nurse places the client in the supine position with the abdomen exposed. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft. The nurse would place the client in the supine position with the abdomen exposed. The nurse would use a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse would note the character of bowel sounds. The nurse would first inspect, then auscultate, then palpate the abdomen. The nurse would not place the client's legs flat against the bed, rather flex the knees slightly. The nurse would not ask the client to drink fluids to fill the bladder before the exam. The nurse would ask the client to empty the bladder before the exam so as not to have the client uncomfortable from a full bladder.

The nurse is talking to a client whose colostomy pouch frequently comes loose and falls off. Which interventions are appropriate suggestions? Select all that apply.

Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch. Apply a commercially available skin barrier before applying the ostomy pouch. In cases in which a client's colostomy bag continues to come loose or fall off, the nurse should either perform or recommend that the client do the following: thoroughly cleanse the skin and apply skin barrier. Allow the area to dry completely. Reapply the pouch. Monitor pouch adhesion and change the pouch as soon as there is an adhesion break. Wrapping an elastic bandage around the colostomy pouch would restrict the flow of feces into the pouch and should not be done. The ostomy pouch should not be left off and replaced with an adult incontinence pad, as this would result in leakage. Having the client lie flat in the prone position for 10 to 15 minutes after applying the pouch to facilitate adhesion is not necessary; the nurse simply needs to apply gentle, even pressure to the appliance for about 30 seconds after applying it.

A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?

Total parenteral nutrition (TPN) TPN is nutritional therapy that bypasses the gastrointestinal tract and is administered through a central vein. PPN is nutritional therapy used for clients who have an inadequate oral intake and require supplementation of nutrients through a peripheral vein. A PEG is a surgically placed gastrostomy tube. A PEJ is a surgically placed jejunostomy tube.

A nurse is checking a client's capillary blood glucose level. Which nursing action is most appropriate?

Touch the test strip directly to a drop of blood. The nurse should touch a drop of blood to pad to the test strip without smearing it. Test strips are not cleaned and blood flow is encouraged by warming or stroking the finger, not having the client make a fist. The site should not be wiped with alcohol after testing.

An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change?

Try eating foods that are attractive and at the proper temperature. The nurse should suggest eating foods that are attractive and at the proper temperature. Other suggestions include eating one food at a time rather than mixing foods and eating foods with different textures and aromas. The nurse should refrain from suggesting spicy foods, which may not be well tolerated by a client or may not be part of the client's flavor profile.

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action by the UAP is noted?

UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan. It is important to place the bedpan in the proper position to prevent spills onto the bed, ensure client comfort, and prevent injury to the skin from a misplaced bedpan. Therefore, the UAP should position the bedpan so the client's buttocks rest on the rounded shelf of the regular bedpan. Applying powder to the rim of the bedpan helps keep the bedpan from sticking to the client's skin and makes it easier to remove, unless it is contraindicated. The nurse uses less energy when placing the hand closest to the client palm up, under the lower back, and assisting with client lifting. A waterproof pad protects the bed from bedpan spillage.

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice?

Urinal

The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed?

Urine culture sensitivity - 100,000/mL 100,000 organisms per milliliter in a urine culture and sensitivity specimen is positive of a urinary tract infection. BUN, hemoglobin, and magnesium are all within the normal ranges.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.

When caring for a client with difficulty defecating, which appropriate nursing interventions would the nurse implement? Select all that apply.

Use moist heat when cleaning the perineal area. Encourage daily consumption of 2,000 to 3,000 mL of water. Use of moist heat soothes the perineal area. Water is preferred because fluids with caffeine and sugars have a diuretic effect. When a client is using the bedpan, the head of the bed should be elevated to a minimum of 30 degrees. A low-fiber diet is recommended for a client with diarrhea. Clients require regular exercise to aid in defecation; once a week is not enough.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription cleansed access port with antiseptic swab aspirated urine from access port into sterile specimen container client tolerated procedure well. The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.

The client reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which dietary element?

Vitamin A Dryness of the eyes (xerophthalmia) is associated with a deficiency of vitamin A.

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?

Vitamin D Severe vitamin D deficiency manifests as rickets, osteomalacia, poor dentition, and tetany

A nurse is educating a group of adolescent girls on bone and teeth growth. Which fat-soluble vitamin assists to build bone and teeth?

Vitamin D Vitamin D stimulates the absorption of calcium, which is an essential component for building strong, healthy bones and teeth. Vitamin A is essential in maintaining visual acuity, cell growth, and the immune system. Vitamin E is an antioxidant and also functions in promoting healing and healthy skin (cell growth). Vitamin K is essential in clotting.

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

Warm the client's hands and try again. Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply.

Wash hands and put on PPE, as indicated. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. The nurse will come into contact with respiratory secretions during the insertion of the oral airway, making it necessary to wear appropriate PPE. The airway will need to be rotated 180 degrees as it passes the uvula because the airway is more easily inserted with the curved tip pointing up towards the roof of the mouth. The airway should be removed for brief periods every 4 hours (or according to facility policy) to prevent constant pressure on the surrounding structures. The airway should reach from the opening of the mouth to the back angle of the jaw. The client should be positioned in a semi-Fowler's position to ease insertion of the airway.

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults. Increasing dietary fiber does not decrease peristalsis. Lactose intolerance is not a developmental change in older adults. Peeling fruit does not impact bowel habits in the older adults.

A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?

When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal tube.

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?

Whole wheat spaghetti and broccoli To promote bowel elimination, the client should consume 20 to 35 g of fiber daily. Foods high in fiber include fresh fruits and vegetables, bran, and whole grains. Cream of wheat is refined cereal and fiber has been removed from apples because of cooking. Other foods low in fiber include soda crackers, chicken noodle soup, tea, and flavored water.

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers?

Yogurt and buttermilk Buttermilk, parsley, and yogurt are foods that are natural intestinal deodorizers. Dried lentils, asparagus, turnips, fish, onions, and garlic are foods that produce odor.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm. When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

a child who has pneumonia An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery Digital removal of stool should not be performed on clients who have bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery. None of the other listed health problems contraindicate digital removal of stool.

The nurse is assessing clients for basal metabolic rate (BMR). Which client would the nurse suspect would have an increased BMR?

a client who has a fever A client who has a fever would have an increased BMR. The energy needs of the body are increased due to the client's fever. The BMR is decreased in an older adult client, a client who is fasting, and a client who is asleep.

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

a flexible sheath that is rolled around the penis A condom catheter is a flexible sheath that is rolled around the penis. A urinary bag (U-bag) is a bag attached by adhesive backing to the skin surrounding the genitals. A straight catheter is a urine drainage tube inserted but not left in place. A retention (or indwelling) catheter is a urine drainage tube that is left in place over a period of time.

At what period of life do nutrient needs stabilize?

adulthood Nutrient needs change across the life span in relation to growth, development, activity, and age. Periods of intense growth and development (such as during infancy, adolescence, pregnancy and lactation) increase nutrient needs. Nutrient needs stabilize during adulthood.

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

age 50 and older a positive family history a history of inflammatory bowel disease The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals.

A nurse documents a client's hemoglobin as 80 g/L. What nutritional condition does this biochemical data signify?

anemia If hemoglobin (normal = 12 to 18 g/dL; 120 to 180 g/L) is decreased, anemia is present. A increased hematocrit signifies dehydration. Malnutrition is related to serum albumin, blood urea nitrogen, and creatinine. Decreased serum albumin also signifies malabsorption.

The proliferation of Clostridium difficile causes:

antibiotic-associated diarrhea. Normal intestinal flora inhibit the growth of Clostridium difficile. When broad-spectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea.

The student nurse is preparing a presentation on bowel elimination. Which would be a potential cause of diarrhea that the student should include? Select all that apply.

antibiotics acute stress

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?

anuria Absence of urine for a 24-hour period reflects anuria.

A client has developed dysphagia secondary to a cerebrovascular accident. The nurse is aware that the client is at risk for

aspiration Dysphagia or difficulty swallowing can occur after a stroke and would place the client at risk for aspirating liquids. Gastritis is irritation of the stomach, usually caused by aspirin or peptic ulcer disease. Incontinence is the inability to have control of urination or defecation. Confusion is a lack of understanding.

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:

atelectasis. Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing:

auscultation When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion prior to auscultation may disturb normal peristalsis and confound the assessment.

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.

After reviewing the client's chart, the nurse notes that the client has been ordered a clear liquid diet. Which meal tray would the client be allowed to eat?

bouillon, apple juice, and gelatin Clear liquid diets contain foods that are clear liquids at room temperature or body temperature, such as gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. Full liquid diets contain all the items on a clear liquid diet, but also include milk and milk drinks, custards, puddings, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes.

The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid?

brussels sprouts Certain foods (e.g., cabbage, onions, legumes) often increase the amount of flatus produced in the intestine.

Which symptom will have a great impact on the extracellular fluid for water conservation?

burns The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.

A student nurse studying human anatomy knows that a structure of the large intestine is the:

cecum The small intestine consists of the duodenum, jejunum, and ileum. The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum.

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.

clay colored black yellow The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan) and yellow are considered abnormal colors for adult stool.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

croup Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.

The nurse is teaching a client about ways in which to reduce sodium in the diet. Which foods will the nurse recommend that the client avoid? Select all that apply.

cured ham table salt bacon Sodium is found in higher concentrations in table salt, bacon, and processed meats. The other choices do not have a high concentration of sodium.

A client has been n.p.o. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color?

dark amber Urine may be dark amber or orange-brown if it is very concentrated secondary to a decreased fluid intake. Urine is lighter than normal if it is diluted. Foods or drugs can also alter the color of urine. Tea-colored or very dark urine is a sign of dehydration.

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy The client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine. Other answers are incorrect.

A 57-year-old man is suffering from polyuria. What can cause polyuria?

diabetes insipidus Untreated diabetes insipidus can cause an increase in the formation and excretion of urine without a concurrent increase in fluid intake. Renal disease often leads to oliguria and even anuria, a decrease in urine outputs. Urinary tract infections cause an increase in frequency but not necessarily an increase in the amount of urine that is produced. Renal calculi can cause hematuria.

Which symptom is a known side effect of antibiotics?

diarrhea A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics.

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery

A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)?

emptying a client's ileostemy appliance It is safe for an experienced UAP to empty an ostomy. GI assessment and insertion and irrigation of an NG tube cannot be delegated.

A woman consumes pasta, grains, and other carbohydrates for which purpose?

energy The main function of carbohydrates is to provide energy.

Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is:

extremely obese a BMI of 40 or greater indicates extreme obesity.

"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces.

false A vagal response, is an involuntary response which increases parasympathetic stimulation, causing a decrease in heart rate. This can occur with administration of an enema. A nurse should assess the client while administration of an enema.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?

fine crackles to the bases of the lungs bilaterally Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

flow meter In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours?

functional incontinence Functional incontinence is urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, or loss of memory or disorientation. Stress incontinence occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. Reflex incontinence is an emptying of the bladder without the sensation to void. Transient incontinence appears suddenly and lasts for 6 months or less.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level. Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition?

iodine A chronic deficiency of iodine can lead to goiter, which manifests as an enlargement of the thyroid gland.

Which medication causes constipation?

iron supplements A common side effect of iron supplements is constipation. Bisacodyl is a stool softener. Aspirin is an analgesic that does not typically cause constipation. Magnesium antacids help to decrease heartburn and do not typically cause constipation.

A client with anemia has been prescribed injections of B12. Which foods high in this vitamin will the nurse also recommend that the client consume? Select all that apply.

lean steak milk yogurt saltwater fish Cyanocobalamin, otherwise known as vitamin B12, is found in lean meats, milk and dairy products, and saltwater fish and oysters. It is not found in high concentrations in foods like peas or butter

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

left lateral The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply.

light or dark brown The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan), and yellow are considered abnormal colors for adult stool.

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency Stool produced from an ileostomy is liquid and contains large quantities of electrolytes.

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet?

maintenance of normal bowel elimination Dietary fiber is a minimal source of energy but plays an essential role in stimulating peristalsis and maintaining normal bowel elimination. Proteins have specific functions of producing hemoglobin for carrying oxygen to tissues, insulin for blood glucose regulations, and albumin for regulating osmotic pressure in the blood. Fats perform the important functions of energy storage of adipose tissue, vitamin absorption, and transport of fat-soluble vitamins A, D, E, and K.

A postmenopausal client wishes to increase the amount of vitamin D that she consumes to help keep her bones strong. Which food will the nurse recommend?

milk Milk contains vitamin D, which helps with the absorption of calcium and phosphorous. The other choices do not.

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?

nasal cannula A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:

negative nitrogen balance. A negative nitrogen balance exists when excretion of nitrogen exceeds the intake.

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a:

neurogenic bladder. Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both.

A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:

niacin Niacin, part of the B vitamins, has a known side effect of flushing and itching after ingestion. The other vitamins that make up the B complex vitamin are B1 thiamin, B2 riboflavin, B3 niacin, B5 pantothenic acid, B6 pyridoxine, B7 biotin, B9 folic acid, and B12 cobalamin. Other adverse effects of the B complex vitamins include nausea, vomiting, constipation, abdominal pain, and black stools.

A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose?

normal Normal blood glucose is 80 to 110 mg/dL (4 to 7 mmol/L).

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?

oil Mineral, olive, or cottonseed oil is used to lubricate the stool and intestinal mucosa without distending the intestine. Water and normal saline do not have these qualities. Soap has lubricant properties but primarily acts by irritating the intestinal mucosa.

The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention?

older adults living on a fixed income Older adults who are socially isolated or living on fixed incomes will benefit most from nutritional counseling and intervention. Other individuals are not at the same level of risk.

A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James?

overweight A body mass index (BMI) between 25 and 29.9 is considered overweight.

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?

overweight A client with a BMI below 18.5 should be considered underweight. A client with a BMI of 18.5 to 24.9 is considered to be at a healthy weight. A client with a BMI of 25 to 29.9 is considered overweight; a client with a BMI of 30 or greater indicates obesity. A BMI greater than 40 is considered extreme obesity.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last?

palpation The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

pattern of thoracic expansion The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?

pulse oximetry Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend?

pursed lip breathing Pursed-lip breathing is most helpful for clients who have excessive levels of carbon dioxide in the blood and chronic hypoxemia. Other choices do not eliminate as much carbon dioxide from the blood.

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:

pus Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI.

A nurse is caring for a client with chronic anemia. What should be included in the diet of this client?

red meat Red meat is a source of iron. It therefore should be included in the diet of a client with chronic anemia. Dairy products, citrus fruits, and yellow vegetables are nutrient-dense foods and not sources of iron. Dairy products are sources of fat, whereas citrus fruits and yellow vegetables are sources of vitamins.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

residual volume During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action?

respiratory assessment As the nurse enters the room, he or she will immediately begin an assessment of respiratory efforts, vocalizations, chest symmetry or lack thereof, and auditory lung sounds. Other actions can take place subsequent to the assessment.

Which laboratory test is the best indicator of a client in need of TPN?

serum albumin Assessment of serum albumin level is the best indicator of a client in need of total parenteral nutrition (TPN). Clients whose levels are 2.5 g/dL (25 g/L) or less are at severe risk for malnutrition. Creatinine is used to assess kidney function. Hemoglobin and hematocrit assess the red blood cells of a client.

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration?

sims Sims position is appropriate as it promotes gravity distribution of the solution. Other choices are incorrect positions.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds Skin turgor response that is greater than 3 seconds, especially in an older adult clients, requires nursing intervention. Older adults with diarrhea can more easily become dehydrated and develop fluid and electrolyte imbalances. Other assessment findings are normal.

A nurse is caring for a client who has a malabsorption disease. The nurse should understand that which structure in the gastrointestinal system absorbs the majority of digested food and minerals?

small intestine Most absorption of digested food and minerals occurs in the small intestines. The stomach is responsible for storing food, secreting digestive enzymes, and digestion. The large intestine forms feces and absorbs water to regulate the consistency of stool. The digestive function of the liver is the production of bile.

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider?

thrill and bruit The client is experiencing decreased circulation to the left arm that has an AV graft for hemodialysis. There is increased risk for the AV graft to clot and create a circulatory emergency. Obtaining a full set of vital signs would be indicated to evaluate overall status of the client; however, the health care provider would need to know if thrill and bruit are present over the AV graft. Absence of thrill and bruit is a medical emergency.

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Urinary incontinence is the inability for the client to control his urine. There are many different causes for urinary incontinence. Urinary tract infections are a leading cause of morbidity and health care expenditures in persons of all ages, accounting for up to 40% of infections reported by acute care hospitals. These infections can be of the upper or lower urinary system. Urinary retention is the inability to urinate. The causes of urinary retention are numerous.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma?

use water and mild soap The nurse will teach the client to use water and mild soap to cleanse the stoma. Water only will not provide cleansing; an alcohol-based sanitizer will dry the stoma; mineral oil is not appropriate for cleansing.

A nurse is conducting client education with a woman who meets the diagnostic criteria for metabolic syndrome. The nurse is teaching the client about the MyPlate tool for promoting healthy food intake. According to MyPlate, the highest proportion of food in each meal should consist of what?

vegetables MyPlate recommends the Americans make half of their plate fruits and vegetables. Dairy, proteins, and unsaturated fats are important components of a healthy diet but they should be consumed in smaller quantities than vegetables.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

vesicular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin?

vitamin B12 Vitamin B12 deficiency is most commonly found in vegetarians, particularly in strict vegans. Individuals who have such rigid dietary restrictions must take care to supplement this vitamin.

Which vitamin is found only in animal foods?

vitamin B12 Vitamin B12 functions in the formation of mature red blood cells and in synthesis of DNA and RNA. This vitamin is only found in animal foods (meats, fish, poultry, milk, and eggs).

The nurse is caring for a client who has been experiencing prolonged wound healing from a surgical procedure. A deficiency in which nutrient would be associated with this condition?

vitamin C Poor wound healing is associated with deficiencies in vitamin C and protein.

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?

vitamin K Specific foods may interact with medications, altering the effectiveness of the drug. Vegetables high in vitamin K decrease the effectiveness of the commonly used anticoagulant warfarin. Calcium, potassium, and Vitamin C do not interact with warfarin.

A client who has bleeding tendencies has a deficiency in which vitamin?

vitamin K Vitamin K deficiencies are manifested in two ways: an increased tendency to hemorrhage and hemorrhagic disease of the newborn, which is common in premature or anoxic newborns.

A client with no significant medical history reports constipation for the past week. Which assessment information will the nurse collect? Select all that apply.

whether the client is taking new medication the client's normal bowel habits if the client feels a sensation of rectal fullness if the client has used laxatives in the past The nurse will ask about new medications, because these can often cause constipation; what the client's normal bowel habits are like to establish a baseline; and whether the client has used laxatives to pass stool in the pass. A sensation of rectal fullness is associated with constipation. Loose stool is associated with diarrhea.