passpoints question

The physician orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?

Softening of the stool.

A client is using healing touch therapy to manage pain. What should the nurse tell the client about how healing touch can be effective in pain management?

directing the flow of energy fields.

Which nursing intervention is most important in preventing postoperative complications?

early ambulation

Which question should the nurse ask first when obtaining a history from the parent of a school-age child with a fever, malaise, and swelling around the eyes?

"Does the child urinate as much as usual?"

Which statement indicates that the client understands the home care of a colostomy?

"I should be able to establish a regular pattern of elimination with my colostomy."

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

"I should lie on my back as much as possible to relieve the pain."

A nurse is teaching a client what to expect following a barium enema. Which client statement indicates a need for further teaching?

"I should limit my fiber intake for 1 to 2 weeks following the procedure."

A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective?

"My ankle looks less swollen now."

Which statement by the student nurse needs correction by the instructor concerning the physiologic effects of smoking cigarettes?

"Smoking decreases coagulability."

n which location would the nurse auscultate the highest point of the lung on the anterior side of the chest?

3 to 4 cm above the clavicle

Which heart rate would be found in a 4-month-old infant with bradycardia?

50

A registered nurse and a nursing assistant are caring for a group of clients. Which client's care may safely be delegated to the nursing assistant?

A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do?

Check on the client at regular intervals to ascertain the need to use the bathroom.

A client with osteoarthritis purchased a copper bracelet to wear and tells the nurse that there is less pain now. Which response by the nurse is most appropriate?

Acknowledge that the client feels better, but encourage the client to continue with the prescribed therapy.

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?

Administer an analgesic.

Which part of the lungs is assessed on the posterior chest?

All parts of the lower lobes

Which abnormality would the nurse expect in a patient with kyphosis?

An exaggerated posterior curvature of the thoracic spine

Which is indicative of rebound tenderness in the abdomen?

Appendicitis

Which method would the nurse use to detect a pericardial friction rub?

Auscultate with the diaphragm of a stethoscope.

The accumulation of lymph in the breasts and upper arms is a result of an obstruction of which lymph nodes?

Axillary

A client has a patient a controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first?

Inspect the infusion site.

Which site is appropriate for palpation of the popliteal pulse?

Below the knee

Which finding supports the nurse's assessment of a patient with acute asthma who the nurse suspects may have pulsus paradoxus?

Blood pressure falls > 10 mm Hg during inspiration.

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the clients stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted.

The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the health care provider's (HCP's) prescription, the nurse notes that the prescription states, "morphine sulfate 60 mg IM every 4 hours as needed for pain." The usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the nurse to take?

Contact the HCP to verify the prescription.

Which term is used to document excessive sweating associated with shortness of breath?

Diaphoresis

Which changes take place during the process of inspiration? Select all that apply.

Diaphragm descends Intercostal muscles contract Intrathoracic pressure decreases

Which murmur is caused by an obstruction of the flow of blood into the ventricles?

Diastolic rumble

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?

Document the client's choice and re-assess pain in 1 hour.

A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client to do?

Empty the bladder every 2 to 3 hours.

Which increased serum level leads the nurse to conclude the patient is at risk of atherosclerosis? Select all that apply.

Glucose, Cholesterol, Triglycerides

A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L (3 mmol/L). Which prescribed order will the nurse implement first?

I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution with 20 mEq (20 mmol/L) of potassium chloride at 100 ml/hr

Which test would the nurse use to assess a patient with suspected appendicitis pain?

Iliopsoas muscle test

Which are changes in the gastrointestinal system because of aging? Select all that apply.

Impaired drug metabolism Decreased sense of taste Decreased liver size

Which finding of an umbilical cord during a newborn's assessment is cause for concern?

It has one artery and one vein.

Which statement precisely describes the "angle of Louis"?

It is the articulation of the manubrium and the body of the sternum.

Which are the normal features of the spleen? Select all that apply.

It lies under the diaphragm. It lies parallel to the tenth rib. it is a soft mass of lymphatic tissue.

Which finding is consistent with sudden onset of severe colicky pain in the lower abdomen?

Kidney stones

Which description of semilunar valves is correct?

Lie between the ventricles and the great vessels

Which is a characteristic of the great saphenous vein?

Located inside the leg

Which feature is specific to the right kidney?

May be palpable

During the chest assessment of a patient, which reference line would the nurse note on the posterior chest wall?

Midspinal

Which stool color is expected for a patient who is taking an iron supplement?

Nontarry black stool

The nurse learns in shift report that the patient has Biot's respirations. The nurse anticipates which assessment?

Normal breathing interrupted by apnea

A child is admitted with constipation and a diagnosis of possible appendicitis. The child is in acute pain. Which nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.

Offer an ice pack. Assume a position of comfort. Limit the child's activity.

Which section of the electrocardiogram (ECG) indicates atrial depolarization?

P wave

Which soft, lobulated gland is located behind the stomach?

Pancreas

Arrange the order of the steps that the nurse would follow to determine the weak peripheral pulse of a patient by using a Doppler ultrasonic probe.

Place the patient in a supine position with the legs rotated externally. Place a drop of coupling gel at the end of the handheld transducer. Place the transducer over the pulse site at a 90° angle. Apply very light pressure and locate the pulse site.

Decreased tactile fremitus is consistent with which diagnosis?

Pleural effusion

Which condition causes the stool to be gray in color?

Presence of jaundice or hepatitis

Arrange the following steps to show the order in which lung development takes place from the embryonic stage to the birth of the infant.

Primitive lung bud emerges during the first 5 weeks of fetal life. Conducting airways reach the same number as in an adult Surfactant is a complex lipid substance needed for sustained inflation of the air sacs Lungs have 70 million primitive alveoli Blood supply is detached from the placenta. Blood gushes into the pulmonary circulation.

Which is a normal finding in the assessment of a 3-year-old child?

Protuberant abdomen

For which complications would the nurse monitor in a patient with deep vein thrombosis?

Pulmonary embolism

Which would the nurse infer from the finding of enlarged, warm, and tender cervical lymph nodes on an infant?

Respiratory infection

Which condition can cause a wide split in the second heart sound?

Right bundle branch block

Which quadrant would the nurse assess in a pregnant patient for pain related to appendicitis?

Right lower quadrant (RLQ)

Which additional muscles are involved in increasing the size of the thoracic cage during forced inspiration after heavy exercise? Select all that apply.

Scaleni Trapezii Sternomastoids

Which is the nurse performing when placing the stethoscope over the xiphoid process while lightly stroking the skin with one finger up the midclavicular line from the right lower quadrant (RLQ)?

Scratch test

Which term is used to describe the pacemaker of the heart?

Sinoatrial node

Which patient positions are necessary during a cardiac assessment? Select all that apply.

Sitting Supine Left lateral recumbent

A client has requested to have patient-controlled analgesia (PCA) after surgery? When is it appropriate for a client to receive PCA?

The client has the ability to self-administer.

When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches the client how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?

The client keeps the drainage bag below the bladder at all times.

Which teaching instructions by the nurse is appropriate for a client with constipation?

The client will consume foods high in fiber.

Which statements would the nursing instructor include in a lecture about inguinal lymph nodes? Select all that apply.

They drain the lymph of the lower extremities. They drain the lymph of the external genitalia They drain the lymph of the anterior abdominal wall.

Palpable rhonchal fremitus indicates which condition?

Thick bronchial secretions

Which statement describes the pericardium?

Tough, fibrous sac surrounding the heart

A child with rheumatic fever complains of painful joints. Which nonpharmacologic measures should the nurse use to reduce the child's pain?

Use a bed cradle to keep linens from pressing on the child's joints.

Three days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse ask the client before administering the pain medication?

When did you last have a bowel movement?

Which client would benefit from the application of warm moist heat?

a client with low back pain

A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:

a diminished response to a drug so that more medication is required to achieve the same effect.

Which client is at highest risk for developing a urinary tract infection?

a man with an indwelling urinary catheter

Which intervention would be least appropriate for a client who is in a double hip spica cast?

advising the client to eat large amounts of cheese

A client is receiving massage therapy to relieve pain. Which statement explains why massage is an effective way to relive pain?

blocks pain impulses from the spinal cord to the brain.

A client who recently immigrated from Korea to the US or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?

checking vital signs and assessing for nonverbal indications of pain

When planning pain control for a client with terminal gastric cancer, a nurse should consider that

clients with terminal cancer may develop tolerance to opioids.

The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). What additional signs should the nurse assess?

deep vein thrombosis (DVT) in the left leg.

The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem?

friction along the urethra when the catheter is being inserted..

A client's serum ammonia level is elevated, and the health care provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug?

increased bowel movements

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

inserting a Foley catheter

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal?

keeps the new urethra from closing

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?

laxative

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

limiting fluid intake to 1,000 mL/day

A nurse is caring for an 8-year-old girl with multiple chronic urinary tract infections. The child's parents appear protective, never leaving their daughter's side. While the nurse helps the child's mother provide morning care, the child states, "My uncle doesn't " clean me that way. Her mother becomes visibly upset and gives the girl a stern warning not to discuss the matter. She states, "Don't tell anyone about that again." The nurse has a legal responsibility to:

notify the nursing supervisor and the authorities of the possibility of abuse.

The second morning after surgery for a below-the-knee amputation of the left leg, the client says, "This sounds crazy, but I feel my left toes tingling." This statement would indicate to the nurse that he is experiencing a:

phantom-limb sensation.

The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?

an orange, raisin bran and milk, and wheat toast with butter

Which abdominal assessment would the nurse use to confirm rebound tenderness?

Blumberg sign

Which blood vessel drains the blood from the head and upper extremities?

Superior vena cava

Which statement describes a lift with respect to the cardiovascular system?

Sustained thrust of the ventricle of the heart

Which statement describes the structure of the lungs?

The right lung is shorter and wider than the left lung

A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:

breathe deeply.

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first?

Assess the pain using a pain scale and compare to the previous assessment.

Which jugular pulse component reflects ventricular contraction?

C wave

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged?

The client voids 500 mL of urine

After teaching the client how to use the patient-controlled analgesia (PCA) pump, the nurse determines that the client understands the use of the PCA when the client makes which statement?

The machine will give me only the prescribed amount of pain medication even if I push the button too soon.

The nurse teaches a primigravid client how to do Kegel exercises. What does the nurse explain is the expected outcome of these exercises?

strengthening the perineal muscles

A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her?

This symptom is normal and results from the fetus exerting pressure on the bladder.

While assessing a patient with an infection of the forearm, the nurse uses one hand to shake the patient's hand and keeps the other hand near the patient's elbow. Which is the reason for the nurse's action?

To check for enlarged epitrochlear nodes

Which arteries are described as having superficial and deep palmar arches? Select all that apply.

Ulnar artery Radial artery

The client has been taking magnesium hydroxide to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids?

diarrhea

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:

incorporate the clients toileting schedule into the pattern of his wandering