Unit 5,6,7 review

A client has developed a urinary tract infection after being catheterized during surgery. The nurse anticipates the health-care provider will prescribe an: A) Antiparasitic. B) Anti-infective C) Antibiotic. D) Antiviral.

C Antibiotic

A client experiencing pain rated as a 7 on a scale from 1 to 10 continues to have pain despite having medication 2 hours ago. Which response should the nurse make when the client requests additional medication? a) "I can't give you any more medication for 2 hours." b) "Sometimes thinking about the pain makes it feel worse." c) "Let me reposition you and rub your back to help relieve the pain" d) "I will shut the door and turn out the light to help the medication work faster."

C) "Let me reposition you and rub your back to help relieve the pain"

The nurse observes that although several clients are experiencing pain, the pain response and tolerance are different. Which factors about pain perception should the nurse keep in mind when assessing for pain? Select all that apply. a) Emotions b) Individual values c) Educational level d) Developmental stage e) Ethnic and cultural beliefs

Emotions, Individual values, Developmental stage, Ethnic and cultural beliefs

The nurse reinforces education for a patient with a history of orthostatic hypotension. Which patient statement indicates the need for additional teaching? a) "I will remain flat in bed." b) "I will change position in bed frequently." c) "I will ensure dorsal and plantar flexion of my feet." d) "I will perform active range-of-motion exercises several times a day."

a) "I will remain flat in bed."

The nurse assesses a client 24 hours after abdominal surgery. The client is experiencing nausea, anorexia, and is vomiting foul-smelling emesis. Physical assessment reveals an extended abdomen and hypoactive bowel sounds. Which order does the nurse expect from the client's physician? a) A nasogastric tube inserted to provide enteral nutrition b) A prescription for anti-nausea and anti-emetic medication c) A schedule for six small liquid meals to be given daily d) A nasogastric tube inserted for gastric decompression

d) A nasogastric tube inserted for gastric decompression

A client's stomach contents will be removed by inserting a double-lumen nasogastric (NG) tube through the nose into the stomach and then connecting the tube to a suction. The nurse identifies this procedure as ____________________.

gastric-decompression

An emergency department nurse admits an adult client for a drug overdose. The physician writes an order for the nurse to instill charcoal through a nasogastric (NG) tube. Which size tube will the nurse select? a) 4 French b) 8 French c) 12 French d) 16 French

d) 16 French

A nurse is donning gloves for contact isolation. Place the following steps in the correct chronological order (1-5). (Enter the number of each step in the proper sequence, do not use commas. For example, 123456.) 1. Pull glove on nondominant hand. 2. Pull sleeve edges down over proximal part of the hand. 3. Pull glove cuff over the wrist. 4. Pull glove on dominant hand. 5. Perform hand hygiene.

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The mother of a preschool-age child reports having difficulty getting the child to go to sleep at night. Which suggestion should the nurse provide this mother? a) Read a bedtime story to the child. b) Encourage the child to play a game. c) Turn on the television in the child's room. d) Permit the child to stay awake until feeling sleepy.

A) Read a bedtime story to the child.

A client asks why the shoulder is hurting when the problem is in the abdomen. Which type of pain should the nurse explain this client is experiencing? a) Referred b) Radiating c) Intractable d) Intermittent

A) Referred

A 23-year-old female client has been diagnosed with a yeast infection. The nurse identifies that this is which type of pathogen? a) Fungi b) Protozoa C) Virus D) Bacteria

A. fugui

The nurse is aware that good nutrition is essential for __________________, the process when the body uses components to build or reconstruct new components or tissue.

Anabolism

A client with chronic pain reports that pretending to be lying on a beach with the sun warming the legs helps relieve the chronic hip and leg pain caused by arthritis. Which nonpharmacological method is this client using to control pain? a) Distraction b) Guided imagery c) Progressive relaxation d) Therapeutic suggestion

B) Guided imagery

A client reports feeling pain "only when I move." Which type of pain is this client experiencing? a) Visceral b) Cutaneous c) Neuropathic d) Deep somatic

D) Deep somatic

The nurse finds a client who is sleeping difficult to arouse to provide routine prescribed medications. Which stage of sleep was this client most likely experiencing? a) Stage I b) Stage II c) Stage III d) Stage IV

D) Stage lV

The nurse has determined that a client's pain is acute and plans to administer pain medication. Which signs and symptoms of acute pain did the nurse use to make this clinical determination? Select all that apply. a) Dilated pupils b) Constricted pupils c) Syncope d) Increased heart rate e) Reduced attention span

Dilated pupils, Syncope, Increased heart rate, Reduced attention span

The nurse provides care for an immobile patient. Which interventions does the nurse include in the patient's plan of care to prevent psychological complications for this patient? Select all that apply. a) Making all decisions about the patient's care b) Distracting the patient by turning on the television c) Encouraging the patient to stay awake most of the day d) Talking to the patient about photographs of the adult children e) Closing blinds to decrease natural lighting in the patient's room

Distracting the patient by turning on the television, Encouraging the patient to stay awake most of the day, Talking to the patient about photographs of the adult children

The nurse is concerned that a client is experiencing chronic pain. Which psychological symptoms did the nurse assess to make this clinical determination? Select all that apply. a) Fear b) Fatigue c) Depression d) Low self-esteem e) Poor attention span

Fatigue, Depression, Low self-esteem

A client expresses understanding about the role dietary fiber has in the prevention of constipation. Which other reasons should the nurse present about the importance of fiber in the diet? Select all that apply. a) Dietary fiber will decrease the LDL cholesterol level. b) Adequate dietary fiber increases the absorption of minerals. c) Fiber prevents bowel cancer by increasing the pH in the colon. d) Fiber supports normal flora in the GI tract by providing a food source. e) Adequate intake of dietary fiber will contribute to weight loss.

a) Dietary fiber will decrease the LDL cholesterol level. b) Adequate dietary fiber increases the absorption of minerals. d) Fiber supports normal flora in the GI tract by providing a food source. e) Adequate intake of dietary fiber will contribute to weight loss.

The nurse is caring for a client admitted with a diagnosis of bulimia nervosa. Which assessment finding will the nurse expect? Select all that apply. a) Evidence of dental caries b) Verbal reports of indigestion c) Statements about constipation d) Frequent bouts of sore throat e) Poor skin turgor and sunken eyes

a) Evidence of dental caries b) Verbal reports of indigestion d) Frequent bouts of sore throat e) Poor skin turgor and sunken eyes

A physician has ordered "Clear liquids, advance as tolerated." Which factors indicate to the nurse the advancement of the client's diet should be delayed? Select all that apply. a) Hypoactive bowel sounds b) Nausea and vomiting c) Reports of indigestion d) Expression of hunger e) Verbalizing thirst

a) Hypoactive bowel sounds b) Nausea and vomiting c) Reports of indigestion

A client is prescribed the medication lithium as a mood-stabilizing agent. Which laboratory report indicates the client may be retaining higher than prescribed levels of lithium? a) Low sodium levels b) High sodium levels c) Low potassium levels d) High potassium levels

a) Low sodium levels

The LPN/LVN is assigned to feed a client who was admitted with the diagnosis of a cerebral vascular accident (CVA). The client's ability to swallow is intact, but chewing remains difficult. Which type of food will most likely cause the LPN/LVN to consult with the RN? a) Mechanical soft b) Pureed c) Full liquid d) Thickened liquid

a) Mechanical soft

The LPN/LVN is caring for a client with diabetes mellitus and obtains a morning blood glucose level of 60 mg/dL. The LPN/LVN reports the finding to the RN. Which intervention does the LPN/LVN expect? a) Provide the client with one-half cup of orange juice. b) Cover the client with insulin using a sliding scale. c) Chart the finding in the client's medical record. d) Wait for fifteen minutes and repeat the assessment.

a) Provide the client with one-half cup of orange juice.

The nurse is providing dietary teaching to a client who is a vegetarian. Which is a single source of complete protein that the nurse should recommend to the client? a) Soy b) Seeds c) Wheat d) Brown rice

a) Soy

The nurse assesses a client just admitted from the emergency department with pain in the lower right quadrant of the abdomen. The physician's order reads, "Diet as tolerated." Which conclusion will impact the nurse's decision regarding the client's diet? a) The client will be NPO due to the probability of surgery. b) A clear liquid diet is appropriate to avoid possible nausea. c) The client can have a regular diet until symptoms worsen. d) A diet high in protein and vitamin C will promote healing.

a) The client will be NPO due to the probability of surgery.

The nurse is providing care for a client after joint replacement surgery. The nurse delivers a lunch tray with a cheeseburger, French fried, slaw, and fresh fruit. After the meal, the nurse picks up an empty tray. Which comment is more important for the nurse to make if the client states, "My husband ate part of my lunch because I'm just not that hungry"? a) "That's fine. Most of our clients do not eat all their meals." b) "I will need to know which foods you actually ate." c) "The trays are overfilled so clients have plenty to eat." d) "Let's discuss what foods you would like for the next meal."

b) "I will need to know which foods you actually ate."

A client has been vomiting without relief from medications. The physician orders the client on NPO status. Which action by the nurse violates the physician's order? a) Maintains previously ordered IV fluids b) Gives ice chips when the client indicates mouth dryness c) Provides mouth swabs and lip balm for client comfort d) Offers mouth care on a regular basis

b) Gives ice chips when the client indicates mouth dryness

The nurse prepares a presentation for parents of adolescents with eating disorders. The parents have expressed an interest in understanding the causes and effects of the disorder. Which information will the nurse include? Select all that apply. a) It is more prevalent in males than in females. b) It can cause a client's health to be severely affected. c) It generally occurs during adolescence or early adulthood. d) It is evidenced by extreme disturbances in eating habits. e) It may result from either physical or psychological causes.

b) It can cause a client's health to be severely affected. c) It generally occurs during adolescence or early adulthood. d) It is evidenced by extreme disturbances in eating habits. e) It may result from either physical or psychological causes.

The nurse provides care to a patient who develops respiratory distress. The patient needs to be positioned to allow for the chest to expand to maximum capacity for moving air in and out of the lungs. In which position does the nurse place the patient? a) Supine b) Orthopneic c) Right Sims d) Trendelenburg

b) Orthopneic

The nurse plans care for a patient who has a history of becoming dizzy, pale, clammy, and nauseated when moving from a lying position to a sitting position. The nurse plans interventions to prevent which condition? a) Thromboembolism b) Orthostatic hypotension c) Orthostatic hypertension d) Symptomatic bradycardia

b) Orthostatic hypotension

Which term does the nurse recognize as the process that gently propels the food bolus into the small intestine? a) Digestion b) Peristalsis c) Indigestion d) Absorption

b) Peristalsis

The nurse is teaching a client newly diagnosed with diabetes mellitus about the eating and nutrition parameters required with the client's diagnosis. Which comment by the client indicates that teaching is understood? a) "I will need to eat 3 meals and 2 snacks daily." b) "I can plan for a special dinner if I skip my lunch." c) "I will find a new method for cooking besides frying." d) "Once a week I can splurge and eat whatever I want."

c) "I will find a new method for cooking besides frying."

The nurse is completing the placement of a nasogastric (NG) tube. Which is the most reliable way for the nurse to initially confirm the placement of the tube? a) Quickly instill 10 mL of air into the tube and listen for a "whoosh" in the epigastric area. b) Withdraw some of the stomach contents and check for a pH between 1 and 4. c) After placement of a radiopaque tube confirm the location of the tube by x-ray. d) Check a line marked on the tube for location at the entrance of the nares.

c) After placement of a radiopaque tube confirm the location of the tube by x-ray.

The nurse brings a dinner tray to a client on a regular diet. The nurse notes that the client has been blind since birth. Which intervention by the nurse is most helpful in assisting this client to eat? a) Ask the client how they would like their dinner tray arranged. b) List and describe the foods that are present on the client's tray. c) Compare the location of the food on a plate with the face of a clock. d) Inquire if the client wants anything added or removed from the tray.

c) Compare the location of the food on a plate with the face of a clock.

Which fact should the nurse teach a client about the American Heart Association (AHA) recommendation regarding dietary fat? a) Disregard the number of daily calories consumed. b) Eat red meat and dairy products at each meal. c) Consume 25% to 35% of total daily calories from fat. d) Gradually eliminate all forms of fat from the diet.

c) Consume 25% to 35% of total daily calories from fat.

The nurse provides education to a client who needs to increase intake of complete proteins. The nurse recognizes that teaching is effective if the client selects which food? a) Nuts b) Corn c) Eggs d) Beans

c) Eggs

The LPN/LVN is obtaining a blood glucose level on a client with diabetes mellitus, and notes that the blood glucose level is 280 mg/dL. Knowledge of which condition prompts the LPN/LVN to report the finding to the RN? a) Hypoglycemia b) Diabetic coma c) Hyperglycemia d) A normal value

c) Hyperglycemia

The nurse is preparing teaching for a client ordered on long-term treatment with corticosteroids. As part of the teaching about side effects, the nurse should inform the client that which body function is primarily affected? a) Absorption b) Appetite c) Metabolism d) Excretion

c) Metabolism

The nurse shares information with a client about essential nutrients. Which fact is important for the nurse to emphasize? a)Minerals lose their structure once they are ingested. b)Micronutrients include proteins and carbohydrates. c)Nutrients are important, but too much of certain nutrients is problematic. d)Optimal health is supported by equal amounts of major and trace minerals.

c) Nutrients are important, but too much of certain nutrients is problematic.

When the nurse inserts a nasogastric (NG) tube, the client becomes cyanotic, coughs incessantly, and is unable to speak. Which action should the nurse take immediately? a) Encourage swallowing. b) Continue to insert the tube. c) Remove the tube completely. d) View the posterior pharynx.

c) Remove the tube completely.

A client is prescribed isoniazid (INH), a medication that treats tuberculosis (TB). Which condition will prompt the nurse to remind the physician that the client will need a specific vitamin during the therapy? a) Vitamin K is not absorbed when a client has TB. b) Vitamin C will increase lung healing with TB. c) Vitamin B6 excretion will increase with INH. d) Vitamin B12 prevents nerve damage from INH.

c) Vitamin B6 excretion will increase with INH.

The nurse is caring for a client in the hospital. On assessment, the nurse discovers the client's hands and feet are swollen. A review of the client's past medical history reveals a history of cardiac problems. Which diet does the nurse expect the physician to order for this client? a) A fat-restricted diet b) A carbohydrate-restricted diet c) A calorie-restricted diet d) A sodium-restricted diet

d) A sodium-restricted diet

The RN provides teaching to a client with newly diagnosed diabetes mellitus. Which method will the LPN/LVN reinforce as the best indicator of long-term glycemic control? a) Creatinine level b) Urine glucose level c) Blood glucose level d) Glycosylated hemoglobin

d) Glycosylated hemoglobin

The nurse provides care for a client who is emaciated and exhibits a severely enlarged abdomen and liver. The health-care provider also diagnoses the client with skin infections, small for age stature, and notably delayed mental development. Which condition does the nurse expect the health-care provider to diagnose? a) Neglect b) Starvation c) Protein excess d) Kwashiorkor disease

d) Kwashiorkor disease

The nurse reinforces teaching for the caregiver on an immobile patient who will be discharged home soon. Which caregiver action when supervising care indicates the need for the nurse to intervene? a) Using mild soaps for cleansing the skin b) Repositioning in bed at 2-hour intervals c) Offering the patient high-protein snacks d) Massaging directly on reddened bony prominences

d) Massaging directly on reddened bony prominences

The nurse is providing care for an older, sedentary female client. The client admits a lack of knowledge regarding a healthy diet. Which nutrition information is correct for the nurse to share? a) The "My Plate" guidelines are visually and comprehensively complex. b) "Dietary Guidelines for Americans" only covers vegetarian diets. c)Pregnancy requires an intake of 200 mcg of synthetic folic acid daily. d)The FDA suggests minimum daily intake of nutrients to prevent disease.

d) The FDA suggests minimum daily intake of nutrients to prevent disease.

The nurse is inserting a nasogastric (NG) tube. Which conclusion does the nurse make if a client coughs continually? a) The client is resisting insertion. b) The client has a strong gag reflex. c) The client needs to have a break. d) The client's airway is compromised.

d) The client's airway is compromised.

The nurse reviews the food diary of a client who is on a weight reduction plan. Which entry listed in the food diary provides the nurse with an idea why the client has not lost weight? a) Whole grain breads and cereals b) Fresh fruits and vegetables c)Lean meats and fish d) Whole milk and cheese

d) Whole milk and cheese

When a client has an intact digestive system but has difficulty with swallowing, digestion, or the absorption of food, the nurse can expect the client to be ordered on ____________________ feedings.

enteral