Week 4 Lab Quiz

A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include? a. Empty the pouch when it is 1/2 full. b. Hold pressure on the skin barrier for 10 to 15 sec to secure the seal. c. Clean the peristomal skin four times a day. d. Expect firm fecal content.

a. Empty the pouch when it is 1/2 full.

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? a. Lower the height of the solution container. b. Encourage the client to bear down. c. Allow the client to expel some fluid before continuing. d. Stop the enema and document that the client did not tolerate the procedure.

a. Lower the height of the solution container.

A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse? a. Lubricates the first 2.5 to 5 cm (2 in) of the catheter. b. Dons sterile gloves before cleaning the client's meatus. c. Secures the tubing to the client's upper thigh. d. Pulls gently on the catheter to check for resistance after inflating the balloon.

a. Lubricates the first 2.5 to 5 cm (2 in) of the catheter.

Which of the following would be an inappropriate indication for placement of an indwelling foley catheter? a. Urinary incontinence b. Pre-operational intervention for abdominal surgery c. Urethral blockage d. Need for accurate output monitoring

a. Urinary incontinence

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? a. 6.0 b. 4.0 c. 7.0 d. 8.0

b. 4.0

A nurse at a health fair is assessing the weight status of four clients. Which of the following clients are classified as overweight? a. A female client who has a body mass index of 24 b. A male client who has a body mass index of 29 c. A female client who has a waist circumference of 101.6 cm (40 in) d. A male client who has a waist circumference of 96.52 cm (38 in)

b. A male client who has a body mass index of 29

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? a. Insert the needle into the needless port at a 60° angle. b. Withdraw 3 to 5 mL of urine from the port. c. Wipe the area of needleless port with sterile water. d. Don sterile gloves.

b. Withdraw 3 to 5 mL of urine from the port.

Which are appropriate interventions for a patient complaining of dry mouth with an NPO order (Select all that apply): a. The patient may have sips of water, no more than 50 ml/hr b. The patient may have ice chips only c. The patient may use moistened swaps as needed d. The nurse offers oral care frequently e. The patient may swish and spit water or mouthwash as needed

c, d, e

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction (gastric outlet obstruction). Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching? a. Determine the pH of the gastric secretions. b. Supply nutrients via tube feedings. c. Decompress the stomach. d. Administer medications.

c. Decompress the stomach.

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider? a. Stoma oozing red drainage b. Shiny, moist stoma c. Purplish-colored stoma d. Rosebud-like stoma orifice

c. Purplish-colored stoma

he nurse is caring for a patient receiving continuous enteral feedings. What is the first action of the nurse if she suspects aspiration of the feeding? a. Obtain a chest x-ray b. Initiate oxygen therapy c. Stop the feeding d. Auscultate breath sounds.

c. Stop the feeding

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? a. "I will allow him to be in the position where he is most comfortable during the feeding." b. "I will elevate the head of the bed 10 degrees during the feeding." c. "I will turn him on his left side during the feeding." d. "I will have him sit in his chair during the feeding."

d. "I will have him sit in his chair during the feeding."

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? a. Creatine kinase b. Troponin c. Total bilirubin d. Albumin

d. Albumin

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

260 mL

The nursing student is calculating the output for their patient over the last four (4) hours. The patient had voided 250 mL clear urine and had a large formed stool the first time the student assisted him to the bathroom. The next time the student entered the room, they dumped 150 mL of clear urine from the urinal. The student has refilled the patient's water three times for 350 mL each. How many mL of output would the student calculate?

400 mL

A nurse is preparing to insert an NG tube for a client who requires gastric suctioning. Place the following steps in the appropriate order. (Place the steps of NG tube placement in the correct order of performance. All steps must be used. Use 1, 2, 3, 4, 5, 6 format.) 1) Measure the NG tube. 2) Instruct the client to flex the head forward. 3) Instruct the client to extend the neck backward. 4) Connect the tube to the suction device. 5) Prepare equipment at the bedside. 6) Obtain an x-ray.

5, 1, 3, 2, 6, 4

nurse is preparing to perform a capillary blood glucose test. Identify the sequence of steps the nurse should follow. (Place steps in 1, 2, 3, 4, 5, 6 format.) 1) Document results. 2) Perform a quality control test. 3) Apply blood sample onto test strip. 4) Cleanse puncture site. 5) Perform hand hygiene. 6) Check expiration date on test strips.

6,2,5,4,3,1

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? a. Deflate the catheter balloon using a sterile syringe. b. Measure and document the urine in the drainage bag. c. Remove the tape or device securing the catheter to the client's thigh. d. Position the client supine.

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? a. Deflate the catheter balloon using a sterile syringe. b. Measure and document the urine in the drainage bag. c. Remove the tape or device securing the catheter to the client's thigh. d. Position the client supine.

A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)? a. Wound drainage for culture b. Urine from an indwelling catheter c. Blood for PaCO2 d. Random stool specimen

d. Random stool specimen

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? a. To confirm the placement of the NG tube b. To remove gastric acid that might cause dyspepsia c. To determine the client's electrolyte balance d. To identify delayed gastric emptying

d. To identify delayed gastric emptying