215 Exam 3 Mobility and Nutrition

4. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents.

4. A. CORRECT: Auscultate for bowel sounds, because the client's gastrointestinal tract might not be able to absorb nutrients. Then withhold feedings and notify the provider. B. CORRECT: Place the client in an upright position, with at least a 30° elevation of the head of the bed. Upright positioning helps prevent aspiration. Upright positioning helps prevent aspiration: C. CORRECT: Before administering enteral feedings, verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations. D. Have the enteral formula at room temperature before administering the enteral feeding. E. Return the residual to the client's stomach, unless the volume of gastric contents is more than 250 mL or the facility has other guidelines in place.

4. A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage (herbal tea).

4. A. CORRECT: Cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. B. An abdominal binder can help prevent, not treat, a wound evisceration. C. Do not handle or apply pressure to any exposed organs or tissues, because these actions increase the risks of trauma and perforation. D. CORRECT: This position minimizes pressure on the abdominal area. E. Keep the client NPO in anticipation of the surgical team taking them back to the surgical suite for repair of the evisceration.

4. A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting

4. A. Expect the client who has hypercalcemia to have decreased reflexes. B. CORRECT: Expect the client who has hypercalcemia to have confusion and a possible decreased level of consciousness. C. Expect the client who has hypocalcemia to have a positive Chvostek's sign. D. CORRECT: Expect the client who has hypercalcemia to have bone pain. E. CORRECT: Expect the client who has hypercalcemia to have nausea and vomiting along with anorexia.

4. A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

4. BMI = weight (kg) ÷ height (m?). Step 1: Client's weight (kg) and height (m) = 80 kg and 1.6 m Step 2: 1.6 x 1.6 = 2.56 m2 Step 3: 80 ÷ 2.56 = 31.25 A BMI greater than 30 identifies obesity.

A client has finished a 16-oz container of orange juice. The intake and output sheet documents fluid in milliliters. What amount should the nurse document as the client's intake?

480 mL

5. A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest. C. Administer oral pain medication. D. Obtain a Dobhoff tube for insertion. E. Have a petroleum-based lubricant available.

5. A. CORRECT: Establish a means for the client to communicate that they want to stop the procedure before inserting an NG tube. B. CORRECT: Place a disposable towel across the client's chest to provide for a clean environment and protect the client's gown from becoming soiled. C. Because the purpose of the procedure is to remove stomach contents, the procedure would also remove the oral pain medication. D. Plan to use the prescribed type of tube for gastric decompression, which is a Salem sump, Miller-Abbott, or Levin. A Dobhoff tube is for feeding. E. Plan to use a water-based lubricant to reduce complications from aspiration.

5. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.

5. A. CORRECT: Sensations of thirst diminish with age, leaving older adults more prone to dehydration. B. CORRECT: These requirements do not change from middle adulthood to older adulthood. However, some older adults need additional vitamin and mineral supplements to treat or prevent specific deficiencies. C. CORRECT: If older adults ingest insufficient calcium in the diet, they need supplements to help prevent bone demineralization (osteoporosis). D. Older adults have a slower metabolic rate, so they require less energy (unless they are very active), and therefore need fewer calories. E. Many older adults need more carbohydrates for the fiber and bulk they contain. They should, however, reduce their intake of fats and of "empty" calories (pastries and soda pop).

5. A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30° B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed.

5. A. CORRECT: Slightly elevate the head of the client's bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels, B. Deep tissues can be traumatized when massaging the skin over bony prominences. C. Cornstarch and powder can abrade the client's sensitive skin and increase the risk for aspiration. D. CORRECT: Have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. E. Reposition the client at least every 2 hr. Frequent position changes are important for preventing skin breakdown, but every 3 hr is not frequent enough.

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

5. A. CORRECT: The client should hold the cane on the uninjured side to provide support for the injured left leg. B. CORRECT: The client should keep two points of support on the ground at all times for stability. C. The client should place the cane 15 to 25 cm (6 to 10 in) in front of their feet before advancing. D. CORRECT: The client should advance the weaker leg first, followed by the stronger leg. E. The client should advance the stronger leg past the cane.

A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "Avoid green, leafy vegetables while taking this medication." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "Report diarrhea while taking this medication.

5. A. Green, leafy vegetables are rich in magnesium and do not hinder oral magnesium therapy. B. Thiazide diuretics increase magnesium output, thereby worsening the client's hypomagnesemia. C. Encourage the client's intake of foods that are high in magnesium (whole grains, nuts, cocoa). D. CORRECT: Instruct the client to report diarrhea while taking oral magnesium replacement. This is a potential adverse effect of taking oral magnesium, which could worsen the client's hypomagnesemia.

5. A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule. B. Check the client's weight each morning. C. Notify the provider of a urine output greater than 30 mL/hr. D. Encourage independent ambulation four times a day.

5. A. Hypotension is a manifestation of dehydration therefore the administration of antihypertensive medication would further lower the client's blood pressure and increase the risk for injury. B. CORRECT: Include obtaining the client's weight each day in the plan of care. To ensure accuracy the client's weight should be obtained at the same time each day using the same scale. By determining the client's weight gain or loss each day the nurse can evaluate the client's response to treatment. C. A urine output greater than 30 mL/hr is an expected finding and is an indicator of adequate fluid balance. Plan to monitor the client's urine output and notify the provider if it is less than 30 mL/hr. D. The client who has dehydration is at risk for falls due to orthostatic hypotension, possible decrease in level of consciousness, and possible gait instability. Encourage the client to use the call light and ask for assistance when getting out of bed or ambulating.

A nurse is encouraging an older adult client to invest in a pedometer to track the amount of walking she does each day and to challenge herself to increase her activity level gradually each day. When explaining the benefits of walking, the nurse should include which of the following information? A. A single calorie fuels about 25 steps of walking. B. Walking at 4 miles/hr burns about 12 calories/min. C. A single calorie fuels climbing one flight of stairs.

A single calorie fuels about 25 steps of walking

Which of the following food choices are appropriate for a client who is prescribed a full liquid diet? (Select all that apply.) A.Plain yogurt B.Custard C.Ice cream D.Mashed potatoes E.Puréed meat F.Gelatin

A, B, C, F

A nurse is caring for client with antiembolic stockings. Which of the following is true regarding antiembolic stockings: (Select all that apply). If a response is FALSE, correct the answer to be true/appropriate. A. A prescription is required for antiembolic stockings. B. To select the appropriate size, the nurse must measure the circumference of the ankle. C. Remove the stockings every 8 hours to assess the skin. D. They are used to promote venous return such as clients with lower extremity edema. E.The stockings must be dry and wrinkle free to prevent skin breakdown.

A, C, D, E

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply) A. Contractures of the extremities B. Excessive Urination C. Diarrhea D. Crackles in lungs E. Pressure Ulcers

A, D, E

A nurse is teaching a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients needs nasogastric tube intubation for gastric decompression? A.6-year-old child who ingested a toxic substance B.A 60-year-old client who has a gastrointestinal hemorrhage C.A 40-year-old client who has a postoperative bowel obstruction D.A 20-year-old client who has malabsorption syndrome

A. 40-year old client who has a postoperative bowel obstruction - a client who has a postoperative bowel obstruction should have a nasogastric tube inserted for decompression to remove gastric secretions - relieve distention, nausea, and pain

Which of the following actions should a nurse take to aspess a client who had a stroke for complications secondary to inadequate swallowing? A. Auscultate the client's lungs. B. Place the tip of a tongue depressor on the client's posterior tongue. C. Inspect the client's uvula and soft palate with a penlight. D. Place fingers on the client's throat at the level of the larynx and ask the client to swallow

A. Auscultate the client's lungs.

1. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated."

A. CORRECT: Flush the tube after instilling the feeding to help keep the NG tube patent by clearing any excess formula from the tube so that it doesn't clump and clog the tube. B. Tape a securing device, not flush the tube with water, to help maintain the position of the NG tube. C. Administer additional fluids. The small amount used for flushing the NG tube will not be adequate. D. Contact the dietary staff to prepare formula according to the prescription before the nurse instills it.

4. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. C. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.

A. CORRECT: To reduce the risk of injury, at least two staff members should reposition clients. B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury. C. When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back. D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements helps prevent injury. E. It is important to take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles.

3. A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented.

A. Checking that the container has not exceeded its expiration date, either for having it open or for opening it, is important. However, there is a higher assessment priority among these options. B. CORRECT: The greatest risk to the client receiving enteral feedings is injury from aspiration. The priority nursing assessment before initiating an enteral feeding is to verify proper placement of the NG tube. C. Assess the client for any possible complications of enteral feedings (diarrhea). However, there is another assessment that is the priority. D. Determine the client's level of consciousness as an assessment parameter that is ongoing and should precede any procedure. However, another assessment is the priority.

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor

A. Distended neck veins is an expected finding of hypervolemia. B. Hypothermia is an expected finding of hypovolemia. C. CORRECT: Tachycardia is an expected finding of hypovolemia. D. CORRECT: Syncope is an expected finding of hypovolemia. E. CORRECT: Decreased skin turgor is an expected finding of hypovolemia.

Which of the following interventions should a nurse use at mealtimes for a client who has visual impairment? A.Identify the food location as though the plate were a clock. B.Direct the order in which food items are consumed. C.Have the client tilt their head forward while eating. D.Avoid talking to the client during mealtime,

A. Identify the food location as though the plate were a clock

A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of tube feeding? A.Limit the time the formula hangs to 8 hr. B.Flush the tube every 8 hr. C.Deliver the formula at a brisk rate. D.Allow the feeding bag to empty before refilling it.

A. Limit the time the formula hangs to 8 hr

2. A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds. B. Stop the feeding. C. Obtain a chest x-ray. D. Initiate oxygen therapy.

A. Listen to breath sounds whenever there is suspicion of the client aspirating. However, another assessment is the priority. B. CORRECT: The greatest risk to the client is aspiration pneumonia. The first action to take is to stop the feeding so that no more formula can enter the lungs. C. Obtain a chest x-ray whenever there is suspicion of the client aspirating. However, another assessment is the priority. D. Initiate oxygen therapy whenever there is suspicion of the client aspirating. However, another assessment is the priority.

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? A.Move their leg behind their body. B.Move their leg forward and up. C.Move their leg medially toward their other leg. D.Turn their foot and leg away from their other leg.

A. Move their leg behind their body.

A nurse is providing teaching about risk for aspiration with a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? A. A feeling of fullness B. Persistent coughing C. Discomfort in the naris D. Postfeeding belching

A. Persistent Coughing

A tai chi master is teaching an introductory session on the basics of this health-promoting activity. He explains that, to boost energy without causing stress, the tai chi movements are A. Soft. B. Slow. C. Continuous.

A. Soft

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva maneuver, B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change positions often.

A. The Valsalva maneuver increases the workload of the heart, but it does not affect peripheral circulation. B. CORRECT: Elastic stockings promote venous return and prevent thrombus formation. C. A review of the client's total protein level is important for evaluating his ability to heal and prevent skin breakdown D. Placing pillows under the knees and lower extremities can impair circulation of the lower extremities. E. CORRECT: Frequent position changes prevents venous stasis.

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A."Lie on your back with our head and shoulders supported by a pillow. B."Have your head turned to the side while you lie on your stomach." C."Have a table beside your bed so you can sit on the bedside and rest your arms on the table." D."Lie on your side with your top arm resting on the bed and your weight on your hip.

A. The nurse is describing the supine position, not the orthopneic position. B. The nurse is describing the prone position, not the orthopneic position. C. CORRECT: This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD. D. The nurse is describing the lateral or side-lying position, not the orthopneic position.

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B."The lower my center of gravity, the more stability I have. C."To broaden my base of support, I should spread my feet apart." D"When I lift an object, I should hold it as close to my body as possible." E."When pulling an object, I should move my front foot forward."

A. To reduce the risk of falling, the line of gravity should fall within the base of support, not outside it. B. CORRECT: Being closer to the ground lowers the center of gravity, which leads to greater stability and balance. C. CORRECT: Spreading the feet apart increases and widens the base of support. D. CORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevent injury and instability. E. To promote stability, move the rear leg back when pulling on an object.

A fitness trainer who is giving a presentation on weight training is pointing out the dangers of using androgenic anabolic steroids to build muscle strength. Which of the following is an adverse outcome of using these products for this purpose? Select all that apply. A.Infertility B. Cancer C. Liver disease D. Seizures E. Psychotic episodes

A. infertility B. Cancer C. Liver disease

A nurse is reviewing a client's laboratory values. Which of the following information is correct regarding albumin levels and nutritional status? A.Albumin level is a poor short-term indicator of protein status. B.Hydration status does not affect a client's albumin level. C.An albumin level of 3.2 g/dL is within the expected reference range. D.Albumin level is calculated by keeping a 24-hr record of protein intake.

A.Albumin level is a poor short-term indicator of protein status.

A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experiencing social isolation. Which of the following interventions should the nurse recommend? A.Encourage the client to go to the dining room at meal times to talk with other clients B.Suggest that the client watch television while feedings are being administered. C.Remind the client that they can have visitors after feeding administration times. D.Ask the facility chaplain to speak with the client.

A.Encourage the client to go to the dining room at meal times to talk with other clients

A nurse is performing a nasogastric intubation on a client and has reached the tube's predetermined length. Which of the following actions should the nurse take first? A.Inspect the oropharynx with a penlight and a tongue blade. B.Obtain an x-ray examination of the chest and abdomen. C.Tape the tube securely in place with a tube holder device. D.Aspirate gastric contents.

A.Inspect the oropharynx with a penlight and a tongue blade.

A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the initial placement of the tube? A.Obtain an X-ray. B.Auscultate injected air. C.Take a pH measurement of gastric aspirate. D.Identify the color of gastric contents.

A.Obtain an x-ray

To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe and from the earlobe to the A. xiphoid process plus 20 to 30 cm more. B. manubrium plus 10 to 20 cm more. C. xiphoid process. D. umbilicus.

A.xiphoid process plus 20 to 30 cm more.

A nurse is presenting a program on safe and effective exercise for older adults who have rheumatoid arthritis. Which of the following instructions should she recommend for this client population? A. Exercise everyday B. Exercise with a companion or group. C. Consider a regular program of walking. D. Get up and stretch regularly throughout the day. E. Use exaggerated movements during daily activities.

B, C, D, E

Using the FITTE factor, what should a nurse recommend as a general fitness and health guideline for clients who wish to improve their physical activity level? A. Perform moderate exercise at least 20 min/day. B. Choose rhythmic exercise of large muscle groups. C. Engage in vigorous exercise at least 30 min/day

B. Choose rhythmic exercise of large muscle groups.

A nurse is giving a presentation at a senior community center about factors that affect the ability to engage in physical activity. The nurse should explain that which of the following disorders specifically affect exercise endurance? (Select all that apply.) A. Osteoporosis B. Diabetes Mellitus C. Anemia D. Arthritis E. Heart Failure

B. Diabetes C. Anemia E. Heart failure

Which of the following dietary modifications should an adolescent who participates in sports implement? A. Increase fats to 30% to 40% of daily kilocalories. B. Drink water before and after sports activities. C. Keep protein intake at the same level. D. Decrease carbohydrates to 30% to 40% of daily kilocalories.

B. Drink water before and after sports activities.

A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas s the nurse administer to the client? A.Modular B. Elemental C.Polymeric D. Specialty

B. Elemental

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia .. Which of the following bed positions should the nurse use for safe care of this client ? A. Supine . B. Semi - Fowler's C. Semi - prone D. Trendelenburg

B. Helps prevent regurgitation and aspiration, best for clients receiving enteral feeding

A nurse is informed during shift report that a client has a nasogastric tube connected to continuous suction. The nurse should identify that this client must have which of the following types of tubes? A. Sengstaken-Blakemore tube B. Salem sump tube C. Ewald tube D. Dobhoff tube

B. Salem sump tube

A nurse is caring for a client who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this client undergo which of the following? A.Chest x-ray B.Swallowing examination C.Olfactory nerve evaluation D.Nasogastric tube insertion

B. Swallowing examination

A nurse is counseling a client who has multiple risk factors for osteoporosis. Which of the following exercise strategies should the nurse recommend to help the client maintain bone density? A. Using a seated rowing machine B. Working out on an elliptical trainer C. Taking a water aerobics class

B. Working out on an elliptical trainer.

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include? A."Lean on the crutches to support your body weight when standing." "Fully extend your arms when holding onto the hand grips." B."Hold the crutches on your unaffected side when preparing to sit in a chair." C."Hold the crutches 9 inches in front of and to the side of each foot."

B."Hold the crutches on your unaffected side when preparing to sit in a chair."

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? A. Adducting the arm so that it lies next to the client's side B.Flexing the shoulder by raising the arm from a side position to a 180° angle. C.Abducting the arm to a 90° angle from the side of the body D.Circumducting the shoulder in a 180° half circle

B.Flexing the shoulder by raising the arm from a side position to a 180° angle

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene? A.Places a removable cover over the sling B.Leaves the bed in the lowest position throughout the procedure C. Locks the hydraulic valve before attaching the sling to the lift D. Raises the head of the bed to a sitting position just before transfer

B.Leaves the bed in the lowest position throughout the procedure

A nurse is assessing a client who has required strict bedrest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate? A. Needs assistance raising her legs to put on socks. B. Demonstrates mild dyspnea while eating breakfast. C. Performs active ROM exercises of all extremities. D. Develops fatigue when assisting with morning hygiene care.

C

A charge nurse is reviewing anthropometric values with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A."Isolated measurements of height and weight are of greater significance than changes over time." B. "A weight increase of 4 pounds in a client who has renal failure indicates retention of 1,000 mililiters of fluid. C."The client should be weighed on the same scale at the same time each day." D."The ratio of height-to-wrist circumference is the most accurate way to identify obesity.

C. "The client should be weighed on the same scale at the same time each day."

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique? A. Positioning the chair slightly behind the nurse so that the seat faces the client. B. Placing the client's left leg in front of the right leg just prior to the transfer. C. Aligning the nurse's knees with the client's knees just before the transfer. D. Grasping the client under the axillae to assist them to their feet

C. Aligning the nurse's knees with the client's knees just before the transfer.

A nurse is checking the client's nasogastric tube for placement. Which of the following procedures should the nurse implement? A. Instill 20 mL of air into the tube and listen for a whooshing sound. B. Aspirate stomach contents and check the pH. C. Aspirate stomach contents and check their color. D. Auscultate lung sounds.

C. Aspirate stomach contents and check the pH

A nurse is caring for a client who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the client with feeding? A. Provide the client with a straw. B. Offer the client thin fluids. C. Elevate the head of the bed 45° to 90° D. Place food in the weaker side of the mouth.

C. Elevate the head of the bed 45 to 90 degrees.

Which of the following strategies for enhancing the intake of healthy foods is appropriate for an adolescent? A. Encouraging the adolescent to consume snack foods from the grains food. B.Permitting the adolescent to skip breakfast to enhance appetite at later meals. C.Making healthful food choices more convenient and available for the adolescent. D.Allowing the adolescent complete autonomy in making food choices

C. Making healthful food choices more convenient and available for the adolescent.

A nurse is caring for a client who has a significant risk of aspiration and requires nutritional support for about 2 weeks because they are unable to consume adequate nutrients orally. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe? A. Percutaneous endoscopic gastrostomy tube B.Nasogastric tube C.Nasointestinal tube D.Percutaneous endoscopic jejunostomy tube

C. Nasointestinal tube-is recommended for clients at a high risk of aspiration who require short-term feedings of less than 4 weeks

A nurse is teaching a client who is starting an exercise program to calculate his target heart rate. The nurse should include which of the following instructions? A. Challenge himself to exceed the target range for brief periods. B. Find the target rate by subtracting his age from 200. C. Sustain the target range for at least 20 minutes.

C. No matter the exercise activity, the client should increase his heart rate gradually to a target rate that hi can sustain for at least 20 minutes to allow for a safe yet challenging aerobic workout.

A nurse is giving a presentation at a family-oriented recreation center about getting children involved in physical activities. The nurse should explain that children develop exercise-related abilities and preferences during which of the following stages? A.Toddler B. Preschool C. School Age

C. School Age

A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? A. A client who has a paralytic ileus B. A client who has recently experienced facial trauma C. A client who has dysphagia D. A client who has a decreased appetite

C.A client who has dysphagia

A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? A.Preventing curling of the tube in the mouth B.Allowing the client to breathe through the mouth C.Closing off the glottis D.Opening the lower esophageal sphincter

C.Closing off the glottis

When teaching the guardian of a toddler about feeding and eating, the nurse should include which of the following safety measures? A.Do not give the child peanut butter. B.Have the child drink 28 to 32 oz of milk daily. C.Do not offer the child raw vegetables. D.Give the child 8 to 12 oz of fruit juice daily.

C.Do not offer the child raw vegetables.

A nurse is caring for a client who is recovering from gastric surgery, is NPO, and as a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A.Offer throat lozenges for the client to use. B.Apply petroleum jelly to the client's naris. C.Provide frequent mouth care. D.Allow the client to suck on ice chips.

C.Provide frequent mouth care.

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? A. Relax her abdominal muscles while lifting object B. Twist at the waist when she moves an object to one side. C. Hold the object away from her body as she lifts it. D. Bend at the knees when picking up an object.

D. Bend at the knees when picking up object

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? A. Wrap both arms around the client's arms and shoulders. B. Move both feet together when the client begins to fall. C. Protect the client's extremities while lowering them to the floor. D. Extend one leg and allow the client to slide down the leg to the floor.

D. Extend one leg and allow the client to slide down the leg to the floor.

A nurse is caring for a client who is sitting in a chair and asks to return to bed . Which of the following actions is the nurse's priority at this time ? A.Obtain a walker for the client to use to transfer back to bed . B. Call for additional staff to assist with the transfer . C. Use a transfer belt and assist the client back into bed . D. Determine the client's ability to help with the transfer .

D. First action that shoukd be taken using the nursing process is to assess or collect data from the client. Determine the clients ability to help with transfer and then procedd with safe transfer.

A nurse is caring for a client who has a nasogastric tube connected to suction. Which of the following findings indicates that the tube has become occluded? A. Active bowel sounds B. Increase in gastric secretions C. Passing flatus D. Increased abdominal distention

D. Increased abdominal distention

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take? A. Place the stockings on the client after the client ambulates to the restroom. B.Ensure the client's toes are visible after placing the stockings on the client. C.After applying the stockings, place two fingers between the client's leg and stocking to check the fit. D.Measure the client's calf circumference and leg length from heel to knee.

D. Measure the client's calf circumference and leg length from heel to knee.

Which of the following is the primary purpose for asking a client to keep a 3- to five-day food diary? A. To allow the client to rely on health professionals to identify problem areas. B. To determine any changes in the client's appetite C. To evaluate any significant changes in body weight D. To assess the pattern of intake and compare with daily reference intakes

D. To assess the pattern of intake and compare with daily reference intakes

A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement? A.Measure the pH of gastric aspirate B.Auscultate the epigastric area while injecting air. C.Place the open end of the tube in a cup of water. D.Obtain an x-ray.

D.Obtain an x-ray

A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? A.Ensure the formula is at room temperature. B.Add blue food coloring to the enteral formula. C.Flush the feeding tube with 30 mL of water. D.Place the client in Fowler's position.

D.Place the client in a Fowler's position.

Semi-Fowler's Position

Lies supine 30 degrees This position prevents regurgitation of enteral feedings and aspiration by clients who have difficulty swallowing. It also promotes lung expansion for clients who have dyspnea or are receiving mechanical ventilation.

Sims' or semi-prone position

The client is on their side halfway between lateral and prone positions, with the weight on their anterior ileum, humerus, and clavicle. The lower arm is behind them while the upper arm is in front. Both legs are in flexion but the upper leg is flexed at a greater angle than the lower leg at the hip as well as at the knee. It differs from the side-lying position in the distribution of the client's weight. This is a comfortable sleeping position for many clients, and it promotes oral drainage.

Prone

The client lies flat on their abdomen and chest with the head to one side and back in correct alignment. A pillow may be placed under the leg. This promotes relaxation by permitting some knee flexion and dorsiflexion of the ankles. This position promotes drainage from the mouth after throat or oral surgery, but inhibits chest expansion. It is for short-term use only. This position helps prevent hip flexion contractures following a lower extremity amputation.

supine or dorsal recumbent position

The client lies on their back with the head and shoulders elevated on a pillow and forearms on pillows or at their sides. A foot support prevents foot drop and maintains proper alignment. Ensure that the vertebrae are in straight alignment without excessive flexion or extension of the head and neck.

lateral or side-lying position

The client lies on their side with most of the weight on the dependent hip and shoulder and the arms in flexion in front of the body. They should have a pillow under the head and neck, upper arms, and legs and thighs to maintain body alignment. This is a good sleeping position, but the client needs turning regularly to prevent the development of pressure ulcers on the dependent areas. A 30° lateral position is essential for clients at risk for pressure ulcers.

Fowler's position

The client lies supine with the head of the bed elevated 45° to 60° This position is useful during procedures (nasogastric tube insertion and suctioning). It allows for better chest expansion and ventilation and better dependent drainage after abdominal surgeries.

High Fowler's Position

The client lies supine with the head of the bed elevated 60° to 90°. This position promotes lung expansion by lowering the diaphragm and thus helps relieve severe dyspnea. • It also helps prevent aspiration during meals.

Modified Trendelenburg

The client remains flat with the legs above the level of their heart. This position helps prevent and treat hypovolemia and facilitates venous return.

Orthopneic

The client sits in the bed or at the bedside with a pillow on the overbed table, which is across the client's lap. They rest their arms on the overbed table. This position allows for chest expansion and is especially beneficial for clients who have COPD.

Reverse Trendelenburg

The entire bed is tilted with the foot of the bed lower than the head of the bed. This position promotes gastric emptying and prevents esophageal reflux.

A nurse is counseling a client who is 48 years old and is about to start a physical activity program. Calculate the upper range of the client's heart rate. (Round off to the nearest whole number)

To calculate the client's target heart rate, first calculate her maximum heart rate by subtracting her age from 220. That's 172. Then obtain the target heart rate as 60% to 85% of her maximum heart range: 60% of 172 is 103.2; 85% of 172 is 146.2. So her target heart rate is 103 to 146/min. The upper range is 146/min.

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A. Infuse hypotonic IV fluids. B. Implement a fluid restriction. C. Increase sodium intake. D. Administer sodium polystyrene sulfonate.

1. A. CORRECT: Hypotonic IV fluids are indicated for the treatment of hypernatremia related to fluid loss to expand the ECF volume and rehydrate the cells. B. Increased fluid intake is indicated for the treatment of hypernatremia. C. Decreased sodium intake is indicated for the treatment of hypernatremia. D. Administration of sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia.

1. A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

1. A. The client is at risk for decreased subcutaneous fat due to altered mobility. However, there is another risk that is the priority. B. The client is at risk for muscle atrophy due to altered mobility However, there is another risk that is the priority. C. CORRECT: The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hr. D. The client is at risk for fecal impaction due to altered mobility. However, there is another risk that is the priority.

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care

1. A. The client is not at either extreme of the age spectrum. B. CORRECT: Diabetes mellitus is a chronic illness that places additional stress on the body's healing mechanisms. C. CORRECT: Hgb is essential for oxygen delivery to healing tissues, and this client's Hgb level is low. D. CORRECT: A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished. Deficiencies in essential nutrients delay wound healing. E. There is no indication that there have been any breaches in aseptic technique during wound care.

1. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids. B. Instruct the client to tuck their chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals.

1. A. Thin liquids increase the client's risk for aspiration. B. CORRECT: Tucking the chin when swallowing allows food to pass down the esophagus more easily. C. Using a straw increases the client's risk for aspiration. D. Sitting for an hour after meals helps prevent gastroesophageal reflux and possible aspiration of stomach contents after a meal.

2. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

2. A. Although the body gets more than half of its energy supply from fat, it is an inefficient means of obtaining energy. It produces end products the body has to excrete, and it requires energy from another source to burn the fat. B. Protein can supply energy, but it has other very essential and specific functions that only it can perform. So it is not the body's priority energy source. C. Glycogen, which the body stores in the liver, is a backup source of energy, not a primary or priority source. D. CORRECT: Carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins from depletion.

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism

2. A. CORRECT: Crohn's disease is a risk factor for hypocalcemia. This malabsorption disorder places the client at risk for hypocalcemia due to inadequate calcium absorption. B. A thyroidectomy places the client at risk for hypocalcemia due to the possible removal of or injury to the parathyroid glands. C. A history of bone cancer increases the client's risk of hypercalcemia due to the shift of calcium from bone to ECF. D. Hyperthyroidism places the client at risk for hypercalcemia due to the shift of calcium from bone to ECF.

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst

2. A. CORRECT: Expect the client to have pain and tenderness at the wound site with an incisional infection. B. CORRECT: Expect the client to have fever and chills with an incisional infection. C. CORRECT: Expect the client to have reddened or inflamed wound edges with an incisional infection. D. Expect the client to have purulent drainage with an incisional infection. E. Do not expect changes in thirst as an indication of an incisional infection.

2. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an toxic dose of sodium bicarbonate antacids

2. A. CORRECT: Identify that a client who has nasogastric suctioning is at risk for hypovolemia due to excessive gastrointestinal losses. B. Diarrhea, rather than constipation, places the client at risk for hypovolemia due to excessive gastrointestinal losses. C. Syndrome of inappropriate antidiuretic hormone places the client at risk for hypervolemia due to overhydration. D. A toxic dose of sodium bicarbonate antacids places the client at risk for hypervolemia due to excessive sodium intake.

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

3. A. CORRECT: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation. B. Instruct the client to cough and deep breathe every 1 to 2 hr to reduce the risk of atelectasis. C. Increase the client's intake of fluids, unless contraindicated, to reduce the risk of thrombus formation, constipation, and urinary dysfunction. D. Reposition the client every 1 to 2 hr to reduce the risk for pressure injuries.

3. A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

3. A. CORRECT: Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. B. Sutured surgical incisions heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. C. Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin. D. Lacerations sealed with tissue adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. E. CORRECT: Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.) A. Hct 55% B. Blood osmolarity 260 mOsm/kg C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035 E. Blood creatinine 0.6 mg/dL

3. A. CORRECT: This Hct is greater than the expected reference range of 42-52% for males and 37-47% for females and is an indication of dehydration due to hemoconcentration. B. This blood osmolarity is within the expected reference range of 285-295 mOsm/kg. A blood osmolarity greater than 295 mOsm/kg is an indication of dehydration. C. CORRECT: This blood sodium level is greater than the expected reference range of 136-145 mEq/L and is an indication of dehydration due to hemoconcentration. D. CORRECT: This urine specific gravity is greater than the expected reference range of 1.005-1.030. An increased urine specific gravity is an indication of dehydration. E. This blood creatinine is within the expected reference range of 0.6 to 1.3 mg/dL. An elevated blood creatinine level is an indication of dehydration.

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage

3. A. Initiate an IV infusion of a fluid containing dextrose to promote the movement of potassium from ECF to ICF. B. Withhold oral potassium and provide the client with a potassium-restricted diet. C. CORRECT: A potassium level of 5.2 mEq/L indicates hyperkalemia. Anticipate the initiation of continuous cardiac monitoring due to the client's risk for dysrhythmias (ventricular fibrillation). D. Gastric lavage is not indicated for the treatment of hyperkalemia. However, prepare the client for dialysis if hyperkalemia becomes severe.

3. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

3. A. Whole grains (barley and oats) are high in fiber and thus inappropriate components of a low-residue diet. B. Raw and gas-producing vegetables (broccoli and the cabbage in coleslaw) are high in fiber and thus inappropriate components of a low-residue diet. C. CORRECT: A low-residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs (custard and yogurt) are appropriate for a low-residue diet. D. Legumes (lentils and black beans) are high in fiber and thus inappropriate components of a low-residue diet.

4. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites

4. A. A client who has adrenal insufficiency is at risk for isotonic fluid volume deficit (hypovolemia) because of a decrease in aldosterone secretion and an increase in sodium and water excretion B. CORRECT: Anticipate a client who has heart failure to require fluid and sodium restriction to reduce the workload on the heart. C. A client who has diabetic ketoacidosis is at risk for dehydration because hyperglycemia can cause osmotic dieresis which leads to dehydration and electrolyte loss. D. A client who has ascites is at risk for hypovolemia because of a fluid shift from the intravascular space to the abdomen.

A nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? A "This device will keep me from getting sores on my skin.' B "This device will keep the blood pumping through my leg." C "With this device on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

4. A. Assess the skin under the sequential pressure device every 8 hr to check for manifestations of a thrombus and skin breakdown. B. CORRECT: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation. C. Continuous passive motion machines, not sequential pressure devices, provide some muscle movement that can assist in preserving some muscle strength. D. Continuous passive motion machines, not sequential pressure devices, exercise the knee joint after arthroplasty.

Trendelenburg position

•The entire bed is tilted with the head of the bed lower than the foot of the bed. This position facilitates postural drainage and venous return.