clicker questions

1. The nurse is planning care for an older adult with a pressure ulcer (see figure). What should the nurse do? Select all that apply. 1.Elevate the head of the bed to 50 degrees. 2.Obtain daily cultures. 3.Cover with protective dressing. 4.Reposition the client every 2 hours. 5.Request an alternating pressure mattress.

3,4,5

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? A. 3.5 B. 6.5 C. 7.35 D. 8.0

A. 3.5

A client who is weak, dyspneic, and jaundiced has an elevated bilirubin level. With which problem are these clinical findings consistent? A.Hemolytic anemia B.Pernicious anemia C.Iron Deficiency anemia D.Anemia of chronic disease.

A.Hemolytic anemia

Before administering an intermittent enteral feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to accomplish which purpose? A. To relieve gastric pressure B. Assess fluid and electrolyte status. C. Evaluate absorption of the last feeding. D. Confirm proper nasogastric tube placement.

C. Evaluate absorption of the last feeding.

A 67-year-old man is admitted with an embolic stroke and is started on a heparin drip within two hours. Six hours later, The activated partial thromboplastin time is greater than 120. The nurse should A. Increase the Heparin dose B. Decrease the Heparin Dose C. Stop the Heparin D. Administer Vitamin K

C. Stop the Heparin

On assessment of a patient with a colostomy, you note the stoma is located on the right lower quadrant. Due to its location, this is known as what type of colostomy? A. Descending Colostomy B. Transverse C. Ileostomy D. Ascending Colostomy

D. Ascending Colostomy

A patient with diabetes mellitus self monitors blood sugar at home. Now the primary care provider wants to assess the client's average blood sugar over a 3-month period. The best test for this would be: A.Fasting plasma glucose B.Urine dipstick for glucose C.Glucose tolerance test D.Hemoglobin A1C

D.Hemoglobin A1C

True or False: Symptoms of hypoglycemia include excessive hunger, fatigue, excessive sweating, and shakiness.

true

MATCH 1.Lab value monitoring for Coumadin therapy 2.Lab value monitoring for Heparin Therapy 3.Antidote for Coumadin 4.Antidote for Heparin A.Protamine Sulfate B.PT/INR C.PTT D.Vitamin K

1- B 2- C 3- D 4- A

MATCHING 1.Protein responsible for osmotic/oncotic pressure 2.Breakdown of hemoglobin 3.Estimate of Renal function A.GFR B.Bilirubin C.Albumin

1- C 2- B 3- A

Before administering an intermittent enteral feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to accomplish which purpose 1.Observe the digestion of formula. 2.Assess fluid and electrolyte status. 3.Evaluate absorption of the last feeding. 4.Confirm proper nasogastric tube placement.

3.Evaluate absorption of the last feeding.

A client is admitted to the emergency room with a diagnosis of acute myocardial infarction. The client tells the nurse, "I'm scared. I think I'm going to die." Which of the following responses by the nurse would be MOST appropriate? 1. "Everything is going to be fine. We'll take good care of you." 2. "I know what you mean. I thought I was having a heart attack once." 3. "I'll call your doctor so you can discuss it with him." 4. "It's normal to feel frightened. We're doing everything we can for you."

4. "It's normal to feel frightened. We're doing everything we can for you."

Your patient is NPO and is receiving continuous tube feeding via PEG tube. All of the following are appropriate nursing actions EXCEPT: A. Check blood sugar AC/HS B. Keep the bead of bed at or above a 30-degree angle C. Place feeding on hold when placing patient in a supine position D. Checking residual every 4 hours

A. Check blood sugar AC/HS

A patient with an ascending colostomy would have what type of stool from the stoma? A. Liquid stool B. Lose to partly formed stool C. Similar to normal stool D. Semi-solid stool

A. Liquid stool

Sitz baths are prescribed for a client with an inflamed painful hemorrhoid. How do the sitz baths aid the healing process? A. Promoting vasodilation B. Cleansing perineal tissue C. Softening the incision site D. Tightening the rectal sphincter

A. Promoting vasodilation

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which action by the home health aide indicates understanding about the nursing team's responsibility in relation to pressure ulcers? A.Inspecting the skin daily B.Providing a rubber cushion on which to sit C.Massaging body lotion over reddened areas D.Applying a heating pad to bony prominences

A.Inspecting the skin daily

The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? A.Protruding stoma B.Sunken and hidden stoma C.Narrowed and flattened stoma D.Dark and bluish colored stoma

A.Protruding stoma

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A.This is a normal, expected event. B.The client is experiencing early signs of ischemic bowel. C.The client should not have the nasogastric tube removed. D.This indicates inadequate preoperative bowel preparation.

A.This is a normal, expected event.

A patient has had colon surgery as a result of an intestinal obstruction. Which is a method of delivering nutrition that avoids the gut? A.Total parenteral nutrition (TPN) B.Puree diet with thickened liquids C.Tube feeding per gastrostomy tube D.Tube feeding per nasogastric (NG) tube

A.Total parenteral nutrition (TPN)

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? A.transparent film B.gauze C.hydrocolloid dressing D.hydrogel sheet

A.transparent film

The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, "I'm upset because I know I won't be able to have children now that I have an ileostomy." Which response by the nurse is best? A. "Many women with ileostomies decide to adopt. Perhaps you could consider that option?" B. "Having an ileostomy doesn't necessarily mean that you can't bear children. Let's talk about your concerns." C. "I can understand your reasons for being upset. Having children must be important to you." D. "I'm sure you will adjust to this situation with time. Try not to be too upset."

B. "Having an ileostomy doesn't necessarily mean that you can't bear children. Let's talk about your concerns."

Mrs. D returns from surgery with a new colostomy. The nurse assesses the stoma and notes that it is red and edematous. What is the best nursing action based on this finding? A. Place patient in a prone position B. Document the findings C. Apply ice immediately D. Call the health care provider

B. Document the findings

The nurse is caring for a child with neutropenia. Which beverage is unsuitable for the client with a low neutrophil count? A. 2% milk, need to be pasteurized or warmed B. Fresh squeezed lemonade C. Kool-aid D. Coffee

B. Fresh squeezed lemonade

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? A. Administer TPN through a nasogastric or gastrostomy tube. B. Handle TPN using aseptic technique. C. Auscultate for the presence of bowel sounds prior to administering TPN. D. Designate a peripheral IV site for TPN administration.

B. Handle TPN using aseptic technique.

How should the nurse determine the length of the nasogastric tube to be inserted? A. Insert the tube until resistance is felt. B. Measure from the nose to the earlobe to the xiphoid process. C. Insert the tube nasally until the patient feels discomfort. D. Have the patient to swallow some water, and insert the tube to the third premarked line.

B. Measure from the nose to the earlobe to the xiphoid process.

An outpatient care nurse is providing instructions to a patient who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure? A.Clear liquids may be consumed starting 24 hours after the procedure. B.A bowel preparation will be required in preparation for the procedure. C.Clear liquids only are allowed on the day of the scheduled procedure. D.You can drive back from the procedure by yourself

B.A bowel preparation will be required in preparation for the procedure.

A client is one day post-op following a transverse loop colostomy. Which assessment finding would be indicative of a complication? A.Hypoactive bowel sounds B.A dusky color to the stoma C.Soft stool measuring 200 mL D.Scant bleeding at the stoma site

B.A dusky color to the stoma

A Muslim female client has been stabilized after an assault in the parking lot of a local restaurant. The nurse manager is making assignments for the oncoming shift. Which action by the nurse manager is the most appropriate to ensure the client's comfort? A.Assign the best male nurse to the client B.Assign the client a female nurse for every shift C.Allow the client to pick which nurses she would like to care for D.Remove the client's clothing each shift to perform a skin assessment

B.Assign the client a female nurse for every shift

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer? A.Partial-thickness skin loss involving the epidermis, dermis, or both B.Full-thickness skin loss involving damage to subcutaneous tissue C.Redness with intact skin that client reports as "itchy" D.Full-thickness

B.Full-thickness skin loss involving damage to subcutaneous tissue

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? A.Administer TPN through a nasogastric or gastrostomy tube. B.Handle TPN using strict aseptic technique. C.Auscultate for the presence of bowel sounds prior to administering TPN. D.Designate a peripheral IV site for TPN administration.

B.Handle TPN using strict aseptic technique.

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses? A.Elevated blood pressure B.Increased blood viscosity C.Fragility of the blood cells D.Immaturity of red blood cells

B.Increased blood viscosity

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? A.Maintain comfort B.Prevent pressure ulcers C.Prevent flexion contractures of the extremities D.Improve venous circulation in the lower extremities

B.Prevent pressure ulcers

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema? Refer to Figure. A.Right side laying B.Sim's position C.Supine D. lithotomy

B.Sim's position

A patient diagnosed with terminal cancer says to the nurse "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? A. "Have you shared your feelings with your family?" B. "I think we should talk more about your anger with your family." C. "You're feeling angry that your family continues to hope for you to be cured?" D. "You are probably very depressed, which is understandable with such a diagnosis."

C. "You're feeling angry that your family continues to hope for you to be cured?"

The nurse is caring for a client with cancer who is neutropenic. Which plan would be inappropriate? A. Notify the doctor of any temperature over 100° F. B. Use sterile technique when performing invasive procedures. C. Avoid any spicy foods. D. Avoid client exposure to anyone who is ill.

C. Avoid any spicy foods.

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? A. Stage 2 Pressure injury B. Stage 1 Pressure injury C. Deep tissue injury D. Unstageable injury

C. Deep tissue injury

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? A. Right side B. Low Fowler's C. High Fowler's D. Supine with the head flat

C. High Fowler's

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions? A. A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. B. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. D. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.

C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? A.Stage 2 Pressure injury B.Stage 1 Pressure injury C.Deep tissue injury D.Unstageable injury

C.Deep tissue injury

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving? A.The patient's fasting blood sugar decreased from 100 to 90 mg/dL. B.The patient's prothrombin time (PT) increased from 20 to 25 seconds. C.The patient's ammonia level decreased from 160 to 120 mg/dL. D.The patient's AST (SGOT) increased from 24 to 30 units.

C.The patient's ammonia level decreased from 160 to 120 mg/dL.

While a client is receiving TPN, it is MOST important for the nurse to monitor A.vital signs and level of consciousness. B.arterial blood gases and liver enzymes. C.serum glucose and electrolytes. D.skin turgor and daily weights.

C.serum glucose and electrolytes.

A nurse is caring for a client scheduled for a CT scan with contrast. Which action is most appropriate? A.Checking the history for and asking the patient about metal or clips in or on the body- priority for MRI B.Keeping the patient NPO after midnight the night before the procedure C.Assessing the client's hemoglobin and hematocrit D. Checking the client's creatinine level

D. Checking the client's creatinine level

Nasogastric or naso-enteric tubes are used for all the following purposes EXCEPT: A. Short term enteral feedings. B. Monitoring of G.I. bleeding. C. Decompression of stomach. D. Permanently feeding patients

D. Permanently feeding patients

Prior to being transported to the surgery suite, the nurse asks the client whether the client has any allergies. The client responds, "Does anyone communicate with anyone? I've been asked that question over and over!" What is the nurse's best response? A."I'm sorry! I just have to ask that question for the record." B."It's an important question, and we just have to check." C."You will hear it again and again as you go through surgery." D."This question is asked for verification and safety with each new phase of treatment."

D."This question is asked for verification and safety with each new phase of treatment."

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? A.Continue the infusion until the remaining 300 mL is infused. B.Change the filter on the tubing, and continue with the infusion. C.Notify the health care provider (HCP), and obtain prescriptions to alter the flow rate of the solution. D.Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

D.Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A.Prepare to administer an antidote. B.Draw a sample for type and crossmatch and transfuse the client. C.Draw a sample for an activated partial thromboplastin time (aPTT) level. D.Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

D.Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

A patient with atrial fibrillation is receiving warfarin (Coumadin) 5 mg each day. His INR today is 2.4 (N= 0.8-1.2). What is the expected change in medication dosage? A.His INR is too low. His warfarin dose needs to be increased. B.His INR is too high. His warfarin dose needs to be decreased. C.His INR is too high. His warfarin dose needs to be increased. D.His INR is within desired range. No change in warfarin dose is needed.

D.His INR is within desired range. No change in warfarin dose is needed.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A.Intact skin B.Full-thickness skin loss C.Exposed bone, tendon, or muscle D.Partial-thickness skin loss of the dermis

D.Partial-thickness skin loss of the dermis

Which of following interventions would a nurse utilize for a patient with thrombocytopenia? A.Instruct the client on foods to eat that are high in iron B.Assess the client for an allergic reaction C.Place the client on neutropenic precautions and limit visitors D.Use an electric razor when shaving and avoid taking rectal temperature

D.Use an electric razor when shaving and avoid taking rectal temperature