CM Qs E2

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based in which of the following factors contributing to the postoperative complication? - Blood loss - NPO status after surgery - Nasogastric tube suctioning - Impaired peristalsis of the intestines

- Impaired peristalsis of the intestines

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? - Carminative - Hypertonic - Oil retention - Sodium polystyrene sulfate

- Oil retention

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A. "A nurse will show me how to care for my wound!" B. "A nurse will stay with me at home during the day!" C. "I will call the nurse to change my bed linens." D. "I will call the nurse to help me bathe in the morning."

A. "A nurse will show me how to care for my wound!"

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." c. "Hold your breath." D. "Raise your head off of the pillow."

A. "Bear down."

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.) A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

A. Vitamin C and zinc

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation

Auscultation

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A."I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." C. "Ill need to take a pain pill 30 minutes before I change the dressing." D."I'll wear sterile gloves when I apply the new dressing."

B. "I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is teaching a female client who has pyelonephritis about the disorder. Which of the following pieces of information should the nurse include to help the client prevent a recurrence? A. "Douche after vaginal intercourse." B. "Wipe from front to back after defecation." C. "Avoid foods that are high in phosphate." D. "Add yogurt to your diet regularly."

B. "Wipe from front to back after defecation."

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30° or 45° C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

B. Elevate the head of the bed to 30° or 45°

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound

B. Keeping microorganisms from entering the wound

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? A. Give the client a bronchodilator immediately after the procedure B. Position the client for drainage of secretions by gravity C. Schedule postural drainage following meals D. Instruct the client regarding the importance of fluid restrictions

B. Position the client for drainage of secretions by gravity

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's hares

B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. Spreading the labia with the dominant hand D. Using a cotton ball to wipe the right and left labia majora

B. Wiping the labia minora in an anteroposterior direction

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? A. "Wake up every 2 hr to urinate during the night." B. "Drink citrus juices throughout the day." C. "Try to block the urge to urinate until the next scheduled time." D. "Limit fluids to no more than 1 L (34 oz) during waking hours."

C. "Try to block the urge to urinate until the next scheduled time."

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carefully remove the gloves and proceed with hand hygiene D. Ask the provider to order a blood culture to determine the risk of infection.

C. Carefully remove the gloves and proceed with hand hygiene

A nurse is caring for a client who has a stage Ill pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

C. Check the client's pain level

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria

C. Diuresis

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting. B. Wear a mask while in the client's room. C. Don gloves when entering the room and use hand sanitizer when exiting. D. Take no special precautions unless engaging in direct contact with the client.

C. Don gloves when entering the room and use hand sanitizer when exiting.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

C. Pinch the NG tube while removing the tube

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. Insist that the AP attend an in-service training about standard precautions C. Talk with the AP about the technique used D. Observe the AP a second time and intervene if the technique remains the same

C. Talk with the AP about the technique used

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Wear a gown when in the client's room D. Dispose of all bed linens used by the client

C. Wear a gown when in the client's room

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23-gauge needle B. Insert the needle into the skin at a 25° angle C. Massage the area of injection following removal of the needle D. Circle the injection area with a pen

D. Circle the injection area with a pen

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAls). Which of the following routes of infection should the manager identify as an iatrogenic HAI? A. Infection acquired from improper hand hygiene B. Infection acquired by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure

D. Infection acquired from a diagnostic procedure

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves. D. Perform hand hygiene.

D. Perform hand hygiene.

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500 mg/day of vitamin E C. Limit fluid intake to 20 mL/kg of body weight per day D. Provide a protein intake of 1.5 g/kg of body weight per day

D. Provide a protein intake of 1.5 g/kg of body weight per day

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." "I will use cold water when I wash my hands to protect my skin from becoming too dry." C."I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down."

"There are times I should use soap and water rather than an alcohol-based rub to clean my hands."

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? - A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage - A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage - A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 m-/hr ofserosanguinous orainage - A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

- A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make? - Lunch trays should be here within the hour - I am going to listen to your abdomen - I'll get you some water to drink - Lets wait a bit so you don't feel sick

- I am going to listen to your abdomen

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? - Drink a minimum of 1,000 mL of fluid daily - Increase your intake of refined fiber foods - Sit in the toilet 30 min after eating a meal - Take a laxative every day to maintain regularity

- Sit in the toilet 30 min after eating a meal

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing

Grimacing

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A. Percussion B. Auscultation C. Inspection D. Palpation

Palpation

A nurse if caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? - Frequent bowel sounds with flatus - Absent bowel sounds with distention - Hyperactive bowel sounds with diarrhea - Normal bowel sounds with increased peristalsis

- Absent bowel sounds with distention

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? - Auscultate bowel sounds after each feeding - Ensure the formula is cold before administering - Elevate the head of the client's bed to 45' before the feeding - Flush the tubing with 15 mL of water after the enteral feeding

- Elevate the head of the client's bed to 45' before the feeding

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? - Give the client a glass of water - Assist the client into a sitting position - Explain the procedure to the client - Measure the length of tubing to be inserted

- Explain the procedure to the client