comp exam

On admission of an older dehydrated adult from the extended care facility, the nurse notes a history of liquid fecal incontinence. Which nursing intervention will facilitate identifying the cause of the client's incontinence? a. Perform abdominal percussion. b. Perform a digital rectal examination c. Collect urine culture and sensitivity test. d. Order a pelvic and abdominal ultrasound.

b

The nurse is caring for a client who had major abdominal surgery 1 day ago. Which factor increases the risk of this client developing wound dehiscence? a. Placement of a tube b. A body mass index (BMI) of 35 c. Presence of excessive flatus d. Receiving beta blockers

b

Which type of incontinence can be improved by teaching the client Kegel exercises? a. Reflex incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence

b

How would the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid słough and exudate?

yellow

Which findings in the older adult client are associated with a urinary tract infection (UTI)?

confusion, incontinence, slight rise in temp

The nurse is preparing to administer pain medication to an older adult . To promote safety which would the nurse assess before giving the medication ? a. Blood pressure b. Client's pain level rating c. Bowel sounds and function d. Other preseribed medications

d

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand would the nurse teach the client to hold the cane? a. Left hand b. Right hand c. Stronger hand d. Dominant hand

a

A 60-year-old woman is admitted for a vaginal hysterectomy and anterior and posterior repair of the vaginal wall. Which symptom would the client be likely to state as a reason that she is having surgery? a. Hematuria b. Dysmenorrhea c. Pain on urination d. Stress incontinence

d

Which term is used to describe a client passing air and bubbles during urination? a. Nocturia b. Oliguria c. Pneumaturia 4. Stress incontinence

c

The nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a clientWhich statements made by the nursing student indicate effective Select all that apply. One, some , or all responses may be correct. 1. " I will elevate the head of the client's bed to no more than 30 degrees . 2. " I will ensure that the client is turned and repositioned at least every 2 hours" 3. " I will advise the client to apply talc directly to the perineum . 4. "I will ensure that the client's fluid intake is 2000 to 100 mL/day; " 5. "I will teach the client to refrain from eating a highprotein and calorie diet."

1, 2, 4

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? a. Irish Americans b. African Americans c. Chinese Americans d. Egyptian Americans

c

Which instruction provides a client the best description of how to use a prescribed, stationary (nonrolling) walker? a. Place the walker's back leg tips about an arm's length ahead of the feet, shift the body weight to the walker and step forward b. Move the walker about an arm's length ahead while stepping forward and transferring body weight to all walker leg tips. c. Put the walker's front leg tips about an arm's length ahead of the feet, shift the body weight to the walker, and step forward d. Position the walker's front leg tips onto the floor about an arm's length ahead of the feet and step forward until all tips touch the floor.

c

While assessing the client for a pressure injury, the nurse identifies exposed bone and tendons Which stage would the nurse document for this pressure injury? a. l b. ll c. lll d. lv

d

Which information would the nurse provide an older adult and caregivers regarding medication safety? a. Use a pill organizer . b. Read all medication labels c. Place pills in unlabeled bottles . d. Review medications with pharmacist . e. Empty medicine cabinet every 2 years .

a, b, d

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries? a. Incontinence; inability to move independently b. Periodic diaphoresis; occasional sliding down in bed c. Minimal reaction to painful stimuli; receiving tube feedings d. Spending extensive time in a chairbody mass index (BMI) of 23

a

Which instruction from the nurse to an 80-year-old client with thinning of a subcutaneous layer would be beneficial? a. Dress warmly in cold weather. b. Use soaps with high fat content. c. Change the position of bed once every 5 hours. d. Apply moisturizer 2 hours after bathing .

a

Which intervention is most important in preventing hospital-acquired catheter-associated urinary tract infections (CAUTIS )? a. Removing the catheter b. Keeping the drainage bag off of the floor c. Washing hands before and after assessing the catheter d. Cleansing the urinary meatus with soap and water daily

a

Which statement describes the primary reason why the nurse raises three of the four side rails on the bed of an 83-year-old client who is postanesthesia for a fractured hip? a. The action is a safety measure because of the client's age b. Clients older than 60 years of age should use side rails c. The side rails serve as handholds to facilitate the client's ability to move in bed. d. All older adults are disoriented for several days after anesthesiz.

a

Which symptom supports the nurse's suspicion that a client has overflow incontinence? a. Constant dribbling of urine b. Abrupt and strong urge to void c. Loss of urine with physical exertion d. Large amount of urine loss with each occurrence

a

Which intrinsic factors may contribute to falls in older adults? a. Lack of exercise b. Impaired vision c. Inappropriate footwear d. Improper use of assistive devices e. Unfamiliar environment of hospital room

a, b

Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions ? a. Area rugs on the floor b. Clogged, dirty fireplace c. Multiple electrical cords d. Multiple prescribed medications e. Wheeled walker with uneven legs

a, b, c, e

Which intervention would the nurse implement first when providing care for an older adult male client who is immobile and incontinent urine? a. Restrict the client's fluid intake. b. Regularly offer the client a urinal. c. Apply incontinence pants. d. Insert an indwelling urinary catheter.

b

Which intervention would the nurse implement to ensure an older adult client's safety when demonstrating mild confusion after surgical repair of an abdominal hernia? a. Use a night-light in the client's room b. Activate the position-sensitive bed alarm. c. Raise the four side rails on the client's bed. d. Secure a prescription for a soft vest restraint.

b

Which dressings would the nurse view as beneficial for the recovery of a client's red-colored wound that was caused by pressure? a. Absorptive dressings b. Hydrocolloid dressings c. Transparent film dressings d. Moist gauze dressings with antibiotics. e. Non-adhering dressings with antibiotic ointment

b,c,e

The nurse has provided discharge instructions to a client who received a prescription for a walker . The nurse determines that the teaching has been effective when the client does which? a. Picks up the walker and carries it for short distances b. Uses the walker only when someone else is present c. Moves the walker no more than 12 inches (30.5 cm) during use d. States that a walker will be purchased on the way home from the hospital

c

In which area of the body will the nurse most likely discover a pressure injury in a client who is maintained in the low-Fowler position excessively? a. Elbows b. Occiput c. Hium d. Sacrum

d

Which factors contribute to development of osteoporosis in female clients? a. Cigarette smoking b. Moderate exercise c. Use of street drugs d. Familial predisposition e. Inadequate intake of dietary calcium

a, d, e

While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. Which nursing intervention helps prevent complications associated with this condition? a. Providing thorough perineal care after each voiding b. Encouraging the client to use the toilet or bedpan every 2 hours c. Responding quickly to the client's indication of the need to void d. Applying voiding stimulants to the perineum

a

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? (Select all that apply) A. Providing meticulous skin care B. Reducing shear forces and friction C. Providing beverages and snacks frequently D. Using a support surface base all the time E. Avoiding pressure with proper positioning

a,b,e

Which instructions to minimize the risk of falls in the home would the nurse provide the caregiver of an older client who requires the use of a walker with wheels? a. Remove cords. b. Apply bed alarms. c. Use bright lighting d. Get rid of throw rugs e. Keep phone close by

a,c,d

Which part of the client's body would the nurse assess to identify osteoporotic changes? a. Long bones b. Facial bones c. Vertebral column d. Joints of the hands

c

Which definition would the nurse use to explain osteoporosis a. It is avascular necrosis. b. It is caused by pathological fractures. c. It is hyperplasia of osteoblasts. d. It involves a decrease in bone substance .

d

Which meal is most appropriate for a client with a large pressure injury? a. Hamburger with french fries b. Turkey meatloaf with brown rice c. Pasta and tomato sauce with a side salad d. Grilled chicken, steamed spinach, and a side of orange slices

d

A client has a stage pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force? a. Maintain the head of the bed at 30 degrees or less . b. Use draw sheets to pull up, transfer , and position the client . c. Reposition the client every 2 hours, propping with pillows. d. Perform passive range -of-motion exercises every 8 hours.

b

A client with left-sided weakness is learning how to use a cane. The nurse would demonstrate proper use of the cane by holding it where? a. On alternating sides b. On the right side c. On the side of the weakness d. On the side of the client's choice

b

The nurse assists a client on a rehabilitation unit after a cerebrovascular accident ( CVA, also known as a "brain attack") with residual hemiparesis to walk with the use of a cane. To help achieve the goal of safe walking with a cane, which method would the nurse teach the client? a. Shorten the stride of the unaffected extremity. b. Advance the cane and the affected extremity simultaneously c. Lean the body toward the side with the cane when ambulating d. Hold the cane on the same side as the affected extremity and increase the base of support

b

The nurse has provided teaching to a client who has impaired balance and uses a walker Which observation of the client would indicate to the nurse that further teaching is required? a. Slides toward the edge of the seat before standing b. Holds both handles of the walker while rising to stand c. Moves forward into the walker after transferring from sitting to standing d. Stands in place holding on to the walker for at least 30 seconds before walking

b

Which intervention would be included in the plan of care for the prevention of a pressure injury? a. Positioning a client directly on the trochanter b. Keeping the client's skin directly off plastic surfaces c. Keeping the head of the bed elevated above 30 degrees d. Placing a rubber ring or donut under the client's sacral area

b

Which rationale supports the nursing intervention to turn the client with paraplegia every to 2 hours? a. To maintain client comfort b. To prevent development of pressure injuries c. To prevent contractures of the extremities d. To improve venous circulation in the lower extremities

b

A client has undergone pelvic surgery, and the nurse removes the catheter in a week according to instructions . In the follow-up within several hours, which finding in the client indicates a need for reinsertion of catheter? a. Anuria b. Polyuria c. Retention d. Incontinence

c

Family members received discharge instructions for an older adult male recovering from a urinary tract infection. Which statement indicates family understanding of age-related changes and required care? a. a small glass of water at his side to ensure sipping before bedtime. b. " respond immediately with the urinal whenever he indicates a need to void c. "provide privacy and stand by assistance to help him void." d. " i encourage him to use the urinal at least every 2 hours during the day."

c

Which intervention would the nurse provide to an older adult client with a low body mass index (BMI) with osteoporosis ? a. Encourage continuous, steady weight gain. b. Monitor for decreased urine calcium . c. Provide instructions relative to diet and exercise. d. Teach about safety factors in the use of opioids and nonsteroidal anti- inflammatory drugs.

c

Which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence ? a. Answer the client's call light immediately to prevent incontinence b. Place a waterproof pad under the client to prevent soiling the linens. c. Check the dient's buttocks at least every 2 hours and clean after incontinence . d. Offer toileting to the client every 2 hours to prevent incontinence .

c

Which physiological change occurs in older adults and warrants the nurse teaching the client about safety tips to prevent falls? a. Slowed movement b. Cartilage degeneration c. Decreased bone density d. Decreased range of motion (ROM)

c

Which term would the nurse use to document a client experiencing urinary incontinence via involuntary loss of small amounts (25 - 35mL) of urine from an overdistended bladder? a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence

c

The nurse teaches a client and the caregiver about pressure injury care. Which statement made by the caregiver indicates the need for further teaching? a. "will inspect the client's skin daily." b. "will manage the client's incontinence as quickly as possible." c. "will properly dispose of the client's contaminated dressings." d. " will not worry about what the client eats. "

d

Which medication is derived from a natural source and may be prescribed for the treatment of osteoporosis ? a. Calcitonin b. Raloxifene c. Clomiphene d. Bisphosphonates

a