Custom: Week 4 Practice Problems

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.)

*-After each medication* -Before aspirating gastric contents -When the flow of the medication by gravity slows *-Prior to administering each medication* *-After giving multiple medications*

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

*-Yogurt* -Popsicle -Gelatin -Broth

A nurse is preparing to insert an NG tube. Place the following steps in the appropriate order. (Move the steps of NG tube placement into the box on the right, placing them in the selected order of performance. Use all the setps.)

*-prepare equipment at the bed side.* *-measure the NG tube.* *-Instruct the client to extend the neck backward* *-Instruct the client to flex the head forward.* *-Obtain an X-ray.* *-Secure tube*

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leadin gzero if it applies. Do not use a trailing zero.)

*0.8*

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should he nurse take?

-Reconstitute the formula with tap water. -Discard unused formula after 8 hr. -Administer 200 mL of formula during the initial infusion. -Give the initial feeding over 15 min.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurs's priority?

-Request a prescription for a medication to east the client's anxiety. -Irrigate the NG tube with 100 mL of sterile water. *-Check to see if the suction equipment is working.* -Remove and reinsert the NG tube.

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

-Symmetrical convex sphere shape -Concave umbilicus -Bilateral bowel sounds in lower quadrants *-Ecchymosis*

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

1,170 mL

A nurse identifies a pressure ulcer after a client has a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions?

-Document what the nurse believes was the cause of ulcer development. *-Include any relevant statements the client made about the ulcer.* -Document in the client's medical record that she completed an incident report. -Question the charge nurse about care deficits that might have contributed to the ulcer's development.

A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

-Electrolyte Imbalance *-Diarrhea* -Constipation -Delayed Gastric emptying

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

-Set the pad's temperature to 42.2 degree C (108 degree F). *-Stop the treatment if the client's skin becomes red.* -Leave the pad in place for at least 40 min. -Use safety pins to keep the pad in place.

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

-The nurse initiates the feeding after aspirating 50 mL of gastric residual -The nurse irrigates the NG tube with tap water after feeding -The nurse administers the feeding through a syringe barrel by gravity *-The nurse allows the client to rest in a supine position during feeding.*

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

-Use a stiff toothbrush to clean the client's teeth. -Use the thumb and index finger to keep the client's mouth open *-Turn the client on his side before starting oral care.* -Apply petroleum jelly to the client's lips after oral care.

A nurse is preparing to administer acetaminophen 650 mg PO every 4 hr PRN to a client. The amount available is acetaminophen 325 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

*2 tablets*

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

-Weigh the second client *-Obtain vital signs for both clients.* -Administer pain medication to the first client. -Change the dressings of both clients.

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

-allow the AP to deliver the food tray to the client. *-Call the dietary department and ask for a kosher tray.* -Replace the nonfat milk with apple juice -Explain to the client that he needs the protein in the milk and the beef.

A nurse is preparing to administer amitriptyline 150 mg PO at bedtime. The amount available is amitriptyline 75 mg/tablet. How many tablets should the nurse administer per dose? (Rouse the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

*2 tablets*

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

-"I will keep spare crutch tips handy." -"I will bear the weight of my body on my hands." -"I will inspect my crutches every day for signs of wear." *-"I have a set of my brother's crutches in my basement I can also use."*

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

-An adolescent who has cervical fracture and is in a halo brace -a young adult who has a femur fracture and is in skeletal balanced suspension traction -a middle adult who has a fractured radius and an arm cast *-an older adult who has a hip fracture and is in Buck's traction*