exam 3 concepts

when the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which findings indicates a need for more staff education about oxygen therapy

oxygen flow rate is set to 8 L/min

What nursing intervention would help an older adult experiencing urinary incontinence?

provide voiding opportunities avoid indwelling catheterization promote measures to prevent skin breakdown

NG tube irrigations are prescribed for a client after abdominal surgery. the nurse instills 30 ml of saline solution and 10 ml is returned. how would the nurse proceed

record 20 ml as intake

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine?

regularly offer the client a urinal

A client is receiving intermittent NG tube feedings to supplement oral nutritional intake, the nurse administers the feeding over 30-60 minutes to reduce which hazard

regurgitation

which recommendations would the nurse provide an overweight adolescent to promote weight loss?

perform physical activities regularly eat small frequent meals throughout the day reduce the intake of sugar and sweetened beverages

the nurse is caring for a client with a new colostomy. which client outcome is most important for achievement of long term goals associated with adjusting to a new colostomy

readiness to accept an altered body function

which observation supports the nurses suspicion that a client may have myoglobinuria

red-colored urine

oxygen given to clients during stage 4 COPD would be administered what?

1-2 L via nasal cannula to keep SaO2 above 90 *oxygen therapy is delayed until stage 4 for COPD

What factors would the nurse assess for a client reporting constipation? SATA Diet Fluid intake Use of laxatives date of last bowel movement use of opioid pain medications

All the above

Which food would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas?

Cabbage

The nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods would the nurse include?

Carrots, cantaloupe, sweet potatoes, apricots, Dark-leafy greens

what urine characteristic is consistent with a UTI

Cloudy

When the oxygen sat of a client with pneumonia is 89 to 90 while using a nonrebreather mask, which collaborative action would the nurse anticipate?

oxygenation administration with bi-level positive airway pressure (BiPAP)

A client with emphysema reports increased shortness of breath and becomes increasingly anxious. The health care provider prescribes oxygen at 1 L/min via nasal cannula. The nurse recognizes that this is appropriate because?

High concentrations of oxygen eliminate the respiratory drive in some patients

After the nurse teaches the client who is obese, measures to calculate the BMI, which client statement indicates effective learning?

I should lose at least 1/2 a pound to a pound each week Ill make sure to eat foods meeting my daily nutritional requirement I should stay away from unhealthy foods between meals and after dinner

a client has a NG tube in place. which health care team member is most likely to be assigned to provide medications to the client through the NG tube

LPN

The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation?

Oxygen is exchanged for carbon dioxide in the alveolar membrane

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition. The nurse explains that the TPN therapy provides which benefit?

Will meet the clients nutritional needs without causing the discomfort precipitated by eating

which signs support the nurse's suspicion that a client has urge incontinence?

abrupt and strong urge to void- loss of large amounts of urine with each occurence

What data is assessed for Braden scale when predicting pressure injury

anorexia hemiplegia history of diabetes urinary incontinence

What is the best nursing intervention to support a hospitalized child's nutrition who is apathetic toward eating

asking the parent to visit during meal time

which action would the nurse take when collecting a urine sample from the toddler who is not toilet trained

attach single-use bags over the child's urethral meatus use terms of urination that the child can understand

a client with a recent colostomy expresses concern about the inability to control the passage of gas. which recommendation would the nurse make?

avoid foods that caused flatus in the past

A client has a surgically created colostomy. Which is the most effective nursing intervention initially to help the client accept the colostomy?

begin to teach self care of the colostomy by introducing equipment

which assessment finding would the nurse report to the health care provider when giving immediate postoperative care to a client with a newly placed stoma?

blanching, dark red to purple color of stoma

which represents appropriate nursing management of a client's nasogastric tube in the immediate postoperative period after gastroduodenostomy?

carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working

The postanesthesia care unit receives a client postabdominal surgery with a NG tube with low intermittent wall suction in place. Which initial action would the nurse implement when the client vomits 90 ml of bile colored fluid

check the patency of the tube

a client is admitted to the hospital with gastrointestinal bleeding and subsequently has a NG tube inserted. prescriptions include irrigating the tube with normal saline as needed to maintain patency. the nurse assesses the NG tube and determines that it is not patent. which initial action would the nurse take

check the tube for placement

which nursing interventions would provide safe oxygen therapy

checking tubing for kinks post no smoking signs in the clients room

dark, amber urine indicates

concentrated urine

which signs support the nurse's suspicion that a client has overflow incontinence?

constant dribbling of urine

which client response during the insertion of NG tube indicates to the nurse that the client is experiencing serious difficulty with insertion

cyanosis

A client who had surgery for a resection of the colon and the formation of a colostomy is scheduled to be discharged in several days. which is a primary nursing intervention for this client?

determine the clients ability to care for the colostomy

which would the nurse include in dietary teaching for a client with a colostomy

diet should be adjusted to result in manageable stools

Which conclusion would the nurse make about the assessment finding of a client's very pale yellow colored urine?

dilute urine

the nurse observes that an older adult patient seldom eats the meat on the meal trays. The nurse discusses this observation with the client and the client states " I only eat meat once a week because old people dont need protein every day." Which need would the nurse address in his or her reply

foods that meet basic nutritional needs

a client has a NG feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. Which action does the nurse take first

get chest x-ray to confirm placement

Which suggestion would the nurse provide to the parent whose child has been constipated for 3 days?

give laxatives to the child increase physical activity include high fiber foods

what are health promotion activities

good nutrition regular exercise

the nurse provides education to a client about how to prevent constipation. the nurse concludes the teaching is understood when the client states?

i should drink at least 6 glasses of water a day i can include bran muffins in my daily breakfast i will walk everyday as part of my exercise regimen

the nurse gives the client with a history of constipation a list of foods to help prevent it. which statement made by the client indicates that further teaching is needed?

i should eat eggs

what statement by an obese adolescent about healthy dietary habits and the risk associated with obesity indicates the need for further counseling

i should watch more tv to reduce stress

A client with coronary occlusion is experiencing chest pain and distress. what is the primary reason that the nurse administers oxygen?

increase oxygen concentration to heart cells

brown colored urine indicates

increased bilirubin

A client with COPD exacerbation is recieving oxygen at 2 L/min per nasal cannula and has a oxygen saturation of 88. what actions would the nurse ancipate taking next?

increasing oxygen flow rate to 3 L/min

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best assessment sites

lips mouth nail beds

which signs support the nurse's suspicion that a client has stress incontinence?

loss of urine with physical exertion

which action would be appropriate to implement when collecting a 24 hour urine test

start the time of the test after discarding the first voiding

which concept would the nurse consider when caring for school aged children who are obese

there are familial influences on childhood eating habits

which instruction would the nurse provide a client needing to collect a clean catch urine specimen

urinate a small amount, stop flow, and then fill one half of the specimen cup

what instruction would the nurse include in health practices teaching plan for a female with history of UTI?

wear cotton underwear

what urinalysis report signifies presence of excessive bilirubin?

yellow-brown to olive green urine