Exam 4 Practice Test

The nurse is teaching a group of older adults about basic eye examinations. What would the nurse recommend about the frequency for eye examinations for most people over 65 years of age? a. Every 1 to 2 years b. Every 2 to 4 years c. Every 3 to 5 years d. When the primary health care provider recommends

a. Every 1 to 2 years

After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection indicates that the client understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

d. Roasted chicken breast, baked potato with chives, and orange juice

Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? a. The patient complains of a right-sided headache. b. The sclera on the right eye has broken blood vessels. c. The area around the right eye is bruised and tender to the touch. d. The patient complains of "a curtain" over part of the visual field.

d. The patient complains of "a curtain" over part of the visual field.

A young adult client admitted with a diagnosis of cholecystitis from cholelithiasis has severe abdominal pain, nausea, and vomiting. Based on these assessment findings, which client problem is the highest priority for nursing intervention at this time? A. Anxiety B. Risk for dehydration C. Acute pain D. Malnutrition

C. Acute pain

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

b. Beginning venous thromboembolism prophylaxis

A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) a. Cleanse the perineum with an antibacterial soap. b. Use medicated wipes instead of toilet paper. c. Identify foods that decrease constipation. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

b. Use medicated wipes instead of toilet paper. d. Apply a thin coat of aloe cream to the perineum. e. Gently pat the perineum dry after cleansing.

A client is receiving bolus feedings through a small-bore nasoduodenal tube. What action by the nurse is the priority? a. Auscultate lung sounds after each feeding. b. Weigh the client daily on the same scale. c. Check tube placement every 8 hours. d. Check tube placement before each feeding.

d. Check tube placement before each feeding.

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? a. Consuming too much fruit b. Consuming fried or pickled foods c. Consuming dairy products d. Consuming raw seafood

d. Consuming raw seafood

A client is taking timolol eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? a. Ask the client about excessive salivation. b. Take the client's blood pressure and temperature. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the primary health care provider.

d. Hold the eyedrops and notify the primary health care provider.

A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? a. Client with an albumin of 3.5 g/dL b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) c. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) d. Client with a prealbumin of 28 mg/dL

b. Client with a cholesterol of 142 mg/dL (3.7 mmol/L)

A nurse is teaching a client about ear hygiene and health. Which statement by the client indicates a need for further teaching? a. "A soft cotton swab is alright to clean my ears with." b. "I make sure my ears are dry after I go swimming." c. "I use good earplugs when I practice with the band." d. "Keeping my diabetes under control helps my hearing."

a. "A soft cotton swab is alright to clean my ears with."

A nurse is teaching a community group about preventing hearing loss. What instruction is appropriate? a. "Always wear a bicycle helmet." b. "Avoid swimming in ponds or lakes." c. "Don't attend fireworks shows." d. "Use a cerumen spoon to clean ears."

a. "Always wear a bicycle helmet."

The nurse teaches a client who has viral gastroenteritis. Which dietary instruction would the nurse include in the health teaching? a. "Drink plenty of fluids to prevent dehydration." b. "You should only drink 1 L of fluids daily." c. "Increase your protein intake by drinking more milk." d. "Sips of cola or tea may help to relieve your nausea."

a. "Drink plenty of fluids to prevent dehydration."

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question(s) would the nurse ask? (Select all that apply.) a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" c. "Does anyone in your family have a history of cystitis?" d. "Are you on steroids or other immune-suppressing drugs?" e. "Do you drink grapefruit juice or orange juice daily?"

a. "How much water do you drink every day?" b. "Do you take estrogen replacement therapy?" d. "Are you on steroids or other immune-suppressing drugs?"

After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I should drink at least 3 L of fluid every day." b. "I will eliminate all dairy or sources of calcium from my diet." c. "Aspirin and aspirin-containing products can lead to stones." d. "The doctor can give me antibiotics at the first sign of a stone."

a. "I should drink at least 3 L of fluid every day."

A nurse teaches a young female client who is prescribed cephalexin for a urinary tract infection. Which statement would the nurse include in this client's teaching? a. "Use a second form of birth control while on this medication." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on this drug." d. "Watch for blood in your urine while taking this medication."

a. "Use a second form of birth control while on this medication."

The nurse teaches a community group ways to prevent Escherichia coli infection. Which statements would the nurse include in this group's teaching? (Select all that apply.) a. "Wash your hands after any contact with animals." b. "It is not necessary to buy a meat thermometer." c. "Stay away from people who are ill with diarrhea." d. "Use separate cutting boards for meat and vegetables." e. "Avoid swimming in backyard pools and using hot tubs."

a. "Wash your hands after any contact with animals." d. "Use separate cutting boards for meat and vegetables."

A client has a foreign body in one eye. What action by the nurse is appropriate for the client's care? a. Administering ordered antibiotics b. Assessing the patient's visual acuity c. Obtaining consent for enucleation d. Removing the object immediately

a. Administering ordered antibiotics

When working with older adults to promote good nutrition, what action(s) by the nurse is(are) most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures (if worn) for appropriate fit. c. Ensure that the client has glasses on or contacts in when eating. d. Provide salty or highly spicy foods that the client can taste. e. Serve high-calorie, high-protein snacks one to two times a day.

a. Allow uninterrupted time for eating. b. Assess dentures (if worn) for appropriate fit. c. Ensure that the client has glasses on or contacts in when eating. e. Serve high-calorie, high-protein snacks one to two times a day.

The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin

a. Alopecia b. Stomatitis c. Muscle wasting d. Peripheral edema e. Anemia f. Dry, scaly skin

The nurse is performing an initial assessment and notes that the client weighs 186.4 lb (84.7 kg). Six months ago, the client weighed 211.8 lb (96.2 kg). What action by the nurse is appropriate? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test.

a. Ask the client if the weight loss was intentional.

An older adult in the family practice clinic reports a decrease in hearing in one ear for over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

a. Assess for cerumen buildup.

The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the nurse take for client care? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours or per agency policy. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the client's chin. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

a. Assess for proper placement of the tube every 4 hours or per agency policy. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the client's skin around the tube site for irritation.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? a. Assess the 24-hour intake and output. b. Assess the client's oral cavity. c. Prepare to hang a normal saline bolus. d. Increase the infusion rate of the TPN.

a. Assess the 24-hour intake and output.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says "I didn't know it would be this hard to live like this." What approach by the nurse is best? a. Assess the client's coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client that lifestyle changes are always hard.

a. Assess the client's coping and support systems.

The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? a. Check the skin around the tube insertion site. b. Weigh the client every shift with the same scale. c. Draw blood to assess albumin every shift. d. Irrigate the tube at least once a day.

a. Check the skin around the tube insertion site.

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

a. Corneal staining

The nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages

a. Cultural food preferences c. Increased need for nutrition d. Need for NPO status e. Staff shortages

The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.) a. Decreased eye muscle tone b. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

a. Decreased eye muscle tone b. Development of arcus senilis d. Decrease in general color perception e. Increase in point of near vision

A nurse prepares to discharge a client who is newly diagnosed with a chronic inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? d. Do you have a scale for daily weights? e. How many bathrooms are in your home?

a. Does your gym provide yoga classes? b. When should you contact your provider? c. What do you plan to eat for dinner? e. How many bathrooms are in your home?

The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply.) a. Dysuria b. Frequency c. Burning d. Fever e. Chills f. Hematuria

a. Dysuria b. Frequency c. Burning f. Hematuria

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) a. Nausea and vomiting b. Distended rigid abdomen c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever

a. Nausea and vomiting c. Abdominal pain d. Bradycardia e. Decreased urinary output f. Fever

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools b. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

a. Patient with acute right eye pain that occurred while using home power tools

After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills. c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back.

a. Void before and after each act of intercourse. c. Do not douche or use scented feminine products. e. Wipe or clean the perineum from front to back.

Which instruction should the nurse include in a teaching plan for a patient with herpes simplex keratitis? a. Wash hands frequently and avoid touching the eyes. b. Apply antibiotic drops to the eye several times daily. c. Apply a new occlusive dressing to the affected eye at bedtime. d. Use corticosteroid ophthalmic ointment to decrease inflammation.

a. Wash hands frequently and avoid touching the eyes.

The nurse is teaching a client about preventing intraocular pressure increase after eye surgery. Which health teaching would the nurse include? (Select all that apply.) a. "Don't lift objects weighing more than 20 lb (9.1 kg)." b. "Avoid blowing your nose or sneezing." c. "Don't bend down from the waist." d. "Don't strain to have a bowel movement." e. "Avoid having sexual intercourse." f. "Don't wear tight shirt or blouse collars."

b. "Avoid blowing your nose or sneezing." c. "Don't bend down from the waist." d. "Don't strain to have a bowel movement." e. "Avoid having sexual intercourse." f. "Don't wear tight shirt or blouse collars."

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. "I will wash my hands often during the day. b. "I will remove my contact lenses at bedtime." c. "I will not share towels with my friends or family." d. "I will monitor my family for eye redness or drainage."

b. "I will remove my contact lenses at bedtime."

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How would the nurse respond? a. "Your immune system becomes less effective as you age." b. "Low estrogen levels can make the tissue more susceptible to infection." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted disease."

b. "Low estrogen levels can make the tissue more susceptible to infection."

A client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? a. "Cap the catheter drain at night to prevent leakage and skin damage." b. "Position the drainage bag lower than the catheter insertion site." c. "Irrigate the catheter with an ounce of saline every night." d. "Pierce a hole in the top of the drainage bag to get rid of odors."

b. "Position the drainage bag lower than the catheter insertion site."

A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for the nurse to provide? a. "Increase the fiber and water in your diet to prevent diarrhea." b. "Report any suicidal thoughts to your primary health care provider" c. "Report dry mouth and decreased sweating." d. "Do not take antibiotics or nay other anti-infective drugs."

b. "Report any suicidal thoughts to your primary health care provider"

Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling antiviral drops for a patient with a corneal ulcer b. Application of a warm compress to a patient's hordeolum c. Instruction about hand washing for a patient with herpes keratitis d. Looking for eye irritation in a patient with possible conjunctivitis

b. Application of a warm compress to a patient's hordeolum

The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by the nurse is most appropriate? a. "Visit your primary health care provider each month for wax removal." b. "Drink plenty of water and other liquids to prevent hardening of the ear wax." c. "Irrigate each ear once a month to remove wax and prevent wax buildup." d. "Put one drop of mineral oil in each ear once a week at bedtime."

d. "Put one drop of mineral oil in each ear once a week at bedtime."

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first? a. Administer the ordered analgesic. b. Check the patient's oxygen saturation. c. Examine the eye for evidence of trauma. d. Assess each of the cranial nerve functions.

b. Check the patient's oxygen saturation.

A client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure.

b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. e. Try to flush the tube with 30 mL of water and gentle pressure.

What should the nurse teach a patient with repeated hordeolum about how to prevent further infection? a. Apply cold compresses. b. Discard all used eye cosmetics. c. Wash the eyebrows with an antiseborrheic shampoo. d. Be examined for sexually transmitted infections (STIs).

b. Discard all used eye cosmetics.

The nurse is caring for a patient diagnosed with adult inclusion conjunctivitis (AIC) caused by C. trachomatis. Which action should be included in the plan of care? a. Applying topical corticosteroids to decrease inflammation b. Discussing the need for sexually transmitted infection testing c. Educating about the use of antiviral eyedrops to treat the infection d. Assisting with applying for community visual rehabilitation services

b. Discussing the need for sexually transmitted infection testing

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? a. Administer a tetanus booster shot. b. Ensure that the client has a patent airway. c. Prepare to irrigate the client's eye. d. Turn the client on the unaffected side.

b. Ensure that the client has a patent airway.

Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? a. Assist the patient to a supine position for the irrigation. b. Fill the irrigation syringe with body-temperature solution. c. Use a sterile applicator to clean the ear canal before irrigating. d. Occlude the ear canal completely with the syringe while irrigating.

b. Fill the irrigation syringe with body-temperature solution.

The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employee's eyes. Which action will the nurse take first? a. Apply ice packs to both eyes. b. Flush the eyes with sterile saline. c. Apply antiseptic ophthalmic ointment to the eyes. d. Cover the eyes with dry sterile patches and shields.

b. Flush the eyes with sterile saline.

A nurse reviews the laboratory findings of a client with a urinary tract infection (bacterial cystitis). The laboratory report notes a "shift to the left" in the client's white blood cell count. What action would the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the primary health care provider and start an intravenous line for parenteral antibiotics. c. Ask assistive personnel (AP) to strain the client's urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

b. Notify the primary health care provider and start an intravenous line for parenteral antibiotics.

After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "I will have my partners tested for STIs." c. "An orange color in my urine should not alarm me." d. "I will drink two glasses of cranberry juice daily."

c. "An orange color in my urine should not alarm me."

A nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the nurse include in the directions to the AP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn't get spoiled. b. Assess the patient's mouth while providing premeal oral care. c. Ensure that warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

c. Ensure that warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

A client with pneumonia and dementia is admitted with an indwelling urinary catheter in place. During interprofessional rounds the following day, which question would the nurse ask the primary health care provider? a. "Do you want daily weights on this client?" b. "Will the client be able to return home?" c. "May we discontinue the indwelling catheter?" d. "Should we get another chest x-ray today?"

c. "May we discontinue the indwelling catheter?"

The nurse is teaching new assistive personnel (AP) about caring for older adults. Which statement would the nurse include about hearing ability of this client group? a. "You need to talk very loudly when communicating with these clients." b. "You always need to check each client's ears for excess ear wax." c. "Remember to face the client when talking with him or her." d. "Assess each client's hearing ability using the voice or whisper test."

c. "Remember to face the client when talking with him or her."

The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? a. Intermittent diarrhea b. Cholecystitis c. Aspiration pneumonia d. Peptic ulcer disease

c. Aspiration pneumonia

A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy sign c. Clay-colored stools d. Upper abdominal pain after eating

c. Clay-colored stools

A client just returned to the surgical unit after an open traditional gastric bypass. What action by the nurse is the priority? a. Assess the patient's pain b. Check the surgical incision. c. Ensure an adequate airway d. Program the morphine pump.

c. Ensure an adequate airway

A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the patient's gastric residual. c. Hold the feeding until the vomiting subsides. d. Reduce the rate of the tube feeding by half.

c. Hold the feeding until the vomiting subsides.

A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time? a. Listen to the client's bowel sounds. b. Call the Rapid Response Team. c. Take the client's vital signs. d. Contact the primary health care provider.

c. Take the client's vital signs.

The nurse assesses a newly admitted client and documents a body mass index (BMI) of 31.2. What does this value indicate to the nurse? a. The client has a healthy weight. b. The client is underweight. c. The client is obese. d. The client is overweight.

c. The client is obese.

What should the nurse teach a patient with recurrent staphylococcal and seborrheic blepharitis to do? a. Irrigate the eyes with saline solution. b. Schedule an appointment for eye surgery. c. Use a gentle baby shampoo to clean the eyelids. d. Apply cool compresses to the eyes three times daily.

c. Use a gentle baby shampoo to clean the eyelids.

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching? a. "I won't let anyone use my dishes or glasses." b. "I'll wash my hands with antibacterial soap." c. "I'll keep my bathroom extra clean." d. "I'll cook all the meals for my family."

d. "I'll cook all the meals for my family."

A client is scheduled for a hepatobiliary iminodiacetic acid (HIDA) scan. What would the nurse include in client teaching about this diagnostic test? a. "You'll have to drink a contrast medium right before the test." b. "You'll need to do a bowel prep the nursing before the test." c. "You'll be able to drink liquids up until the test begins." d. "You'll have a large camera close to you during the test."

d. "You'll have a large camera close to you during the test."

Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1? a. Correct use of the antifungal eyedrops natamycin (Natacyn) b. How to apply corticosteroid ophthalmic ointment to the eyes c. Avoidance of nonsteroidal antiinflammatory drugs (NSAIDs) d. Importance of taking all of the ordered oral acyclovir (Zovirax)

d. Importance of taking all of the ordered oral acyclovir (Zovirax)

A client who has had cold symptoms for a week visits the local urgent care center with report of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings would the nurse expect? a. High fever b. Nausea and vomiting c. Elevated blood pressure d. Purulent ear drainage

d. Purulent ear drainage

The nurse inserts a small-bore nasoduodenal tube for a client who is undernourished. What priority nursing action is required prior to starting the continuous tube feeding to confirm correct tube placement? a. Assess for carbon dioxide using capnometry. b. Perform pH testing of gastric fluid. c. Auscultate over the epigastric area. d. Request an x-ray before starting the feeding.

d. Request an x-ray before starting the feeding.