NPN110 16,20,25,26 ... exam 3/1/23

A nurse is caring for a client with acute back pain. when should the nurse assess the clients pain?

30 minutes after administering a prescribed analgesic

the nurse is providing health teaching for four clients. which client should consider a colonoscopy screening?

50 year old client with family history of polyps

The nurse works at an agency that automatically places certain clients on intake and output ( I& amp O) for which client will the nurse document all I&ampO?

55-year-old with congestive heart failure on furosemide

A physician has asked the nurse to use micro drip tubing to administer a prescribed dosage of IV solution to a client. what is the standard drop factor of micro drip tubing?

60 drops/ mL

A nurse is preparing administer an acetaminophen suppository. for which client would a suppository be preferable to oral medication administration?

A client who has dysphagia following a stroke but who also has a fever

A nurse is caring for an older adult client at his home. the client has had a condom catheter applied. which describes a condom catheter?

A flexible sheath that is rolled over the penis

A nurse is caring for a client with phlebitis. the nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. which actions should the nurse perform to avoid further complications and provide relief to the client?

Discontinue the IV promptly

A nurse is assessing a mentally challenged adult client who is in pain after a fall from a staircase. which scale should the nurse use to assess the clients pain?

FACES scale

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client warm skin. the nurse also notes a decrease in the client's blood pressure. which medical diagnosis may be responsible?

Hypovolemia

A client with dehydration is being administered IV fluids. During rounds the nurse noticed that the skin immediately surrounding the IV site was reddish in color showing signs of inflammation. the nurse recognizes that what phenomenon is likely responsible?

Phlebitis

A nurse is caring for an alert and oriented client with cancer who is experiencing pain. what would be the most appropriate assessment of the client's pain?

The clients pain based on a pain rating.

when collecting a urine sample from a client for examination. the nurse notes that the sample appears reddish-brown color. what could cause this variation in color of the urine?

blood

the nurse is administering a cleansing enema when the client reports cramping. what is the appropriate nursing action ?

clamp the tube for brief period and resume at a slower rate

for which client would a cleansing enema most likely be indicated?

client who scheduled to be screened for colorectal cancer the following morning.

A client who was involved in an accident is bleeding very heavily. what would be required to replace the circulating blood?

colloid solution

A nurse performs catheter irrigation for a client at a health care facility only after verifying that a medical order has been written. why should the nurse take this precaution?

demonstrates legal limits of nursing.

A nurse is caring for an older adult client who experiences urinary urgency. what is possible cause of the client's condition?

diminished bladder capacity

A nurse is administering a prescribe hypertonic saline enema to a client with constipation. which is a function of hypertonic saline enema?

draws fluid from body tissues into the bowel

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristic of what type of incontinence

functional

A nurse is caring for client with primary constipation. which factor is responsible for primary constipation?

inadequate intake of liquid

A nurse needs to administer an oil-retention enema to a client. which intervention should the nurse perform if disposable equipment is unavailable?

insert a 145F to 22F tube into the rectum

A client at a health care facility is being treated for cancer bladder. the physician uses a urinary diversion to help the client with urinary elimination. what describes a urinary diversion.

one or both of the ureters are surgically implanted elsewhere

A nurse is caring for a constipated client who has abdominal distention. which is another sign accompanying constipated?

oozing liquid stool

A severely malnourished client has been admitted to a health care facility. The nurse is preparing to administer total parenteral nutrition ( TPN) to the client. the nurse should administer the TPN solution in a

peripheral vein with its tip terminating in the superior vena cava.

A nurse is caring for a client with an amputated limb. the client tells the nurse that he has burning sensation in his amputated limb. how should the nurse document this pain?

phantom pain

A client in a health care facility has had a urinary catheter in situ for the past several days. the clients nurse amended the clients plan of care to reflect the use of the device. what nursing diagnosis is a priority in this aspect of the client's care?

risk for infection

An elderly client has been experiencing urinary hesitancy and this has resulted in the client's bladder becoming overdistended with urine. what intervention should the nurse attempt before resorting to the insertion of a urinary catheter?

run water from the tap in the client's room to stimulate the urge to void.

a nurse collects a clean-catch specimen from a client at a health care facility. which statement describes a clean-catch urine sample?

sample of urine that is considered sterile

A nurse is caring for a client who administered opioid narcotics. The client reports constipation. what is another potential side effect of opioid narcotics?

sedation

The nurse is performing an assessment for an older adult client admitted with dehydration. when assessing the skin turgor of this client, which area of the body will be best for nurse to assess?

sternum

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. which type of catheter should the nurse use?

straight catheter

A middle-aged client with cancer has been prescribed patient- controlled analgesia ( PCA)the nurse caring for the client explains the functioning of PCA. what is the main advantage of PCA?

the client is actively involved in pain management

when irrigating a client's ear, the nurse avoids occluding the ear canal with the top of syringe. why should the nurse take such a precaution?

the pressure of the trapped solution could rupture the eardrum.

A nurse is caring for a client with dull ache in her abdomen. on the way to the health care facility. the client vomits and shows symptoms of pallor. what kind of pain is the client experiencing?

visceral pain

the nurse is caring for a client with a stoma placed before the terminal ileum. which vitamin does the nurse anticipate will be prescribed?

vitamin b12

A nurse is assessing the stoma of a client with an ostomy. which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

wash it with a mild cleanser and water

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. which action should the nurse perform?

weigh the client's a wet linen or dressing.