NRSG 200 Practice Exam 3

Which of the following are appropriate for the nurse to implement for a patient with orthostatic hypotension? Select all that apply.​ ​ 1. Instruct to call for assistance prior to getting OOB​ 2. When lying in bed, encourage sitting before standing​ 3. Take the blood pressure & pulse prior to activity​ 4. Encourage 2 to 3 liters of fluid per day​ 5. Wear thrombo-embolic devices​ 6. Avoid bending at the waist ​ 7. Avoid foods high in sodium

1, 2, 3, 4, 5, and 6

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? 1. Call the pharmacy and order a STAT dose of glucagon. 2. Immediately give the client 30 g of glucose orally. 3. Start an IV and administer a small amount of a concentrated dextrose solution. 4. Recheck the blood glucose level and call the Rapid Response Team.

2

While undergoing a soapsuds enema, a client c/o abdominal cramping. What is the best action for you to take?​ ​ 1. Stop the fluid flow​ 2. Lower the height of the enema bag​ 3. Advance the enema tubing 2 inches​ 4. Clamp the tubing for 2 minutes, then restart the flow

2

A nurse is caring for a patient that is receiving parenteral nutrition. Which of the following are essential nursing actions when caring for this patient? Select all that apply.​ ​ 1. Use tubing with an in-line filter​ 2. Monitor blood glucose regularly​ 3. Obtain a daily weight​ 4. Hang dextrose 10% if the infusion runs out​ 5. Use a dedicated IV site​

1, 2, 3, 4, and 5

A patients states that she "loses urine" when she coughs or laughs. Which of the following would be relevant to discuss? Select all that apply.​ ​ 1. Kegel exercises​ 2. Habit training​ 3. The double void technique​ 4. Self catheterization​ 5. Caffeine intake​

1, 2, 3, and 5

The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? 1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy

2 Rationale: The ileal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3).

Your client is only comfortable lying on the right or left side (not on the back or stomach). List four potential sites of pressure injuries you must assess.

Potential pressure injury sites for side-lying clients include ankles, knees, trochanters, ilia, shoulders, and ears. These are important areas to assess.

A nurse is caring for a client who had an ileostomy placed 6 hours ago. Which action is the most important?​ ​ 1. Assess the color of the stoma​ 2. Irrigate the colostomy​ 3. Empty the appliance when it is full​ 4. Clean the peristomal skin with normal saline

1

A nurse is preparing to collect a urinary specimen for a culture from a patient with a Foley catheter. Which step ensures the specimen is collected in a sterile fashion?​ ​ 1. Wiping the specimen port with an alcohol swab​ 2. Donning sterile gloves prior to obtaining the specimen​ 3. Collect the specimen early in the morning​ 4. Use a clean specimen container

1

A patient had a chest CT scan with IV contrast at 1100. The patient has an IV running at 125mL/hr, ate 50% of his lunch with a cup of coffee & 4oz of soup. It is now 1900. Which of the following are you most concerned about?​ ​ 1. Urine output -100mL​ 2. Slight nausea​ 3. Mild headache​ 4. BP 150/84 mm/Hg​

1

A patient is post-op day 3 for a colostomy and is concerned that she has not had much stool in her ostomy bag. What is the best response by the nurse?​ ​ 1. Output, called effluent usually starts on the 4th or 5th post-op day​ 2. This is normal, the bowels needs to rest after surgery, this is why you are on a liquid diet​ 3. There should be more output, I will call & update the surgeon​ 4. I will irrigate the colostomy, there may be a small blockage

1

Clinical manifestations associated with a diagnosis of type 1 DM include all of the following except:​ ​ 1. Hypoglycemia​ 2. Hyponatremia​ 3. Ketonuria​ 4. Polyphagia​ 5. Hyperglycemia

1

The risk factors for type 1 diabetes mellitus include all of the following except:​ ​ 1. Diet​ 2. Genetic​ 3. Autoimmune​ 4. Environmental​

1

What should a nurse do to prevent burns during mealtime for patients with mental or physical impairments?​ ​ 1. Assist the patient with hot food & fluid​ 2. Use plastic utensils​ 3. Serve cold or room temperature food & fluid​ 4. Wait until hot food & fluid has cooled before serving

1

Which intervention is appropriate to include on a care plan for improving sleep in the older adult patient?​ ​ 1. Decrease fluids 2 hours before sleep​ 2. Exercise in the evening to decrease fatigue​ 3. Allow the patient to sleep in​ 4. Encourage a daily nap at 1600

1

​ People with diabetes mellitus are at increased risk of heart disease if they also:​ ​ 1. Have an elevated diastolic pressure​ 2. Have high HDL cholesterol levels​ 3. Take a daily aspirin​ 4. Consume a high-fiber diet

1

What is the proper technique with gravity tube feeding? 1. Hang the feeding bag 1 foot higher than the tube's insertion point into the client. 2. Administer the next feeding only if there is less than 25 mL of residual volume from the previous feeding. 3. Place the client in the left lateral position. 4. Administer feeding directly from the refrigerator.

1 Rationale: For proper flow, the feeding container hangs 1 foot above the tube insertion. Feedings may be administered if there is less than 90 to 100 mL of residual volume (unless agency policy specifies otherwise) (option 2). To prevent or reduce the risk of aspiration, the client should be placed in Fowler's position during feeding (option 3). The feeding should be warmed to room temperature before administration to decrease cramping and diarrhea (option 4).

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? 1. Constipation 2. Diarrhea 3. Incontinence 4. Hemorrhoids

1 Rationale: Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result--if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool (option 2). Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence (option 3). Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool (option 4).

When assessing a client's gait, which does the nurse look for and encourage? 1. The spine rotates, initiating locomotion. 2. Gaze is slightly downward. 3. Toes strike the ground before the heel. 4. Arm on the same side as the swing-through foot moves forward at the same time.

1 Rationale: Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward.

During a well-child visit, a mother tells the nurse that her 4-year-old daughter typically goes to bed at 10:30 P.M. and awakens each morning at 7 A.M. She does not take a nap in the afternoon. Which is the best response by the nurse? 1. Encourage the mother to consider putting her daughter to bed between 8 and 9 P.M. 2. Reassure the mother that it is normal for 4-year-olds to resist napping, but encourage her to insist that she rest quietly each afternoon. 3. Recommend that her daughter be allowed to sleep later in the morning. 4. Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap.

1 Rationale: Preschool children require 10 to 12 hours of sleep per night. Young children often rise early, so it is more appropriate to put the child to bed earlier in the evening.

A new nursing graduate's first job requires 12-hour night shifts. Which strategy will make it easier for the graduate to sleep during the day and remain awake at night? 1. Wear dark wraparound sunglasses when driving home in the morning, and sleep in a darkened bedroom. 2. Exercise on the way home to avoid having to stand around waiting for equipment at the gym. 3. Drink several cups of strong coffee or 16 oz of caffeinated soda when beginning the shift. 4. Try to stay in a brightly lit area when working at night.

1 Rationale: Reducing exposure to bright light in the morning, when driving home, and when going to sleep will make it easier to fall asleep after work. Exercising before going to bed will increase arousal (option 2). Caffeine consumed at the beginning of a 12-hour shift will not assist the nurse in remaining awake during the latter part of the shift (option 3). Although working in a brightly lit area will reduce drowsiness, this strategy is rarely available to nurses working the night shift; lights are often dimmed in hospital corridors and client rooms (option 4).

A 55-year-old female is about 9 kg (20 lb) over her desired weight. She has been on a "low-calorie" diet with no improvement. Which statement reflects a healthy approach to the desires weight loss? "I need to: 1. Increase my exercise to at least 30 minutes each day." 2. Switch to a low-carbohydrate diet." 3. Keep a list of my forbidden foods on hand at all times." 4. Buy more organic and less processed foods."

1 Rationale: The Dietary Guidelines recommend 30 minutes of physical activity on most days of the week to achieve optimal weight. Some individuals benefit from a low-carbohydrate diet, but no particular diet is the solution for all individuals (option 2). A reasonable diet emphasizes balance and portion control rather than forbidding or requiring any specific foods (option 3). Fresh and chemical-free foods may be healthier than preserved foods but do not automatically assist with weight loss (option 4).

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? 1. Leaves the catheter in place and gets a new sterile catheter. 2. Leaves the catheter in place and asks another nurse to attempt the procedure. 3. Removes the catheter and redirects it to the urinary meatus. 4. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

1 Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2).

Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains the following to the client: 1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation). 2. It will be acceptable to leave the pad in place if the temperature is reduced. 3. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed. 4. It will be acceptable to leave the pad in place as long as it is moist heat.

1 Rationale: The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect, resulting in vasoconstriction. Lowering the temperature, but still delivering heat--dry or moist-- will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? 1. Inadequate physical energy for activities 2. Potential for inadequate physical energy for activities 3. Impaired self-esteem 4. Potential for falling

1 Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "potential for," as in option 2. There is no evidence that the client has self-esteem problems (option 3), or is in danger of falling (option 4).

Proper technique for performing a wound culture includes which of the following? 1. Cleansing the wound prior to obtaining the specimen 2. Swabbing for the specimen in the area with the largest collection of drainage 3. Removing crusts or scabs with sterile forceps and then culturing the site beneath 4. Waiting 8 hours following a dose of antibiotic to obtain the specimen

1 Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have begin, the interval following a dose will not significantly affect the concentration of wound organisms.

When does the nurse teach a client with diabetes mellitus to avoid exercising? Select all that apply.​ ​ 1. Within 1 hour of receiving insulin​ 2. When blood glucose level is less than 100 mg/dL​ 3. When blood glucose level is 100-249 mg/dL​ 4. When ketones are present in the urine​ 5. After eating a meal

1 and 4

The nurse plans to remove the client's sutures. Which action demonstrates appropriate standards of care? Select all that apply. 1. Use clean technique. 2. Grasp the suture at the knot with a pair of forceps. 3. Place the curved tip of the suture scissors under the suture as close to the skin as possible. 4. Pull the suture material that is visible beneath the skin during removal. 5. Remove alternate sutures first.

1, 2, 3, and 5 Rationale: Option 4 is not correct. The suture material that is visible is in contact with bacteria and must not be pulled beneath the skin during removal.

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. 1. Perineal skin irritation 2. Fluid intake of less than 1500 mL/day 3. History of antihistamine intake 4. History of frequent urinary tract infections 5. A fecal impaction

1, 2, 4, and 5 Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1500 mL/day and clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3).

Common interventions for sleep apnea are... Select all that apply.​ 1. CPAP​ 2. Tonsillectomy​ 3. Weight loss​ 4. CNS stimulants

1, 2, and 3

When teaching an adult patient, what should the nurse consider? Select all that apply.​ ​ 1. Language should be at a 5th or 6th grade level​ 2. Use active not passive wording​ 3. Simple pictures are appropriate​ 4. Withhold narcotics prior to teaching​ 5. Avoid repeating information​ 6. Use approved acronyms

1, 2, and 3

Which nursing interventions are associated with caring for a client experiencing constipation? Select all that apply.​ ​ 1. Ambulate the client TID​ 2. Encourage the intake of prunes​ 3. Respond to the urge to defecate​ 4. Encourage pain control with narcotics

1, 2, and 3

Which of the following items are used to perform wound irrigation? Select all that apply. 1. Clean gloves 2. Mask 3. Refrigerated irrigating solution 4. 60-mL syringe 5. Forceps

1, 2, and 4 Rationale: To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid. A mask should be worn when splashing can occur such as when irrigating a wound. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be room or body temperature--certainly not refrigerated. Forceps may be used to remove or apply a dressing but are not required for irrigation.

Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply. 1. Bowel incontinence 2. Potential for decreased fluid volume 3. Altered body image 4. Social seclusion 5. Potential for developing altered skin integrity

1, 3, 4, and 5 Rationale: Option 1 is the most appropriate. The client is unable to decide when stool evacuation will occur. In option 3, client thoughts about self may be altered if unable to control stool evacuation. In option 4, the client may not feel as comfortable around others. In option 5, increased tissue contact with fecal material may result in impairment. Option 2 is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency.

During admission to a hospital unit, the client tells the nurse that her sleep tends to be very light and that it is difficult for her to get back to sleep if she's awakened at night. Which interventions should the nurse implement? Select all that apply. 1. Remind colleagues to keep their conversation to a minimum at night. 2. Encourage the client's family members to bring in a radio to play soft music at night. 3. Deliver necessary medications and procedures at 1.5- or 3-hour intervals between 11 P.M. and 6 A.M. 4. Encourage the client to ask family members to bring in a fan to provide white noise. 5. Increase the temperature in the room.

1, 3, and 4 Rationale: Reducing environmental noise, as well as the number of times she is disturbed for medications and vital signs, will reduce the likelihood that she will awaken during the night. Delivering necessary care at 1.5- or 3-hour intervals is consistent with multiples of the 90-minute sleep cycle. Since it is unlikely that all of the noise in the environment can be eliminated, using a fan to generate a steady background noise may help mask sounds of people talking, carts being moved through the halls, and other noise. Music is not usually recommended because it can be interesting to listen to, thus encouraging wakefulness (option 2). The room temperature needs to be satisfactory for the client. A room that is too warm is not usually conducive for sleep (option 5).

Which of the following are primary risk factors for pressure injuries? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1, 3, and 4 Rationale: Risk factors for pressure injuries include low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce the chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chances of skin breakdown.

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. 1. Increase muscle tone and improve circulation. 2. Increase blood pressure. 3. Increase muscle mass and strength. 4. Decrease heart rate and cardiac output. 5. Maintain joint range of motion.

1, 3, and 5 Rationale: Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body (option 4). Little or no change in blood pressure occurs (option 2).

A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse's assessment? Select all that apply. 1. Amount of sleep he usually obtains during the week and on weekends 2. How much alcohol he usually consumes 3. Onset and duration of symptoms 4. Whether or not his classes are boring 5. What medications, including herbal remedies, he is taking

1, 3, and 5 Rationale: It is important to find out if he is obtaining sufficient sleep. If he gets more sleep on weekends than weekdays, insufficient sleep may be the cause of his difficulties staying awake in class. It is important to determine if his symptoms are chronic (e.g., longer than 3 months) or if they are of recent onset. Some prescribed and over-the-counter medications and herbal remedies can cause sleep disturbances. Although alcohol abuse or binge drinking can cause health problems, neither is likely to cause excessive daytime sleepiness (option 2). Unless the person is sleep deprived, boring classes will not induce sleep (option 4).

Which of the following statements are true regarding insulin. Select all that apply.​ ​ 1. Should be stored between 46°F - 86°F​ 2. The vial should be shaken prior to use​ 3. Should be discarded after 28 days​ 4. Prefilled syringes should be stored upright​ 5. Injection site irritation may occur when injecting refrigerated insulin

1, 4, and 5

Performance of activities of daily living (ADLs) and active range-of-motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. 1. Elbow flexion with eating and bathing 2. Elbow extension with shaving and eating 3. Wrist hyperextension with writing 4. Thumb ROM with eating and writing 5. Hip flexion with walking

1, 4, and 5 Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3).

A nurse is caring for a patient with continuous NGT feedings via a pump. The nurse identifies that the patient is having difficulty breathing & is restless. What should the nurse do first?​ ​ 1. Use a nasal cannula to provide oxygen​ 2. Activate the hold button on the feeding pump​ 3. Raise the head of the bed to high fowlers​ 4. Notify the primary care provider​

2

A nurse is instructing a patient on how to self administer a fleets enema pre-op. What is important for the nurse to discuss? 1. Insert the applicator 4 inches into the rectum beyond the internal sphincter​ 2. Retain the enema solution for up to 30 minutes to promote evacuation​ 3. Lay on your right side for best results​ 4. Warm in the microwave for 1 minute to decrease cramping​

2

A nurse is teaching a client the correct method to use for walking with crutches. The nurse should explain that weight must be placed:​ ​ 1. In the axillae​ 2. On the arms​ 3. On the affected side​ 4. On the unaffected side

2

A nurse notes that a client's Foley catheter has had no output for 3 hours. The first intervention the nurse would perform is:​ ​ 1. Irrigate the Foley catheter​ 2. Check for kinks in the tubing​ 3. Notify the MD​ 4. Encourage fluid intake​ 5. Remove the Foley catheter​

2

When providing care to a patient with a NGT, the nurse should take measures to prevent what serious complication?​ ​ 1. Skin breakdown​ 2. Aspiration pneumonia​ 3. Retention ileus​ 4. Profuse diarrhea​ 5. Delirium

2

Which patient is at the highest risk for developing Clostridium difficile?​ ​ 1. 56-year-old, s/p MVA with a rib fracture, receiving acetaminophen​ 2. 75-year-old, COVID-19 positive, receiving a fluoroquinolone​ 3. 22-year-old, HIV-AIDS positive, receiving pre-exposure prophylaxis (PrEP)​ 4. 48-year-old, with colon cancer, receiving docusate sodium (Colace)

2

​ Excessive thirst & volume of urine may be symptoms of:​ ​ 1. Urinary tract infection​ 2. Hyperglycemia​ 3. Viral gastroenteritis​ 4. Hypoglycemia

2

Which nursing diagnosis is most appropriate for a client with a body mass index (BMI) of 35? 1. Inadequate dietary intake 2. Obesity 3. Overweight 4. Undernutrition

2 Rationale: A BMI of 30 to 40 indicates moderate to severe obesity. A BMI of less than 18.5 indicates underweight, which may be due to inadequate dietary intake (option 1) or undernutrition (option 4). The nursing diagnosis of overweight is defined by a BMI of 25-29.9 (option 3).

To increase stability during client transfer, the nurse increases the base of support by performing which action? 1. Leaning slightly backward 2. Spacing the feet farther apart 3. Tensing the abdominal muscles 4. Bending the knees

2 Rationale: A key word in the question is base, and the feet provide this foundation. Leaning backward actually decreases balance (option 1), and tensing abdominal muscles alone (option 3) or bending the knees (option 4) does not affect the base of support.

Your client has a Braden scale score of 17. Which is the appropriate nursing action? 1. Assess the client again in 24 hours; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.

2 Rationale: A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment is indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to clients with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.

Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? "By day 5, the client will: 1. Sleep 8 to 10 hours per day." 2. Report falling asleep within 20 to 30 minutes." 3. Have a plan to pay all bills." 4. Decrease worrying about financial problems and will keep busy until bedtime."

2 Rationale: Falling asleep within 20 to 30 minutes is normal for adults and would represent substantial improvement in the client's difficulties. Most adults do not need to sleep 8 to 10 hours per day (option 1). Although it would be ideal to remove the source of the client's stress, he is unlikely to have a plan to pay all his bills within 5 days (option 3). Distraction or keeping busy until bedtime will not prevent the client from worrying about his bills at bedtime (option 4).

Which of the following indicates a proper principle of bandaging? 1. Apply the bandage as tightly as possible without causing pain. 2. Gauze bandages are used to hold absorbent dressings in place. 3. Elastic bandages must be sterile when applied. 4. The bandage should always cover at least one joint of the limb.

2 Rationale: Gauze bandages are used to hold absorbent dressings in place. How tight the bandage is applied depends on the purpose (option 1). Elastic bandages are generally not sterile because they are used to support a body part and not cover a wound (option 3). The bandage may or may not cover at least one joint of the limb (option 4).

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? 1. The client will wear a medical alert bracelet for antibiotic allergy. 2. The client will return to his or her previous fecal elimination pattern. 3. The client will verbalize the need to take an antidiarrheal medication prn. 4. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

2 Rationale: Once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug (option 1). Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock (option 3). Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not (option 4).

You have explained to the client the reason for and steps involved for insertion of an indwelling urinary catheter. List the following actions in the correct sequence: 1. Apply sterile gloves 2. Attach prefilled syringe 3. Secure IUC appropriately to prevent urethural irritation 4. Perform pericare 5. Insert catheter to appropriate length and check urine flow 6. Lubricate catheter 7. Inflate balloon 8. Perform hand hygiene 9. Clean urinary meatus with antiseptic solution 10. Open catheter kit 1. 8, 10, 4, 1, 2, 6, 9, 5, 7, 3 2. 2, 4, 8, 10, 1, 6, 2, 9, 5, 7, 3 3. 4, 8, 1, 10, 6, 2, 9, 5, 7, 3 4. 10, 4, 8, 1, 7, 2, 6, 9, 5, 3

2 Rationale: Option 2 is the correct sequence. Option 1 is incorrect because the nurse needs to perform hand hygiene after providing pericare. Option 3 is incorrect because the outside of the kit is not sterile and the nurse would not open the kit with sterile gloves. The current best practice is to not pre-inflate the balloon (option 4).

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? 1. Prepare to irrigate the colostomy. 2. After assessing the stoma and surrounding skin, notify the surgeon. 3. Assess bowel sounds and administer antiemetic. 4. Administer a bulk-forming laxative, and encourage increased fluids and exercise.

2 Rationale: The client has assessment findings consistent with complications of surgery. Option 1: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option 3: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option 4: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated.

Which action represents the appropriate nursing management of a client wearing an external urinary device? 1. Ensure that the tip of the penis fits snugly against the end of the condom. 2. Check the penis for adequate circulation 30 minutes after applying. 3. Change the condom every 8 hours. 4. Tape the collecting tubing to the lower abdomen.

2 Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight. A 1-in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bag (option 4). An indwelling catheter is taped to the lower abdomen or upper thigh.

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? 1. Heart rate 86 beats/min 2. Reddened area on sacrum 3. Nonproductive cough 4. Urine output of 50 mL/h

2 Rationale: The reddened area of the skin can lead to skin breakdown. The other options are within normal limits.

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1. "I need to drink one and a half to two quarts of liquid each day." 2. "I need to take a laxative such as milk of magnesia if I don't have a BM every day." 3. "If my bowel pattern changes on its own, I should call you." 4. "Eating my meals at regular times is likely to result in regular bowel movements."

2 Rationale: The standard of practice in assisting older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults (option 2). In addition, a normal stool pattern for an older adult may not be daily elimination.

Ketones are not usually found in the urine. In which of the following patients would you expect to see urine ketones? Select all that apply.​ ​ 1. Sodium intake​ 2. Starvation​ 3. Uncontrolled hyperglycemia​ 4. Overhydration​

2 and 3

Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. 1. "Avoid all dietary carbohydrate and fat." 2. "Have your eyes and vision assessed by an ophthalmologist every year." 3. "Reduce your intake of animal fat and increase your intake of plant sterols." 4. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." 5. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." 6. "Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home."

2 and 3

A nurse is caring for a female client who has recurrent UTIs. What should the nurse teach the client to do? Select all that may apply.​ ​ 1. Wear nylon underpants​ 2. Void after having intercourse​ 3. Take a bath instead of a shower​ 4. Urinate when the urge to void is perceived​ 5. Wipe from back to front after a BM​ 6. Perform Kegel exercises weekly

2 and 4

Which foods should be avoided for a patient with a diagnosis of congestive heart failure & on a 1.5L fluid limit? Select all that apply.​ ​ 1. Cottage cheese​ 2. Bacon​ 3. Hard candy​ 4. Soup​ 5. Corn & flour tortillas

2 and 4

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all the apply. 1. Limit fluids to avoid the burning sensation on urination. 2. Review symptoms of UTI with the client. 3. Wipe the perineal area from back to front. 4. Wear cotton underclothes. 5. Take baths rather than showers.

2 and 4 Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of area to bacteria (option 5).

Which of the following behaviors indicates that the client on a bladder retraining program has met the expected outcomes? Select all that apply. 1. Voids each time there is an urge. 2. Practices slow, deep breathing until the urge decreases. 3. Uses adult diapers, for "just in case." 4. Drinks citrus juices and carbonated beverages. 5. Performs pelvic floor muscle exercises.

2 and 5 Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the best indicator of a successful program (option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4).

Which items are allowed on a full liquid diet? Select all that apply. 1. Scrambled eggs 2. Chocolate pudding 3. Tomato juice 4. Hard candy 5. Mashed potatoes 6. Cream of Wheat cereal 7. Oatmeal cereal 8. Fruit "smoothies"

2, 3, 4, 6, and 8 Rationale: A full liquid diet contains only liquids or foods that turn to liquid at body temperature. Pudding, juices, hard candy, Cream of Wheat cereal, and fruit smoothies are permitted on a full liquid diet. Scrambled eggs (option 1), mashed potatoes (option 5), and oatmeal cereal (option 7) are not permitted until the client advances to a soft diet.

The nurse is admitting a client with hypoglycemia. Identify the signs & symptoms the nurse would expect. Select all that apply.​ ​ 1. Polyphagia​ 2. Palpitations​ 3. Diaphoresis​ 4. Slurred speech​ 5. Hyperventilation​​

2, 3, and 4

A nurse is caring for a patient who has been diagnosed with obstructive sleep apnea. Which of the following is most effective in supporting restful sleep?​ 1. Maintain a side lying position while asleep​ 2. Employ breathing exercises for relaxation prior to sleep​ 3. Use an ordered positive pressure device when sleeping​ 4. Position several pillows under the head when sleeping

3

After teaching a patient newly diagnosed with diabetes mellitus, the nurse assesses understanding. Which statement made by the patient indicates correct understanding of the need for eye examinations?​ ​ 1. "I will see the eye doctor when I have a vision problem & yearly at age 40." ​ 2. "My vision may change quickly. I should see an optometrist twice a year." ​ 3. "Diabetes can cause blindness, so I should see an ophthalmologist yearly." ​ 4. "At my age, I should continue seeing the optician as I usually do."

3

The RN is taking a sleep history from a patient. Which statement made by the patient needs follow-up?​ ​ 1. "I go to bed at the same time each night​." 2. "It takes me about 15 minutes to fall asleep​." 3. "I usually feel tired when I wake up." 4. "Sometimes I get up during the night to urinate."

3

Which description fits that of serous drainage from a wound?​ ​ 1. Fresh bleeding​ 2. Thick & yellow​ 3. Clear, watery plasma​ 4. Brown & foul smelling​ 5. Mix of blood & plasma

3

Which one of the following is an indication for an ABD binder?​ ​ 1. To assist with collection of would drainage​ 2. Reduction of ABD swelling​ 3. Decreased stress on the ABD incision​ 4. To increase peristalsis with direct pressure​ 5. To relieve edema

3

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? 1. "Going up, the strong leg goes first, then the weaker leg with both crutches." 2. "Going down, the weaker leg goes first with both crutches, then the strong leg." 3. "The weaker leg always goes first with both crutches." 4. "A cane or single crutch may be used instead of both crutches if held on the weaker side."

3 Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct.

An older Asian client has mild dysphagia from a recent stroke. The nurse plans the client's meals based on the need to: 1. Have at least one serving of thick dairy (e.g., pudding, ice cream) per meal. 2. Eliminate the beer usually ingested every evening. 3. Include as many of the client's favorite foods as possible. 4. Increase the calories from lipids to 40%.

3 Rationale: Always inquire into the client's favorite foods when planning a diet. Dairy may not be indicated for this client due to the high incidence of lactose intolerance in individuals of Asian heritage (option 1). Beer can be a source of calories and, in moderation, is not harmful, and may maintain the client's satisfaction with the dietary changes. The nurse will need to assess the ability to swallow beer safely, however (option 2). Calories from lipid sources should be kept below 35% and, when enhanced wound healing is indicated (not so with a stroke), increased protein and carbohydrates are needed rather than fats (option 4).

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? 1. The stoma extends 1/2 in. above the abdomen. 2. The skin under the appliance looks red briefly after removing the appliance. 3. The stoma color is a deep red-purple. 4. The ascending colostomy delivers liquid feces.

3 Rationale: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink or red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? 1. Habit training: Attempt voiding at specific time periods. 2. Bladder training: Delay voiding according to a preschedule timetable. 3. Credé's maneuver: Apply gentle manual pressure to the lower abdomen. 4. Kegel exercises: Contract the pelvic floor muscles.

3 Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic floor muscles.

Which of the following is most likely to validate that a client is experiencing intestinal bleeding? 1. Large quantities of fat mixed with pale yellow liquid stool 2. Brown, formed stools 3. Semisoft black-colored stools 4. Narrow, pencil-shaped stool

3 Rationale: Blood in the upper GI tract is black and tarry. Option 1 can be a sign of malabsorption in an infant, option 2 is normal stool, and option 4 is characteristic of an obstructive condition of the rectum.

What is the best indication of proper placement of a nasogastric tube in the stomach? 1. Client is unable to speak. 2. Client gags during insertion. 3. pH of the aspirate is less than 5. 4. Fluid is easily instilled into the tube.

3 Rationale: Gastric secretions are acidic as evidenced by a pH of less than 6. If the tube were improperly placed in the client's airway, speaking would usually be impaired (option 1). Gagging during insertion is common and does not indicate that the tube is in the stomach (option 2). Ability to easily instill fluid into the tube does not relate to its placement. The lungs would offer no resistance to the flow of liquid (option 4).

A client has a pressure injury with a shallow, partial skin thickness, and eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. Alginate 2. Dry gauze 3. Hydrocolloid 4. No dressing is indicated

3 Rationale: Hydrocolloid dressings protect shallow injuries and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

Which statement, if made by the client or family member, would indicate the need for further teaching? 1. "If a skin area gets red but then the red goes away after turning, I should report it to the nurse." 2. "Putting foam pads under my heels or other bony areas can help decrease pressure." 3. "If my father cannot turn himself in bed, I should help him change position every 4 hours." 4. "The skin should be washed with only warm water (not hot) and lotion put on where it is still a little wet."

3 Rationale: Immobile and dependent clients should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.

A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the assistive personnel (AP) is most appropriate? 1. "Using proper body mechanics will prevent you from injuring yourself." 2. "You are physically fit and at lesser risk for injury when transferring the client." 3. "Use the mechanical lift and another staff member to transfer the client from the bed to the chair." 4. "Use the back belt to avoid hurting your back."

3 Rationale: It is prudent for nurses to understand and use proper body mechanics at all times to decrease risk, while keeping in mind the importance of assistive devices and help from other staff. While it is generally accepted that proper body mechanics alone will not prevent injury, many work settings do not yet have "no manual lift" and "no solo lift" policies and resources in place.

The nurse is answering questions after a presentation on sleep at a local seniors' center. A woman in her late 70s asks for an opinion about the advisability of allowing her husband to nap for 15 to 20 minutes each afternoon. Which is the nurse's best response? 1. "Taking an afternoon nap will interfere with his being able to sleep at night. If he's tired in the afternoon, see if you can interest him in some type of stimulating activity to keep him awake." 2. "He shouldn't need to take an afternoon nap if he's getting enough sleep at night." 3. "Unless your husband has trouble falling asleep at night, a brief afternoon nap is fine." 4. "Encourage him to consume coffee or some other caffeinated beverage at lunch to prevent drowsiness in the afternoon."

3 Rationale: Napping frequently reappears in older adults. Unless the client has difficulty falling asleep at night, there is no reason he should not be allowed to take a 15- to 20-minute nap in the early afternoon.

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? 1. Soapsuds 2. Retention 3. Return flow 4. Oil retention

3 Rationale: This provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage constipation and do not provide flatus relief.

A nurse is assessing a wound as a result of a bicycle accident. Which clinical manifestation indicates a localized inflammatory response?Select all that apply.​ ​ 1. Temperature 101.4 degrees F​ 2. Heart rate 102 beats/minute​ 3. Serous exudate ​ 4. Area around the wound is swollen​ 5. Erythema of surrounding tissue

3, 4, and 5

After ABD surgery, the patient reports a "pop" after coughing. Upon assessment the RN notes a loop of bowels & an open ABD incision. The RN should _________. Select all that apply​. 1. Allow the area to be exposed to air​ 2. Place cold packs over the open area​ 3. Cover the area with sterile saline soaked gauze​ 4. Cover the area with sterile gauze & applies an ABD binder​ 5. Call the surgeon​ 6. Notify the charge RN

3, 5, and 6

A client is scheduled for thoracic surgery & is told by the surgeon that a Foley catheter will be placed. After the surgeon leaves the client says "Why do I have to have a tube in my bladder if I am having chest surgery?" The nurse's best response is:​ ​ 1. You are likely to be incontinent​ 2. We want you to rest after the surgery​ 3. It allows for ease of obtaining urine specimens​ 4. Urine output is measured to monitor your kidney function​

4

A client with normal intake & no genitourinary or renal disease has not voided in 6 hours. The client reports the need to void & has moderate lower abdominal distention. What should the nurse do first?​ ​ 1. Encourage the client to drink more fluids​ 2. Scan the bladder​ 3. Pour warm water over the client's perineal area​ 4. Assist the client to the toilet or commode

4

A nurse identifies that a client may have a fecal impaction. Which clinical manifestation is most specific to this problem?​ ​ 1. Lack of bowel movement for 24 hours​ 2. Slight distention of the lower abdomen​ 3. Infrequent desire to defecate​ 4. Passage of a small amount of liquid stool

4

A nurse is caring for a client who was admitted for an UGIB. Which clinical indicator is associated with GI bleeding?​ ​ 1. Pale, clay colored stool​ 2. Yellow, greenish stool​ 3. Hard, dry brown stool​ 4. Black, tarry stool

4

A patient on bedrest is performing isometric exercises. Which nursing diagnosis relates to this intervention?​ ​ 1. Disturbed thought process​ 2. Impaired skin integrity​ 3. Disturbed body image​ 4. Activity intolerance

4

A patient reports a recent problem with constipation. What should the nurse instruct the patient to do to minimize the problem?​ ​ 1. Drink 1 liter of fluid per day​ 2. Decrease your daily physical activity​ 3. Hold your breath & push to have a bowel movement​ 4. Try to have a bowel movement after drinking a warm liquid in the morning​

4

In which of the following bowel diversions would the nurse anticipate the most formed stool?​ ​ 1. Ascending colostomy​ 2. Jejunostomy​ 3. Ileostomy​ 4. Descending colostomy

4

Which action would be a priority in preventing a patient from developing a pressure injury?​ ​ 1. Use waterproof materials on the bed​ 2. Massage reddened areas of skin​ 3. Use an air-inflated ring to relieve pressure​ 4. Keep the skin clean & dry

4

Which of the following regimens offers the best blood glucose control for a person with type 1 DM?​ ​ 1. Diet management and oral anti-diabetic agents​ 2. Once daily insulin injection and diet control​ 3. A combination of oral anti-diabetic medications​ 4. Three or four injections of insulin per day​ 5. A regimen of oral anti-diabetic medications and insulin

4

You are educating a patient about diet considerations now that she has a colostomy. Which of the following foods should be avoided to decrease odor?​ ​ 1. Milk​ 2. Cheese​ 3. Coffee​ 4. Cabbage

4

You are transferring a patient from a bed to a chair. The patient has an order for partial weight bearing due to knee surgery. Which of the following is the best technique for transfer?​ ​ 1. Use a transfer board​ 2. Wait for physical therapy to assist with the transfer​ 3. Implement a three person lift​ 4. Use an assistive device

4

Which meal would the nurse recommend to the client as highest in calcium, iron, and fiber? 1. 3 ounces cottage cheese with 1/3 cup raisins and 1 banana 2. 1/2 cup broccoli with 3 ounces chicken and 1/2 cup peanuts 3. 1/2 cup spaghetti with 2 ounces ground beef and 1/2 cup lima beans plus 1/2 cup ice cream 4. 3 ounces tuna plus 1 ounce cheese sandwich on whole-wheat bread plus a pear

4 Rationale: 3 ounces tuna + 2 slices whole wheat bread =3.1 mg Fe; 1 ounce cheese = ˜200 mg Ca2+; pear = 4.2 g fiber. Option 1: 1/3 cup raisins = 1.75 mg Fe; 3 ounces cottage cheese = 90 mgCa2+; 1 banana = 2.1 g fiber. Option 3: 1/2 cup spaghetti + 2 ounces ground beef = 2.3 mg Fe; 1/2 cup ice cream = 97 mg Ca2+; 1/2 cup lima beans = 3.2 g fiber. Option 2: 3 ounces chicken + 1/2 cup peanuts= 2.9 mg Fe; 1/2 cup broccoli ˜158 mg Ca2+; 1/2 cup broccoli =2.4 g fiber.

A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? 1. Do you have a history of cardiac irregularities? 2. Do you have a history of any kind of nasal obstruction? 3. Have you had chest pain with or without activity? 4. Do you have difficulty with daytime sleepiness?

4 Rationale: Most clients with sleep apnea report excessive daytime sleepiness. If they don't volunteer this, clients should be asked if they fall asleep or struggle to stay awake at work. Although cardiac arrhythmias may occur, they are usually only detectable during a sleep study, and thus the client would not be aware of them (option 1). Nasal obstruction is rarely the cause of sleep apnea or a complaint of clients with sleep apnea (option 2). There are many causes of chest pain, and this is unlikely to be something reported by clients with sleep apnea unless they have underlying cardiac disease (option 3).

The client is ambulating for the first time after surgery. The client tells the nurse, "I feel faint." Which is the best action by the nurse? 1. Find another nurse for help. 2. Return the client to her room as quickly as possible. 3. Tell the client to take rapid, shallow breaths. 4. Assist the client to a nearby chair.

4 Rationale: Placing the client in a safe position is the best maneuver. Leaving the client creates unsafe conditions because the client may faint before being able to return to her room (options 1 and 2). Rapid, shallow breathing (hyperventilation) may increase the dizziness (option 3).

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? 1. Oil retention 2. Return flow 3. High, large volume 4. Low, small volume

4 Rationale: Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option 1). Return flow enemas help expel flatus (option 2). Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used (option 3).

A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? 1. Take the last pill on a Friday night so disrupted sleep can be compensated on the weekend. 2. Continue to take the pills since sleeping without them after such a long time will be difficult and perhaps impossible. 3. Discontinue taking the pills. 4. Continue taking the pills and discuss tapering the dose with the primary care provider.

4 Rationale: Suddenly stopping barbiturate sleeping pills can precipitate a dangerous withdrawal. Doses should be tapered gradually and the tapering process supervised by the client's primary care provider.

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? 1. The bladder distends and its capacity increases. 2. Older adults ignore the need to void. 3. Urine becomes more concentrated. 4. The amount of urine retained after voiding increases.

4 Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3).

During a yearly physical, a 52-year-old male client mentions that his wife frequently complains about his snoring. During the physical exam, the nurse notes that his neck is 18 inches, his soft palate and uvula are reddened and swollen, and he is overweight. What is the most appropriate nursing intervention for the nurse to recommend to this client? 1. Recommend that he and his wife sleep in separate bedrooms so that his snoring does not disturb his wife. 2. Refer him to a dietitian for a weight-loss program. 3. Caution him not to drink or take sleeping pills since they may make his snoring worse. 4. Refer him to a sleep disorders center for evaluation and treatment of his symptoms.

4 Rationale: The client's symptoms, combined with his weight, suggest that he has obstructive sleep apnea and should be referred to a sleep disorders specialist for further evaluation. It would not be wrong to refer him to a dietitian for weight-loss counseling (option 2), but being evaluated by a sleep disorders specialist is more critical. Drinking alcohol or taking sleeping pills is not advised in clients with sleep apnea because they disrupt the client's sleep patterns (option 3).

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which specific type of urinary incontinence is the most appropriate for the nursing diagnosis? 1. Stress 2. Reflex 3. Functional 4. Urge

4 Rationale: The key phrase is "the urge to void." Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function.

An adult reports usually eating 3 cups dairy, 2 cups fruit, 2 cups vegetables, 5 ounces grains, and 5 ounces meat each day. The nurse would counsel the client to: 1. Maintain the diet; the servings are adequate. 2. Increase the number of servings of dairy. 3. Decrease the number of servings of vegetables. 4. Increase the number of servings of grains.

4 Rationale: This client needs more grains in the diet. The client should have 6 to 7 oz grains per day, 3 cups/week dark green vegetables, 2 cups/week orange vegetables, 3 cups/week legumes, 3 cups/week starchy vegetables, 1.5 to 2 cups fruit per day, 5 to 6 oz meat and beans per day, and 3 cups milk, yogurt, and cheese per day.

A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? 1. Exercises past the point of resistance. 2. Performs each exercise one time. 3. Performs each series of exercises once a day. 4. Uses the same sequence during each exercise session.

4 Rationale: When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury (option 1). The client should perform each exercise at least three times, not just once (option 2). The client should perform each series of exercises twice daily, not just once per day (option 3).

A nurse is caring for a patient who is receiving enteral feedings via NGT. Which nursing intervention is important to help prevent the patient from experiencing diarrhea? Select all that apply.​ ​ 1. Flush the NGT with 30mL of H2O every 4 hours ​ 2. Check the residual every 4 hours​ 3. Elevate the HOB to 30 degrees​ 4. Use unopened containers when priming the tubing ​ 5. Change the feeding bag & tubing every 24 hours​

4 and 5

A nurse is caring for an older client who has a skin tear on the forearm. What type of dressing should the nurse apply? Select all that apply.​ ​ 1. Hydrogel ​ 2. Dry sterile ​ 3. Wet-to-dry​ 4. Transparent film​ 5. Non-adherent gauze

4 and 5

A patient rings the call bell to notify you of a foul smell to their stool. The stool is black & tarry. You recognize this may be an indication of:​ ​ 1. Internal hemorrhoids​ 2. External hemorrhoids​ 3. An overproduction of bile​ 4. A lower GI bleed​ 5. An upper GI bleed​​

5

A student nurse is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site?

5 Rationale: Option 5 is a sigmoidostomy site. Option 1 is an ileostomy site, option 2 is ascending colostomy, option 3 is transverse colostomy, and option 4 is descending colostomy.