NS 125 quiz 4 practice questions
A practitioner orders a low-residue diet. Which food should the nurse teach the patient to include in the diet? a. scrambled eggs b. orange juice c. green beans d. rye bread
A. scrambled eggs
the total cholesterol level of which adult female patient indicates the need for health teaching about a low-cholesterol diet a. 200 mg/dL b. 190 mg/dL c. 150 mg/dL d. 100 mg/dL
a. 200 mg/dL
A patient is admitted to the hospital with a history of liver dysfunction associated with hepatitis. The nurse anticipates that this patient may have problems with: a. Emulsifying fats b. digesting carbohydrates c. manufacturing red blood cells d. Reabsorbing water
a. Emulsifying fats
which statements by a patient with diverticulosis alerts the nurse that the patient needs additional health teaching? select all that apply a. I should avoid eating high-fiber cereal b. I sit on the toilet for 10 minutes after breakfast every day c. I am going to drink eight glasses of water a day when I get home d. I should hold my breath and bear down when having bowel movements e. I life to massage my lower abdomen when I'm trying to have a bowel movement
a. I should avoid eating high-fiber cereal d. I should hold my breath and bear down when having bowel movements
a nurse is caring for a group of patients with a variety of urinary problems. Which patient response should cause the most concern? a. anuria b. dysuria c. diuresis d. enuresis
a. anuria
A patient is experiencing constipation. Which independent nursing action facilitates defecation of a hard stool? a. applying a lubricant to the anus b. encouraging a sitz bath after defecation c. instilling warm mineral oil into the rectum d. positioning cold compresses again the anus
a. applying a lubricant to the anus
A nurse must administer a large-volume tap water enema. Which mechanism associated with this type of enema increases peristalsis? a. bowel distension b. hypertonic action c. irritating the bowel d. absorption of fluid by stool
a. bowel distension
What route is unrelated to the parenteral administration of medications? a. buccal b. z-track c. intravenous d. intradermal
a. buccal
A patient is reporting burning on urination. Which question should the nurse ask to best obtain information about the patient's dysuria? a. can you tell me about the problems you have been having with urination b. how would you describe your experience with incontinence c. what are your usual bowel movements? d. what color is your urine?
a. can you tell me about the problems you have been having with urination
which clinical manifestation can a nurse expect when a postoperative patient experiences stress associated with surgery? a. decreased urinary output b. low specific gravity c. reflex incontinence d. urinary hesitancy
a. decreased urinary output
A nurse is caring for a patient who is experiencing diarrhea. About which physiological response to diarrhea should the nurse be most concerned? a. dehydration b. malnutrition c. excoriated skin d. urinary incontinence
a. dehydration
A nurse plans to administer a 3-mL intramuscular injection. Which muscle is the least desirable to use for the administration of this medication? a. deltoid b. dorsogluteal c. ventrogluteal d. vastus lateralis
a. deltoid
a nurse is to administer an eye irrigation to a patient's right eye. What should the nurse do? a. direct the flow of solution from the inner to the outer canthus b. irrigate with an asepto syringe several inches from the eye c. don sterile gloves before beginning the procedure d. position the patient in a right lateral position
a. direct the flow of solution from the inner to the outer canthus
A school nurse is preparing a health class about vitamins. Which information about vitamins that is based on a scientific principle should the nurse include? a. eating a variety of foods prevents the need for supplements b. megadoses of vitamins have proved to be most effective in preventing illness c. taking a prescribed vitamin supplement is the best way to ensure adequate intake d. vitamins that are more expensive are more pure than those that are less expensive
a. eating a variety of foods prevents the need for supplements
The nurse is obtaining a health history from a patient. Which information best reflects a healthy behavior? a. eating foods low in fat b. displaying no signs of illness c. visiting a practitioner when ill d. wanting to lose twenty pounds
a. eating foods low in fat
a patient has a high serum cholesterol level. What food should the nurse teach the patient to avoid a. Egg yolks b. skim milk c. turkey burger d. sliced bologna
a. egg yolk
A nurse is preparing to draw up medication from a vial. What should the nurse do first? a. ensure that the needle is firmly attached to the syringe b. rub vigorously back and forth over the rubber cap with an alcohol swab c. inject air into the vial with the needle bevel below the surface of the medication d. draw up slightly more air than the volume medication to be withdrawn from the vial
a. ensure that the needle is firmly attached to the syringe
a patient has a urinary retention catheter. Which is most important when the nurse cares for this patient? a. ensuring that the catheter remains connected to the collection bag b. applying an antimicrobial agent to the urinary meatus two times a day c. wearing sterile gloves when accessing the specimen port d. increasing fluid intake to 3000 mL a day
a. ensuring that the catheter remains connected to the collection bag
What information about the patient is communicated when a nurse documents that the patient has polyuria? a. excreting excessive amounts of urine b. experiencing pain on urination c. retaining urine in the bladder d. passing blood in the urine
a. excreting excessive amounts of urine
A nurse is teaching a patient with a cardiac condition to avoid the Valsalva maneuver. What should the nurse teach the patient to do? a. exhale while contracting the abdominal muscles b. attempt to have a bowel movement everyday c. take a cathartic on a regular basis d. eat rice several times a week
a. exhale while contracting the abdominal muscles
A nurse determines that a fracture bedpan should be used for the patient who: a. has a spinal cord injury b. is on bed rest c. has dementia d. is obese
a. has a spinal cord injury
which goal is most appropriate for a patient with perceived constipation? the patient will: a. have a bowel movement without the use of a laxative b. verbalize the rationale for the use of laxatives c. drink eight glasses of water per day d. defecate every day
a. have a bowel movement without the use of a laxative
A patient without any identified current health problems is having a yearly physical examination. The laboratory results indicate the presence of ketosis. Which rationale explains the presence of ketosis in this otherwise healthy adult? a. inadequate intake of carbohydrates b. increased intake of protien c. excessive intake of startch d. decreased intake of fiber
a. inadequate intake of carbohydrates
A nurse is preparing to reconstitute a medication in a multiple-dose vial. What is the most essential step in the preparation of this medication? a. instilling an accurate amount of diluent into the vial b. using a filtered needle when drawing up the medication from the vial c. instilling air into the vial before withdrawing the reconstituted solution d. wiping the urubber seal of the vial with alcohol before and after each needle insertion
a. instilling an accurate amount of diluent into the vial
what route is inappropriate for a topical medication a. intradermal b. bladder c. rectum d. vagina
a. intradermal
A practitioner prescribes a rectal suppository for an adult patient. What should the nurse do when administering the rectal suppository? a. lubricate the medication before insertion b. warm the medication to body temperature c. insert the medication just inside the rectum's external sphincter d. place the patient in the prone position to administer the medication
a. lubricate the medication before insertion
A nurse identifies that a patient's colostomy stoma is pale. What should the nurse do? a. notify the practitioner b. listen for bowel sounds c. wash the area with warm water d. gently massage around the stoma
a. notify the practitioner
what is the best nursing action to facilitate bladder continence for the patient who is cognitively impaired? a. offer toileting reminders every two hours b. provide clothing that is easy to manipulate c. encourage avoidance of fluid between meals d. explain the need to call for help with toileting every 4 hours
a. offer toileting reminders every two hours
A practitioner prescribes nose drops to be administered twice a day. What should the nurse do when instilling nose drops? a. place the patient in the supine position with the head tilted backwards b. pinch the nares of the nose together briefly after the drops are instilled c. instruct the patient to blow the nose 5 minutes after the drops are instilled d. insert the drop applicator 1/2 inch into the nose toward the base of the nasal cavity
a. place the patient in the supine position with the head tilted backwards
a patient is scheduled for surgery and the nurse is teaching the patient about the importance of vitamin C in wound healing. Which source of vitamin C should the nurse include in the teaching plan? a. potatoes b. yogurt c. minerals d. milk
a. potatoes
A patient has urinary incontinence. Which is the best nursing intervention for this patient? a. providing skin care immediately after soiling b. using a deodorant soap when providing skin care c. drying the area well after providing perineal care d. dusting the perineal area with a light film of cornstartch
a. providing skin care immediately after soiling
A nurse teaches a patient how to self-administer a corticosteroid via metered-dose inhaler with an extender. Which behavior indicates to the nurse that the patient understands the teaching? a. rinses the mouth with water after the treatment b. rolls the canister between the hands slowly before using the inhaler c. positions the mouthpiece directly in front of the mouth while inhaling d. assumes the semi-fowler position with the head supported on a pillow
a. rinses the mouth with water after the treatment
a patient of Latino heritage is to eat a low-fat diet. The patient tells the nurse, "I am going to have a hard time giving up my favorite family recipes." Which food should the nurse recommend that is low in fat and generally is included in the Latino culture? a. salsa b. pasta c. steamed fish d. refried beans
a. salsa
A patient has a prescription for 2 puffs of a bronchodilator via a metered-dose inhaler. What should the nurse teach the patient to do when self-administering the medication? a. start breathing in while compressing the canister b. hold the inspired breath for several seconds c. deliver 2 puffs with each inspiration d. inhale slowly for 8 to 10 seconds
a. start breathing in while compressing the canister
a nurse identifies that a patient has tarry stools. Which problem should the nurse conclude that the patient is experiencing? a. upper gastrointestinal bleeding b. pancreatic dysfunction c. lactulose intolerance d. inadequate bile salts
a. upper gastrointestinal bleeding
a practitioner orders a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen a. use a sterile specimen container b. collect urine from the catheter port c. inflate the balloon with 10 mL of sterile water d. have the patient void before collecting the specimen
a. use a sterile specimen container
a nurse teaches a patient that fat in the diet is unnecessary to absorb: a. vitamin C b. Vitamin A c. Vitamin E d. Vitamin D
a. vitamin C
A nurse is interviewing a newly admitted client in the process of completing a nursing admission history and physical. What information should be included in a medication reconciliation a. vitamins b. drug allergies c. food supplements d. over-the-counter labels e. prescribed medications
a. vitamins c. food supplements d. over-the-counter labels e. prescribed medications
a nurse must administer a medication into the ear of an adult. what should the nurse do to limit patient discomfort when administering ear drops? a. warm the solution to body temperature b. place the patient in a comfortable position c. pull the pinna of the ear upward and backward d. instill the fluid in the center of the auditory canal
a. warm the solution to body temperature
A nurse is teaching a patient with a history of constipation about the excessive use of laxatives. What should the nurse include is the primary reason why their use should be avoided? a. weakens the natural response to defecation b. results in distention of the intestines c. causes abdominal discomfort d. precipitates incontinence
a. weakens the natural response to defecation
What should the nurse use when administering a subcutaneous injection? a. 5-mL syringe b. 25-gauge needle c. tuberculin syringe d. 1 1/2 inch long needle
b. 25-gauge needle
A nurse plans to administer a bolus dose of a medication via a currently running intravenous infusion. What should the nurse do first? a. use a volume-control infusion set with microdrip tubing b. Ensure that it is compatible with the IV solution being infused c. pinch the tubing above the infusion port while instilling the bolus d. instill it into a 50-mL bag of normal saline and infuse it via a secondary line
b. Ensure that it is compatible with the IV solution being infused
a nurse is preparing to administer a tablet to a patient. When should the nurse remove the medication from its unit dose package? a. outside the door to the patient's room b. at the patient's bedside c. in the medication room d. at the medication chart
b. at the patient's bedside
what should a nurse teach the patient to avoid to prevent urinary diuresis? a. narcotics b. caffeine c. activity d. protein
b. caffiene
A nurse is assessing a patient who is admitted to the hospital with withdrawal from alcohol. The nurse anticipates that excessive alcohol intake will directly contribute to health problems because it: a. lengthens passage time of stool through the intestinal tract b. decreases the absorption of many important nutrients c. accelerates the absorption of medications d. interferes with the absorption of glucose
b. decreases the absorption of many important nutrients
The practitioner identifies that a patient may have a fluoride deficiency. What physical characteristics supports this conclusion? a. stomatitis b. dental caries c. bleeding gums d. mottling of the teeth
b. dental caries
A nurse is caring for patients with a variety of nutrition-related problems. Which problem eventually may require a patient to have a nasogastric feeding tube inserted? a. malaborption syndrome b. difficulty swallowing c. nausea and vomiting d. stomatitis
b. difficulty swallowing
Which action is the most important for the nurse to teach patients about the intake of bran to facilitate defecation? a. Eat 3 tablespoons of bran each morning b. drink at least 8 glasses of fluids each day c. have a bowel movement right after ingesting the bran d. take a cathartic that will supplement the action of bran
b. drink at least 8 glasses of fluids each day
A nurse discourages a patient from straining excessively when attempting to have a bowel movement. what physiological response primarily may be prevented by avoiding straining on defecation? a. incontinence b. dysrhythmias c. fecal impaction d. rectal hemorrhoids
b. dysrhythmias
A nurse identifies that a patient understands the need to reestablish bowel flora after a week of diarrhea when the patient states, "i'm going to: a. wean myself off of the antibiotics one day after my temperature is normal b. eat a container of yogurt every day for a few days c. add rice to my diet one meal each day d. drink eight glasses of water today
b. eat a container of yogurt every day for a few days
a nurse must measure the intake and output for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter? a. urinal b. graduate c. large syringe d. urine collection bag
b. graduate
The nurse determines that the teaching about guaiac test of stool is understood when the patient states, "This test can detect the presence of: a. ova and parasites b. hidden blood c. bacteria d. bile
b. hidden blood
a patient is diagnosed with iron deficiency anemia. Which major cause of iron deficiency will influence a focused assessment by the nurse? a. metabolic problems b. inadequate diets c. malabsorption d. hemorrhage
b. inadequate diets
the nurse is evaluating the effectiveness of a nutritional program. Which clinical finding is the best short-term indicator of an improved nutritional status? a. weight gain of two pounds daily b. increasing transferring level c. decreasing serum albumin d. appropriate skin turgor
b. increasing transferring level
A nurse must reconstitute the powdered medication. What should the nurse do? a. keep the needle below the initial fluid level as the rest of the fluid is injected b. instill the solvent that is consistent with the manufacturer's directions c. score the neck of the ampule before breaking it d. shake the vial to dissolve the poweder
b. instill the solvent that is consistent with the manufacturer's directions
A nurse performs a physical assessment of a newly admitted patient who is incontinent of stool. For which characteristic related to bowel incontinence should the nurse assess? a. frequent, soft stool b. involuntary passage of stool c. impaired rectal sphincter control d. greenish-yellow color to the stool
b. involuntary passage of stool
which word is specific regarding how a soapsuds enema works on the mucosa of the bowel? a. dilating b. irritating c. softening d. lubricating
b. irritating
It is most important for the nurse to use a filtered needle when preparing a parenteral medication that: a. has to be reconstituted b. is supplied in an ampule c. appears cloudy in the vial d. is to be mixed with another medication
b. is supplied in an ampule
A nurse is caring for two patients. One patient has reflex incontinence and the other has total incontinence. Which characteristic is common to both reflex incontinence and total incontinence? a. urination following an increase in intra-abdominal pressure b. loss of urine without awareness of bladder fullness c. retention of urine with overflow incontinence d. strong, sudden desire to void
b. loss of urine without awareness of bladder fullness
a nurse is reviewing the laboratory findings of a patient to assess the patients nutritional status. Which laboratory finding is the best indicator of inadequate protein intake? a. high hemoglobin b. low serum albumin c. low specific gravity d. high blood urea nitrogen
b. low serum albumin
a nurse teaches a postoperative patient about foods high in protein that will promote wound healing. Which food selection by the patient indicates that the teaching was effective a. milk b. meat c. bread d. vegetables
b. meat
An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the patient has no teeth and is having difficulty eating. Which diet should the nurse encourage the practitioner to order for this patient? a. liquid supplements b. mechanical softs c. pureed d. soft
b. mechanical softs
What clinical manifestation identified by the nurse most commonly is associated with excessive production of antidiuretic hormone (ADH)? a. diuresis b. oliguria c. retention d. incontinence
b. oliguria
A nurse holds a bottle with the label next to the palm of the hand when pouring a liquid medication. What is the rationale for this action? a. conceal the label from the curiosity of others b. prevent the soiling of the label my spilling liquid c. ensure the accuracy of the measurement of the dose d. guarantee the label is read before pouring the liquid
b. prevent the soiling of the label my spilling liquid
A patient has a history or urinary tract infections. What should the nurse include in teaching plan regarding why 8 ounces of cranberry justice daily helps to minimize the occurrence of UTIs? a. dilutes bacterial growth b. promotes an acidic urine c. prevents urinary retention d. stimulates hypoactive detrusor muscles
b. promotes an acidic urine
a school nurse is planning a health class about bodily functions. what information should be included regarding the purpose of mucus in the gastrointestinal tract? a. activates digestive enzymes b. protects the gastric mucosa c. enhances gastric acidity d. emulsifies fats
b. protects the gastric mucosa
which constituent found in urine indicates the presence of an abnormality? a. electrolytes b. protein c. water d. urea
b. protein
a medication is delivered by the Z-track method when the nurse: a. uses a special syringe designed for Z-track injections b. pulls laterally and downward on the skin before inserting the needle c. administers the injection in the muscle on the anterolateral aspect of the thigh d. injects the needle in a separate spot for each dose on a Z-shaped grid on the abdomen
b. pulls laterally and downward on the skin before inserting the needle
a patient is diagnosed with a Vitamin A deficiency. Which type of pie should the nurse encourage the patient to ingest? a. blueberry b. pumpkin c. cherry d. peacan
b. pumpkin
A nurse is caring for a group of patients with a variety of gastrointestinal problems. WHich factor can influence the occurrence of both diarrhea and constipation? a. inability to perceive bowel cues b. side effects of medications c. high-solute tube feedings d. increased metabolic rate
b. side effects of medications
A nurse is teaching a patient how to irrigate a colostomy. The patient asks why it is necessary to use the cone attachment to the irrigation catheter. What information should the nurse include in a response to this question? a. Prevents prolapse of the bowel during evacuation of the solution b. stops enema solution from flowing out during the procedure c. dilates the stoma so that the enema tube can be inserted d. Facilitates the elimination of drainage from the colon
b. stops enema solution from flowing out during the procedure
How often should "docusate sodium (colace) 100 mg b.i.d" be give a. three times a day b. two times a day c. every other day d. at bedtime
b. two times a day
A nurse is assessing a patient for the appropriateness of administering a medication via the oral route. What clinical manifestation indicates that the nurse should ask the practitioner fora change in route? a. nausea b. unconsciousness c. gastric suctioning d. difficulty swallowing
b. unconsciousness
what should the nurse monitor the best assess a patient's renal perfusion? a. blood pressure every 15 minutes b. urinary output every hour c. body weight every day d. I and O every 24 hours
b. urinary output every hour
a patient's urine is cloudy, amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment? a. urinary retention b. Urinary tract infection c. ketone bodies in the urine d. high urinary calcium level
b. urinary tract infection
A nurse is collecting a bowel elimination history for a newly admitted patient with a medical diagnosis of possible bowel obstruction. Which question takes priority? a. do you use anything to help you move your bowels? b. when was the last time you moved your bowels? c. what color are you usual bowel movements? d. how often do you have a bowel movement?
b. when was the last time you moved your bowels?
A nurse is counseling a patient with the diagnosis of osteoporosis. Based on the practitioner's prescription, which vitamin should the nurse instruct the patient to include in a daily health regimen? a. B b. K c. D d. E
c. D
A practitioner prescribes a medications that must be administered transdermally. The nurse determines that a drug administered transdermally is: a. inhaled in to the respiratory tract b. dissolved under the tongue c. absorbed through the skin d. inserted into the rectum
c. absorbed through the skin
what should a nurse use when placing a cream into a patient's vaginal canal? a. a finger b. a gauze pad c. an applicator d. an irrigation kit
c. an applicator
A patient is admitted with a diagnosis of upper gastrointestinal bleeding. What should the nurse expect the color of this patient's stool to be? a. red b. pink c. black d. brown
c. black
A nurse must administer a medication that is supplied in an ampule. What should the nurse do first to access the ampule? a. Inject the same amount of air as the fluid to be removed b. wipe the constricted neck with an alcohol swab c. break the constricted neck using a barrier d. insert the needle into the rubber seal
c. break the constricted neck using a barrier
A patient has multiple fractures from a skiing accident. To best faclitate bone growth the nurse should encourage the patient eat more foods high in calcium. Which food selected by the patient indicates an understanding of foods that are high in calcium? a. orange juice b. peanut butter c. cottage cheese d. baked flounder
c. cottage cheese
A nurse is caring for a group of patients. Which patient factor should the nurse determine provides the greats risk for bowel incontinence? a. being ninety years old b. taking a sedative for sleep c. disoriented to time, place, and person d. receiving multiple antibiotic medications
c. disoriented to time, place, and person
A nurse instructs a patient to inhale deeply and hold each breath for a second when using a hand-held nebulizer. The patient asks, "why do i have to hold my breath?" the nurse responds, "this technique will: a. prolong treatment b. limit hyperventilation c. disperse the medication d. prevent bronchial spasms
c. disperse the medication
a nurse instructs a patient to close the eyes after administration of eye drops. What rationale for this instruction should the nurse explain to the patient? a. limits corneal irritation b. squeezes excess medication from the eyes c. disperses the medication over the eyeballs d. prevents medication from entering the lacrimal duct
c. disperses the medication over the eyeballs
a nurse is performing a physical assessment on a newly admitted patient. Which problem identified by the nurse is most associated with urinary incontinence a. chronic pain b. reduced fluid intake c. disturbed self-esteem d. insufficient knowledge
c. disturbed self-esteem
a practitioner orders a tap water enema for a patient. The patient asks about the purpose of the enema. What specific information about the purpose of a tap water enema should be included in the nurse's response? a. reduces abdominal gas b. drains the urinary bladder c. empties the bowel of stool d. limits nausea and vomiting
c. empties the bowel of stool
a nurse is caring for a patient on bed rest who has a urinary retention catheter. What should the nurse do? a. irrigate the tubing to ensure patency b. label the tubing with the date of insertions c. ensure the tubing is positioned over the leg d. position the tubing through the side rail of the bed
c. ensure the tubing is positioned over the leg
A nurse is caring for a patient with a condom catheter. Which nursing action is most important? a. providing perineal care every shift b. avoiding kinds in the collection tubing c. ensuring that the Velcro strap is snug, not tight d. retracting the foreskin before the catheter is applied
c. ensuring that the Velcro strap is snug, not tight
a nurse is caring for a patient who is confused and disoriented. What type of food containing chicken is most appropriate for this patient? a. soup b. salad c. fingers d. casserole
c. fingers
Which nutrient should the nurse encourage a patient to include in the diet to provide Vitamin D a. green leafy vegetables b. vegetable oils c. fortified milk d. organ meats
c. fortified milk
which statement by a patient with an ileostomy alerts the nurse to the need for further education? a. i don't expect to have much of a problem with fecal odor b. i will have to take special precautions to protect my skin around the stoma c. im going to irrigate my stoma so i have a bowel movement every morning d. i should avoid gas forming foods like beans to limit funny noises from the stoma
c. im going to irrigate my stoma so i have a bowel movement every morning
What intervention is uniquely related to the administration of an intradermal injection? a. using the air-bubble technique b. pinching the skin during needle insertion c. inserting the needle with the bevel upward d. massaging the area after the fluid is instilled
c. inserting the needle with the bevel upward
a nurse is caring for a patient with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube? a. using sterile technique when irrigating the tube b. recording the intake and output every 2 hours c. maintaining suction at the prescribed level d. providing oral hygiene every 4 hours
c. maintaining suction at the prescribed level
a nurse is caring for a patient who is expending energy that is greater than the caloric intake. Which human response most likely will occur? a. fever b. anorexia c. malnutrition d. hypertension
c. malnutrition
a patient is anorexic because of stomatitis related to chemotherapy. What should the nurse be most concerned about when planning care for this patient? a. aspiration b. dehydration c. malnutrition d. constipation
c. malnutrition
A patient has a decreased hemoglobin level because of a low intake of dietary iron. Which food should the nurse teach the patient is the best source of iron? a. eggs b. fruit c. meat d. bread
c. meat
The practitioner prescribes a troche. The nurse should administer it by planing it in the patient's: a. ear b. eye c. mouth d. rectum
c. mouth
A nurse is providing dietary teaching to a patient with diverticulosis. Which food selected by the patient indicates that the dietary teaching was understood? a. tofu b. pasta c. oatmeal d. grapefruit
c. oatmeal
a nurse is caring for a debilitate female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs? a. encouraging the use of bladder training exercises b. providing assistance with toileting every four hours c. positioning a bedside commode near the bed d. teaching the avoidance of fluids after 5 pm
c. positioning a bedside commode near the bed
The nurse is considering the commonalities and differences of equipment used for gastric decompression. What is the major advantage to using a Salem sump? a. Minimizes the risk of bowel obstruction b. ensures drainage of the intestines c. prevents gastric mucosal damage d. promotes gastric rest
c. prevents gastric mucosal damage
A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation? a. coughing b. mobility deficits c. prostate enlargement d. urinary tract infection
c. prostate enlargement
a nurse identifies that a vegetarian understands the importance of eating kidney beans when the patient says, "kidney beans are essential because they are a great source of: a. carbohydrates b. minerals c. protein d. fats
c. protein
which is the most common independent nursing intervention to help hospitalized older adults maintain body weight? a. making meal time a social activity b. taking a thorough nutritional history c. providing assistance with the intake of meals d. encouraging dietary supplements between meals
c. providing assistance with the intake of meals
A nurse is caring for a patient with an intestinal stoma. Which intervention is most important? a. cleaning the stoma with cool water b. spraying an air-freshening deodorant in the room c. selecting a bag with an appropriate-size stomal opening d. wearing sterile nonlatex gloves when caring for the stoma
c. selecting a bag with an appropriate-size stomal opening
which assessment is not common to monitor both urine and stool? a. constituents b. urgency c. shape d. color
c. shape
when planning nursing care, which factor in the patient's history places the patient at the greatest risk for stress incontinence? a. lumbar spinal cord injury b. urinary obstruction c. six vaginal births d. confusion
c. six vaginal births
a nurse is assessing the urinary status of a patient. Which sign indicates that additional nursing assessments are necessary? a. aromatic odor b. pale yellow urine c. specific gravity of 1.035 d. output of 50 mL every hour
c. specific gravity of 1.035
A nurse teaches a patient about taking a sublingual nitroglycerin tablet. The nurse evaluates that the patient understands the teaching when the patient states, "I should place it: a. on my skin b. inside my cheek c. under my tongue d. in my eye on the lower lid
c. under my tongue
When the nurse brings pills to a patient, the patient is unable to hold the paper cup with the medications. What should the nurse do? a. crush the pills and mix it with applesauce b. have the practitioner prescribe the liquid form of the drug c. use the paper cup to introduce the pills into the patient's mouth d. put the pills into the patients hand and have the patient self-administer the pills
c. use the paper cup to introduce the pills into the patient's mouth
A patient is admitted to the emergency department because of hypertension and oliguria. For what additional clinical manifestation associated with this cluster of information should the nurse assess the patient? a. thirst b. retention c. weight gain d. urinary hesitancy
c. weight gain
A nurse is administering an intradermal injection. At what angle should the nurse insert the needle? a. 90 degrees b. 45 degrees c. 30 degrees d. 15 degrees
d. 15 degrees
Which characteristic is associated with a subcutaneous injection of 5000 units of heparin a. 30-mL syringe b. 22-gauge needle c. 1 1/2-inch needle length d. 90-degree angle of insertion
d. 90-degree angle of insertion
the instructions with a medication states to use the Z-track method. What would the nurse do that is specific to this procedure? a. Pinch the site throughout the procedure b. massage the site after the needle is removed c. remove the needle immediately after the medication is injected d. Change the needle after the medication is drawn into the syringe
d. Change the needle after the medication is drawn into the syringe
what is unrelated to the balance of calcium in the body? a. osteoporosis b. vitamin D C. tetany d. Iron
d. Iron
A nurse is preparing to administer a subcutaneous injection of insulin. What sire should the nurse use to best promote its absorption? a. upper lateral arms b. anterior thighs c. upper chest d. abdomen
d. abdomen
Which abbreviation indicates that he practitioner wants a medication administered before meals? a. pc b. qh c. po d. ac
d. ac
A patient states, "It burns and stings every time I pass urine." The nurse should make the inference that the patient is most likely experiencing: a. reflex incontinence b. stress incontinence c. retention of urine d. an infection
d. an infection
what should the nurse do before collecting a stool sample for occult blood? a. plan to collect the first specimen of the day b. secure a sterile specimen container c. wash the patient's perianal area d. ask the patient to void
d. ask the patient to void
What equipment and technique should the nurse use to administer most intramuscular injections? a. use a 1-inch needle b. use a 25 gauge needle c. insert the needle at a 45 degree angle d. aspirate before instilling the medication e. massage the insertion site after needle removal
d. aspirate before instilling the medication e. massage the insertion site after needle removal
a patient complains of constipation. What should the nurse encourage the patient to eat? a. applesauce b. bananas c. cheese d. beans
d. beans
A nurse is assessing a patient's urinary status. Which clinical manifestation indicates urinary retention? a. wet bed and undergarments b. burning and pain on voiding c. sudden, overwhelming need to void d. bladder fullness in the absence of voiding
d. bladder fullness in the absence of voiding
A patient is admitted with lower gastrointestinal tract bleeding. Which characteristic of the stool supports this diagnosis? a. tarry stool b. orange stool c. green mucoid stool d. bright red-tinged stool
d. bright red-tinged stool
a nurse teaches a patient about the prescribed low-fat diet. Which food selected by the patient indicates that the teach was understood? a. eggs b. liver c. cheese d. chicken
d. chicken
a patient is experiencing bladder irritability. Which fluid should the nurse teach the patient to include in the diet? a. beef b. coffee c. orange juice d. cranberry juice
d. cranberry juice
The nurse is caring for a patient receiving bolus enteral feedings several times daily. Which nursing intervention is most important to help prevent diarrhea? a. flush the tube after every feeding b. check the residual before each feeding c. elevate the head of the bed 30 degrees continuously d. discard the refrigerated opened cans of formula after 24 hours
d. discard the refrigerated opened cans of formula after 24 hours
A practitioner prescribes a medication that must be administered via the intramuscular route. Which site should the nurse eliminate from consideration because it has the highest potential for injury when administering an intramuscular injection? a. vastus lateralis b. rectus femoris c. ventrogluteal d. dorsogluteal
d. dorsogluteal
a patient with flatulence is concerned about the production of unpleasant odors. What should the nurse encourage the patient to avoid? a. alcohol b. raisins c. coffee d. eggs
d. eggs
what is the most effective nursing intervention to prevent UTIs? a. teach female patient to wipe from the back to the front after urinating b. instruct patient to use bath powder to absorb perineal perspiration c. advise patient to report burning on urination to the practitioner d. encourage patients to drink several quarts of fluid daily
d. encourage patients to drink several quarts of fluid daily
a nurse is teaching a patient about the importance of balancing protein, carbohydrates, and fats in the diet. The nurse identifies that the teaching about carbohydrates is understood when the patient states,"carbohydrates are best known for providing: a. electrolytes b. vitamins c. minerals d. energy
d. energy
A practitioner prescribes a medicated powder to be applied to a patient's skin. What is most essential for the nurse to do when applying ht medicated powder? a. apply a thin layer in the direction of hair growth b. protect the patient's face with a towel c. dress the area with dry sterile gauze d. ensure that the skin surface is dry
d. ensure that the skin surface is dry
A nurse adds a medication to an intravenous fluid bag. which nursing action is the priority? a. attaching a completed IV additive label to the bag b. mixing the medication and solution by rotating the bag c. maintaining sterile technique throughout the procedure d. ensuring that the drug and the IV solution are compatible
d. ensuring that the drug and the IV solution are compatible
while providing a health history the patient tells the nurse, "I have gastroesophageal reflux disease." Which most serious consequence associated with this disorder should the nurse anticipate this patient may develop? a. diarrhea b. heartburn c. gastric fullness d. esophageal erosion
d. esophageal erosion
An occupational nurse is facilitating a weight reduction group discussion. What should the nurse explain is the most common contributing factor of obesity? a. sedentary lifestyle b. low metabolic rate c. hormonal imbalance d. excessive caloric intake
d. excessive caloric intake
A nurse is assessing a patient for the presence of dysuria. The nurse should ask, do you" a. feel that you are able to empty your bladder fully each time you void? b. have a problem stopping or starting the flow or urine? c. pass a little urine when you cough or sneeze? d. experience any pain or burning on urination
d. experience any pain or burning on urination
a patient has been blind in one eye for several years because of the complications associated with diabetes mellitus. The patient is admitted to the hospital with a detached retina and resulting loss of sigh in the other eye. What should the nurse do to assist the patient with meals? a. food the patient b. order finger foods that are permitted on the patient's diet c. encourage eating one food at a time according to the preference of the patient d. explain to the patient where items are located on the plate according to the hours of a clock.
d. explain to the patient where items are located on the plate according to the hours of a clock.
An older adult tends to bruise easily and the practitioner recommends that the patient eat foods high in vitamin K. In addition to teaching the patient about foods sources of vitamin K, the nurse should include nutrients that must be ingested for vitamin K to be absorbed. Which foods that increase the absorption of vitamin K should be included in the teaching plan? a. carbohydrates b. starches c. proteins d. fats
d. fats
A patient of Asian heritage is recommended to follow a low-fat diet to lose weight. Which food low in fat generally is consumed by members of an Asian population? a. egg rolls b. spareribs c. crispy noodles d. hot or sour soup
d. hot or sour soup
A practitioner orders a clear liquid diet for a patient. Which food should the nurse teach the patient to avoid when following this diet? a. strawberry gelatin b. decaffeinated tea c. strong coffee d. ice cream
d. ice cream
What should the nurse do to limit discomfort when administering an injection? a. pull back on the plunger before injecting the medication b. apply ice to the area before the injection c. pinch the area while inserting the needle d. inject the medication slowly
d. inject the medication slowly
A home care nurse is helping a patient with short-term memory loss how to remember to take multiple drugs throughout the day. What should the nurse do when teaching this patient? a. suggest that the patient wear a watch with an alarm b. ask a family member to call the patient when medications are to be taken c. design a chart of the medications the patient takes each day during the week d. instruct the patient to put medications in a weekly organizational pill container
d. instruct the patient to put medications in a weekly organizational pill container
a patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. what should the nurse recommend that the patient eat it best increase the bulk in fecal material? a. whole wheat bread b. white rice c. pasta d. kale
d. kale
An obese resident of a nursing home who is receiving a 1500-calorie weight reduction diet has not lost weight in the past two weeks. What should the nurse do? a. inform the primary care practitioner of the patient's lack of progress b. instruct the patient to limit intake to 1000 calories per day c. schedule a multidisciplinary team conference d. keep a log or the oral intake for 3 days
d. keep a log or the oral intake for 3 days
A practitioner orders a return-flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return-flow enema with cleansing enemas. What should the nurse do that is unique to a return-flow enema? a. lubricate the last 2 inches of the rectal tube b. insert the rectal tube about 4 inches into the anus c. raise the solution container about 12 inches above the anus d. lower the solution container after instilling about 150 mL of solution
d. lower the solution container after instilling about 150 mL of solution
What should the nurse do when administering a small-volume hypertonic enema to an adult a. insert the rectal tube 1 to 1.5 inches into the rectum b. position the enema bottle 12 inches above the level of the patient's anus c. direct the rectal tube toward the vertebrae as it is inserted into the rectum d. maintain the compression of the enema container until after withdrawing the tube
d. maintain the compression of the enema container until after withdrawing the tube
A nurse is caring for the patient who consistently is incontinent of feces. Which patient problem is unrelated to bowel incontinence? a. overdistention of the rectum b. anal sphincter dysfunction c. cognitive impairment d. pain on defecation
d. pain on defecation
A home care nurse observes the spouse of a patient inserting a rectal suppository. What behavior indicates that the nurse must provide teaching about suppository administration? a. Lubricates the tip of the suppository b. inserts the suppository while wearing a glove c. inserts the suppository while the patient bears down d. places the suppository a finger length into the rectum
d. places the suppository a finger length into the rectum
A nurse needs to obtain a urine specimen from a patient. Which nursing intervention is the greatest help to most people who need to void for a urine test? a. exerting manual pressure on the abdomen? b. encouraging a backward rocking motion c. running water in the sink d. providing for privacy
d. providing for privacy
A nurse is assisting a patient with a bedpan. Which nursing action is most important? a. position the patient slightly of the back edge of a regular bedpan b. fold the top linen out of the way when putting the patient on the bedpan c. place the flat part of the rim of the fracture bedpan toward the patient's feet d. raise the head of the bed to the Fowler positron after the patient is on the bedpan
d. raise the head of the bed to the Fowler positron after the patient is on the bedpan
where is medication absorbed when the nurse administers a suppository a. ear b. nose c. mouth d. rectum
d. rectum
Which nursing action is most appropriate when administering an analgesic? a. reassess drug effectiveness every 8 hours b. follow the prescription exactly for the first 24 hours c. ask the practitioner to include a medication prescription for breakthrough pain d. seek a new prescription after two doses that do not achieve a tolerable level of relief
d. seek a new prescription after two doses that do not achieve a tolerable level of relief
A patient tells the nurse, " I have to urinate as soon as i get the urge to go." For which contributing factor to urinary urgency should the nurse implement a focused assessment? a. anesthesia b. full bladder c. dehydration d. urinary tract infection
d. urinary tract infection
A nurse collects data about a patient regarding a risk for stress incontinence. Which is a major factor that contributes to this condition? a. decreased bladder capacity b. spinal cord dysfunction c. cognitive impairment d. weak pelvic muscles
d. weak pelvic muscles
When a nurse assesses a patient, which clinical manifestation support the presence of urinary retention? Select all that apply a. nocturia b. hematuria c. bladder contractions d. suprapubic distention e. frequent small voidings
nocturia, suprapubic distention, frequent small voiding
