NUR 303 Adaptive Quizzes

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." Explanation:

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states,"I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse?

"Children vary in their readiness but daytime bowel control may be attained at 30 months."

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

"Discard your first urine and begin the collection after that."

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

"I should only take medication when my pain is intense."

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary?

"I will record the time I go to bed and how long it takes me to fall asleep."

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse?

"I will use clean gloves to handle the catheter and other equipment."

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem?

"Let's explore structuring activities and toileting breaks."

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse?

"Only if the stool has not been contaminated by urine."

A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply.

"The stool from an ileostomy is normally liquid." "You should eat dark-green vegetables to control the odor of the stool." "You may have a tendency to develop food blockages."

The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will:

"urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid."

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum?

3 in (7.5 cm)

Normal urine pH

4.5-8

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply.

78-year-old male patient diagnosed with an enlarged prostate A 75-year-old female patient who is diagnosed with vaginal prolapse A 73-year-old female patient who is taking antihistamines to treat allergies

A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order?

A blood clot threatens to block the catheter.

The three types of responses to pain are physiologic, behavioral, and affective. Which are examples of behavioral responses to pain? Select all that apply.

A patient cradles a wrist that was injured in a car accident A child is moaning and crying due to a stomachache child pulls away from a nurse trying to give an injection

A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely receive analgesics for chronic pain from the nurse? Select all that apply.

A patient is receiving chemotherapy for bladder cancer A patient who has fibromyalgia requests pain medication A patient has back pain related to an accident that occurred last year

A nurse is assessing patients in a skilled nursing facility for sleep deficits. Which patients would be considered at a higher risk for having sleep disturbances? Select all that apply.

A patient who has uncontrolled hypothyroidism. A patient with coronary artery disease. A patient who has GERD.

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply.

A patient who is taking metformin for type 2 diabetes mellitus A patient who is taking amoxicillin for an infection A patient taking over-the-counter antacids

A nurse is providing discharge teaching for patients regarding their medications. For which patients would the nurse recommend actions to promote sleep? Select all that apply.

A patient with Parkinson's disease who is taking dopamine. An older adult taking diuretics for congestive heart failure. A patient who is prescribed antidepressants.

For which patient would a nurse expect the primary care provider to order colostomy irrigation?

A patient with a left-sided end colostomy in the sigmoid colon

A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient?

A saline osmotic laxative

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult?

Acute confusion

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?

Administering an oral dose of morphine to treat the client's breakthrough pain

What will the nurse place at the bedside of a client receiving epidural analgesia?

Ampule of 0.4 mg naloxone

A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors?

An older adult on bedrest following cervical spine surgery

A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select all that apply.

Arrange for assessment for depression and treatment. Discourage napping during the day. Encourage patient to engage in some type of physical activity. Assess medication for side effects of sleep pattern disturbances.

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority?

Asking the client when he or she had last urinated

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline.

A nurse is caring for a patient who states he has had trouble sleeping ever since his job at a factory changed from the day shift to the night shift. For what recommended treatment might the nurse prepare this patient?

Chronotherapy

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?

Collect 15 to 30 mL of the client's liquid stool.

The nurse is caring for a client diagnosed with a urinary tract infection. The primary care provider orders include an antibiotic, an antipyretic, and a urine culture and sensitivity, and urine specimen for nitrates. Which actions should the nurse take? Select all that apply.

Collect the first void clean urine specimen since the client presented in the emergency department at 0500. Obtain the urine specimens before beginning the ordered antibiotic. Instruct the client on the midstream urine collection process. Place the collected specimen with proper label in a biohazard bag and send it to the lab after

A nurse is testing a client's stool specimen for occult blood. Which are responsibilities of the nurse for this testing? Select all that apply.

Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test

A nurse is teaching a patient with a sleep disorder how to keep a sleep diary. Which data would the nurse have the patient document? Select all that apply.

Daily mental activities Daily physical activities Presence of anxiety or worries affecting sleep

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output?

Decreased and highly concentrated

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply.

Difficulty voiding Urinary retention Burning or irritation while voiding

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation.

The health care provider has ordered a 24-hour urine specimen collection for a client. Which nursing action is appropriate? Select all that apply.

Discard first urine just before starting the test, then collect urine thereafter. Ask client to void for the last time at exactly the 24-hour mark.

A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply.

Draw up 30 mL of saline solution into the syringe. Place the tip of the syringe in the tube to gently insert saline solution. After instilling irrigant, hold the end of the NG tube over an irrigation tray. Observe for return flow of NG drainage into an available container.

The nurse is administering magnesium citrate to a client with constipation. What mechanism of action would the nurse expect from this drug?

Drawing water into the intestines to stimulate peristalsis

A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply.

Drink 8 to 10 8-oz glasses of water per day Dry the perineal area after urination or defecation from the front to the back Observe the urine for color, amount, odor, and frequency

When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply.

Encourage fluid intake, unless contraindicated. Record volume and character of the urine. Maintain a closed urinary catheter system.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

Ensure proper positioning of the scanner head and rescan.

When reviewing the chart of an older adult client, the nurse notes that the client identifies as Asian. The nurse realizes the client is referring to which ancestral and cultural factor?

Ethnicity

When describing the concept of ethnicity, which statement would be most appropriate to use?

Ethnicity allows people to define themselves and others to define them.

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube?

Every 4 to 8 hours

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant?

FLACC scale

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter?

Fasten the condom securely enough to prevent leakage without constricting blood flow.

Which statement about ostomy irrigation is true?

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination.

. Vitamin B-complexes can turn the urine

Green

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?

Have the patient follow a low-fiber diet several days before the test.

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation?

Have the patient rest for 30 minutes to see if the prolapse resolves.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this?

Having the client sign a consent form for the procedure

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding?

Having the patient ignore the urge to void until her bladder is full.

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.)

Heat Massage Cold

Which principle should guide the nurse's collection of a fecal occult blood test?

If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client?

Impaired Skin Integrity related to urinary bladder infection and dehydration

A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient?

Incontinence

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include?

Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap.

The nurse is caring for a male client who has a urinary obstruction and is not a candidate for surgery. Which intervention will the nurse prepare the client for?

Insertion of a urologic stent

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds.

The nurse is assessing a client who is unresponsive. To obtain information about the client's culture, the nurse interviews a person who has native knowledge about the client's culture. Which technique is the nurse using?

Key informant

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

The nurse is catheterizing a male urinary bladder, and urine leaks out of the meatus around the catheter. Which actions would the nurse perform next? Select all that apply.

Make sure the smallest sized catheter with a 10-mL balloon is used. Consider an evaluation for urinary tract infection. Ensure that the correct amount of solution was used to inflate the balloon.

A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply.

Many adolescents do not get enough sleep. Total sleep decreases in adults with a decrease in stage IV sleep. Sleep is less sound in older adults and stage IV sleep may be absent.

A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply.

Measure the patient's fluid intake and output. Empty the appliance frequently. Monitor the return of intestinal function and peristalsis.

A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention?

Monitoring bowel movements

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race

Native American patient, Alaska native, White, Hispanic

The nurse has received an order to catheterize a female client. What action should the nurse perform?

Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm).

A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What action would be a priority when caring for this patient?

Preventing the tubing from kinking to maintain free urinary drainage

____________________________ much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap.

REM sleep constitutes

Which urinary care teaching will the nurse provide to a young adult female client?

Refrain from douching unless ordered by a health care provider.

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide?

Refrain from eating red meat 3 days before testing.

Delta sleep

Stage 3 and 4 NREM

What is required for catheterization?

Sterile glove

A PCA has been ordered for a client who is experiencing significant postoperative pain. To minimize the risk of adverse effects of this therapy, the nurse should perform what action?

Teach the client to perform deep-breathing and coughing exercises.

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply.

The United States has become less inclusive of same-sex couples. People may be members of multiple cultural groups at one time.

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

The birth can cause perineal swelling.

A new client comes to the primary care clinic and asks for help treating head lice. The nurse assesses that the client lives in low-income housing, and nine other people live with the client in a one-bedroom apartment. Which consideration is the priority nursing concern?

The client does not have running water

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal?

The client is acutely confused and has been diagnosed with delirium.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?

The graduate places the client in Fowler's position.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?

The largest part of a regular bedpan should be placed under the client's buttocks.

The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure?

The male urethra is more vulnerable to injury during insertion.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted?

The novice nurse selects an 18 French Foley catheter to insert.

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply.

The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient?

The nurse instructs the patient to retain the enema for at least 30 minutes

A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow?

The nurse should use the smallest appropriate indwelling urinary catheter.

The nurse assesses the stool of clients admitted to the hospital with abdominal distress. Which statements accurately describe the normal characteristics of stool and special considerations for observation? Select all that apply.

The rapid rate of peristalsis in the breastfed infant causes the stool to be yellow. Antacids in the diet cause the stool to be whitish. A gastrointestinal obstruction may result in a narrow, pencil-shaped stool.

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia?

The stoma is a purple-blue color.

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation.

A nurse is assessing the freshly voided urine of a client. What characteristics of the urine would indicate a urinary problem? Select all that apply.

The urine smells like ammonia. There is pus in the urine. The urine is cloudy.

Which statements about suprapubic catheters is true?

They are often preferred over an indwelling urethral catheter for long-term urinary drainage.

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care?

Treating each patient at the clinic as an individual

. The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patients (T/F)

True

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?

Wearing gloves when handling the urine

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery

Chronotherapy requires

a commitment on the part of the patient to act over a period of weeks to progressively advance or delay the time of sleep for 1 to 2 hours per day.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet?

a diet lacking in fruits and vegetables

For patients who are having trouble initiating sleep, the nurse should arrange for

assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects.

Functional incontinence takes place when

attempting to overcome obstacles, such as transferring from the wheelchair to the bed.

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should:

deflate the balloon, withdraw the catheter, and use a smaller sized catheter.

A 57-year-old man is suffering from polyuria. What can cause polyuria?

diabetes insipidus

The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing?

functional

The nurse has received an order to remove a client's indwelling urinary catheter. Which actions are appropriate when carrying out this order? Select all that apply.

he nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe.

A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply.

hot tea with meals a turkey sandwich with whole-grain bread prune juice with breakfast

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?

hypertonic saline

A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a p.r.n. drug regimen as an effective method of pain control would be the client:

in the postoperative stage with occasional pain.

Which foods will the nurse recommend to avoid for a client with uncomfortable, frequent episodes of flatulence? Select all that apply.

lentils onions cabbage

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency.

Pasero Opioid-Induced Sedation Scale 2

occasionally drowsy but easy to arouse; requires no action

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

one or both of the ureters are surgically implanted elsewhere

Phenazopyridine cause the urine to turn

orange or orange-red

Diuretics turn the urine

pale yellow

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply.

patient diagnosed with peritonitis Place the patient in a supine position and modify the amount of solution. patient who has paralytic ileus caused by surgery

While using PCA, the nurse should encourage the client to practice coughing and deep breathing to

promote ventilation and prevent pooling of secretions.

Which factor necessitates the need for more sleep in the adolescent population?

rapid growth

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?

removes hardened fecal impactions from the rectum

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds

A client states to the nurse during a sleep assessment that it takes her more than 60 minutes to fall asleep. The nurse documents this time period as the client's:

sleep latency.

Pasero Opioid-Induced Sedation Scale 4

somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?

strongly aromatic, dark amber

The nurse is completing a sleep history on a client who reports sleeping problems. Which of the client's regular behaviors will cause the client to have difficulty with sleep?

taking a diuretic at 9 a.m. and 5 p.m. daily

A client experiencing chronic pain would benefit from

the dosage of pain medication with around the clock dosing.

A client in the early postoperative period would benefit from

the dosage of pain medication with around the clock dosing.

A nursing student is changing the client's bed. Which action requires intervention from the nursing instructor?

tossing soiled linen on the floor

Digital removal may stimulate

vagal response

A nurse observes a slight increase in a patient's vital signs while he is sleeping during the night. According to the patient's stage of sleep, the nurse expects what conditions to be true? Select all that apply.

would be most difficult to awaken him at this time. This stage constitutes around 20% to 25% of total sleep.

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response"

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client?

"Are you taking any B-complex vitamins?"

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24-hour specimen

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?

3

A nurse caring for clients of different cultures in a hospital setting attempts to make eye contact with clients when performing the initial assessment. What assumption might the nurse make based on common cultural practices?

A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest.

The nurse is caring for a client who is postoperative 3 days from coronary artery bypass graft. The client has a prescription to ambulate. What is the best action by the nurse?

Discuss with the client the need for assistance during ambulation.

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding.

Which activity would be appropriate to suggest to the client who reports having difficulty falling asleep every evening?

Eat some crackers with peanut butter at bedtime.

A client experiencing acute pain would benefit from

from the dosage of pain medication with around the clock dosing.

Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy?

gabapentin

Gabapentin is used to treat

nerve pain.

A client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement?

"There's only an extremely small chance that you will become addicted to this drug."

The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the best response by the nurse?

"We can wait until your spiritual healer arrives and work together to answer these questions."

A client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not had the prescribed medicines. The client believes that eating saffron will keep blood sugar under control. What is the most appropriate response by the nurse?

"Why don't you take the medicines, too, and benefit from both?"

The nurse is caring for a client who practices Catholicism and was newly diagnosed with cancer. The client states, "God is punishing me for my past sins." How should the nurse respond?

"You sound upset. Would like you to talk about it?"

Kegel exercise should be performed

3-4 times daily for 2 weeks to 1 month

What is the priority assessment for the nurse when developing a plan of care for a client living in poverty?

Access to care

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

CRIES Pain Scale

The nurse is caring for a client who is admitted for hypertension (HTN). The nurse notes that the client has not been eating the food provided, and family members have brought in homemade food. What would be the best response by the nurse?

Can you tell me what foods you prefer to eat and what your family is bringing you?

Splinting is directed at helping the postsurgical client with what type of pain?

Deep somatic

A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? Select all that apply.

Diminished ability of kidneys to concentrate urine may result in nocturia. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. Decreased bladder contractility may lead to urine retention and stasis. Neuromuscular problems may interfere with voluntary control of urination. Altered thought processes may cause urinary frequency.

Which area is typically included in a cultural assessment?

Food preferences

Which aspects of nursing make it recognizable as a subculture? Select all that apply.

Manner of dress Language used Rituals

A nurse is giving a client a back massage. Which actions should the nurse perform? Select all that apply.

Observe the client's skin over bony prominences. Warm the lubricant in the palm of the hand. Keep hands in contact with the client's skin at all times.

The nurse is caring for a client receiving epidural opioids . What side effects of the medication should the nurse assess for? Select all that apply.

Pruritis Urinary retention Nausea Infection

The nurse is attempting to wake a client from sleep and is having a difficult time arousing them. What stage of sleep does the nurse identify the client is experiencing?

REM sleep

A nurse overhears another nurse make a statement that indicates racism. The nurse makes this determination based on which characteristic indicative of social value?

Skin color

A nurse is collecting a urine specimen for urinalysis. Which factors should the nurse consider when performing this procedure? Select all that apply.

Sterile urine specimens may be obtained by catheterizing the client's bladder. Strict aseptic technique must be used when collecting and handling urine specimens. A clean-catch specimen of urine may be collected in midstream.

Stage 4 NREM vs REM

The NREM arousal threshold is usually greatest in stage 4 NREM, but it is harder to arouse a person who is in REM sleep than NREM sleep.

A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change?

The client states, "I feel like I abandoned my religion."

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

The dose that is delivered when the client activates the machine is preset.

A client who does not speak the dominant language has been admitted to the health care facility reporting chest pain. Because the assigned nurse does not know the client's language, what would be the most appropriate solution for communication until a professional interpreter can be obtained?

The nurse should request the help of a family member if available, if not care should be administered that is in the best interest of the client.

Carbohydrates promote sleep (T/F)

True

Use of an indwelling urinary catheter leads to the loss of bladder tone. (T/F)

True

daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. T/F

True

A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory?

administering backrub when client's head hurts

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

Levodopa turns the urine to

brown or black

Ethnicity allows people to

define themselves and others to define them.

Cholinergic agents stimulate

detrusor muscle, which causes more frequent urination.

Pasero Opioid-Induced Sedation Scale 3

frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?

dehydration

The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother?

"My boys love to roughhouse in their room right before bedtime."

A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?

"One signal of preparedness is when your child is dry for at least 2 hours."

While caring for a client with chronic pain, the nurse talks with a family member. Which family member statement does the nurse identify as consistent with caregiver role strain?

"Sometimes it seems like I can never get a moment to myself."

Two hours after receiving a pain medication, the client reports still suffering from pain. Which question is most appropriate to ask the client?

"Tell me more about your pain."

The nurse is caring for a client who frequently comes to the emergency department (ED) reporting a headache that is an "8" or "9" on a pain scale of 1 to 10. The client is routinely noted to be laughing while on the phone, and chatting with staff. What is the appropriate nursing action when the client again comes to the ED and states that the headache is now a "10" on a 1-10 scale?

Acknowledge the client's reported pain level.

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?

Administer the pain medication.

A middle-age client reports to the nurse that he has difficulty falling asleep at night. The nurse assessed the client as having poor sleep hygiene habits. Which instruction does the nurse provide to the client? Select all that apply.

Avoid activities after 5 p.m that are stimulating. Participate in a quiet activity, such as reading, prior to attempting to fall asleep.

The nurse is assessing a client while they are presumed asleep. How would the nurse determine that the client is experiencing rapid eye movement sleep? Select all that apply.

Blood pressure and pulse rate show wide variations and may fluctuate rapidly. A person is unable to move during this stage. Deep tendon reflexes are depressed.

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

Check health record for provider's order.

A client could experience increased urination when using which classification of medication?

Cholinergic agents

A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first?

Clean each side of the urinary meatus with a separate wipe.

For the last 3 weeks, a nurse in a long-term care facility has administered a sedative hypnotic to a client who complains of insomnia. The client does not seem to be responding to the drug and is now lying awake at night. What is the most likely explanation?

Most sedative hypnotics lose their effect after 1 or 2 two weeks of administration.

The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client?

Offer client a small carbohydrate and protein snack before bedtime.

A nurse has attended a pain control workshop and learned about the psychological and physiological basis of placebos. What principle should guide the use of placebos in the treatment of pain?

Placebos involve the use of deception and are considered unethical in most circumstances.

A nurse is caring for a client with restless leg syndrome who complains of sleeplessness. Which nursing diagnosis is most appropriate for this client?

Sleep Deprivation

The younger nurses on a unit, who seem to adapt easily to the new technology presented, are perceived as threatening by two nurses who have worked on the unit for years. The older nurses begin to ridicule the younger nurses, saying, "You might be able to work a computer, but we know how to provide real care." How should the charge nurse respond?

The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit.

The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep?

The child should limit fluids after supper.

What are characteristics of nurses that make them a subculture? Select all that apply.

Uniforms worn based on place of employment Language or medical terminology used to communicate Legal authorization to provide health care to others

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted.

A p.r.n. (as needed) medication would be most appropriate for

a client in the postoperative stage with occasional pain.

Soiled linen should be placed directly into

a pillow case or laundry hamper to prevent transferring microorganisms

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:

anticipate sleeping overnight at a health care center.

Pasero Opioid-Induced Sedation Scale 1

awake and alert; no action necessary

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake.