Questions for Exam 4 (Prep U & ATI lab Book)

The nurse is reviewing the medical record of the client. The nurse should identify which of the following findings is a risk factor for the development of hypocalcemia? (Select all that apply)

1) Bariatric surgery 2) Diarrhea 3) Thyroid cancer

A nurse is preparing to initiate a bladder-retraining program for a client who has urge incontinence. Which of the following actions should the nurse take? (select all that apply)

1) Have the client record urination times 2) Gradually increase the time of the client's urination intervals 3) Remind the client to try to hold urine until the next scheduled urination time

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply.

1) Have you started a new medication 2) What are your normal bowel habits 3) Do you use laxatives

A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance. Match to risk factor

1) Hypernatremia= Diabetes insipidus 2) Hyponatremia=Excessive water intake 3)Hypocalcemia=Hypoparathyroidism 4)Hypercalcemia=Hyperparathyroidism

A nurse is performing an assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply)

1) Hyperthermia 2) Orthostatic hypotension 3) Decreased skin turgor

A nurse is teaching a class about electrolyte imbalances. Match to clinical manifestation

1) Hypocalcemia=Tingling around mouth 2)Hypomagnesemia=Hypertension 3)Hypernatremia=Dry swollen tongue 4)Hyperkalemia=muscle weakness

The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia?

1) Increased Hct 2) Decreased urine output 3) Increased sodium level

A nurse is caring for a client who has an indwelling urinary cath. Which of the following actions should the nurse take? (Select all that apply)

1) Keep the urinary bag below the level of the clients bladder 2) Assess the client's need for the indwelling urinary cath daily 3) Maintain a closed system of the client's urinary cath

Which assessment data, collected by the nurse, indicates that a client may be assigned the nursing concern of urge urinary incontinence? Select all that apply.

1) Loses urine when a toilet is not readily available 2) Urinates 20 times in 24 hours 3) experience accidental loss of urine when there is an urgent need to urinate

A nurse is teaching a newly liscensed nurse about urine specimen collection. Match to procedure

1) Random urinalysis=Obtain a non-sterile urine specimen 2) Clean-catch midstream for culture and sensitivity=CLean the urethral meatus prior to obtaining the urine specimen 3) Timed urine specimen=Collect urine for a 24 hr period 4) Catheter urine specimen for C & S=Obtain a sterile urine specimen from an indwelling urinary cath

A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply.

1) Stop the infusion immediately 2) Apply warm compresses as ordered by the primary care provider 3) Restart the IV at another site

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.

1) The client is willing to look at the stoma 2) The client makes neutral or positive statements about the ostomy 3) The client expresses interest in learning self-care

A nurse is teaching a client who has recurrent UTIs. Which of the following instructions should the nurse include? (Select all that apply)

1) Urinate after sexual intercourse 2)Clean perineum from front to back 3) Avoid bubble baths

A nurse is preparing to administer a cleansing enema to a client. Place the steps the nurse should plan to take in correct order.

1) Warm the enema solution 2) Lubricate the end of the rectal tube 3) Slowly insert rectal tube into clients rectum 4) Hang enema container 30-45 cm above clients anus 5) Ask the client to retain solution

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

1) age 50 and older 2) a positive family history 3) a history of inflammatory bowel disease

A nurse is performing a physical assessment of a client's urinary system. Which nursing actions are appropriate during this assessment? Select all that apply.

1) if using a bedside scanner, place the client in a supine position 2) Inspect the urethral orifice for any signs of inflammation, discharge, or foul odor 3) Retract the foreskin of an uncircumcised male client to visualize the meatus 4) The nurse assess the client's urine for color, odor, clarity, and the presence of any sediment

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000

A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?

50 gtt/min

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

50-year-old client with a family history of polyps

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

83 mL/hr

What is the lab test commonly used in the assessment and treatment of acid-base balance?

ABGs

At what period of life do nutrient needs stabilize?

Adulthood

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg

A home care nurse is visiting a client with acute kidney injury who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids

Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention?

Before removing tube, discontinue suction and separate the tube from suction

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

Blood

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus?

Certain veggies can cause flatus, as they are more difficult to digest

Which is a common anion?

Chloride

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?

Cloudy, foul odor

A nurse is teaching a client about performing a fecal occult blood test at home. Following info should nurse include.

D- Ensure the specimen does not include urine

A client has been diagnosed with a dental infection and been prescribed a course of clindamycin. The nurse will monitor for what potential change in bowel function?

Diarrhea

A nurse is planning caring for a client who has a potassium level of 5.2 mEq/L. What action should the nurse plan to take?

Ecg monitoring, stop diffusions of potassium, potassium restrict diet, IV with insulin

A woman consumes pasta, grains, and other carbohydrates for which purpose?

Energy

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?

Every 4 to 6 hours

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

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

Fluid in the tissue space between and around cells

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

A nurse is teaching a class about t fluid imbalances. Sort the following manifestations into either Hypovolemia or Hypervolemia>

Hypervolemia (Breath sounds with crackles, weight gain, decreased urine specific gravity) Hypovolemia (Flat neck veins, sunken eyeballs)

A nurse on a med surg unit is caring for a group of clients. Sort the following clients to those at risk for Hypovolemia/Hyper

Hypovolemia (A client who has nasogastric suctioning, A client who is taking diuretics) Hypervolemia (A client who has syndrome of inappropriate antidiuretic hormone, a client who has cirrhosis)

What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding?

If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?

If within 2 hrs after NG tube removal, the client's abdomen is showing signs of distension, notify the health care provider

A nurse is teaching a client who reports stress urinary incontinence. Instructions nurse include?

Instruct client to maintain adequate fluid, empty bladder completely each void, avoid bladder irritants like coffee/alc, pelvic exercises (Kegal)

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?

Intermittent urethral catheter

The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition?

Iodine

The nurse is caring for a client with an enlarged thyroid. The nurse's nutritional assessment will prioritize what aspect of the client's nutrition?

Iodine intake

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters

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 caring for a client with an ileoostomy that was created 5 days ago. The nurse will teach the client to anticipate what type of expected ostomy output?

Liquid output

A client with influenza is prescribed a diet that is rich in fiber and carbohydrates. Which would the nurse incorporate into the education plan as a major reason for the high fiber diet?

Maintenance of normal bowel elimination

What should the nurse consider when teaching a man with well-defined muscle mass about meal planning?

Men have a higher need for proteins

The nurse is planning care for the client who is admitted to an acute care facility with dehydration. What actions will the nurse include in POC?

Monitor RR, O2, oxygen supply. Alert provider, electrolytes, measure wt/ht, neuro, rehydration thru IV

A nurse is planning care for a client who has hypernatremia. What actions should the nurse include in the POC?

Monitor clients LOC, ensure saftey, provide oral hygeine, comfort measures, monitor I & O, labs, hypotonic IV fluids

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in what state?

Negative nitrogen balance

A client is suspected of having a disease process affecting the basic functional unit of the kidney. Which structure is most likely involved?

Nephron

The nurse assesses redness, drainage, and odor to the area around a client's peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in?

Overweight

The nurse is administering a large-volume enema to a client as prescribed. The client reports abdominal cramping. What should the nurse do first?

Pause the administration of the enema momentarily

A client has been diagnosed with excessive levels of aldosterone. The nurse's assessment will include what value?

Potassium level

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is represented by what value?

Recommended dietary allowance

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding?

Reddened perineal skin

The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse?

Reinstruct the client on use of collection container for next bowel movement

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?

Remove the peripheral intravenos catheter

Which laboratory test is the best indicator of a client in need of TPN?

Serum albumin

A nurse is administering a cleansing enema to a client who reports abdominal cramping. What actions should the nurse take?

Slow the flow of solution lower container, decrease abd pain, if severe abd pain stop enema, assess VS, notify provider

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed

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

The birth can cause perineal swelling

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?

The client has an enlarged prostate

During a general survey, the nurse documents the waist circumference of an overweight female client as 43 in (109 cm). Which teaching should the nurse include about the risks associated with this waist circumference?

The client is at risk for diabetes

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

The client will have to wear an external appliance to collect urine

The nurse caring for a client with a new colostomy. Which assessment finding would be considered abnormal and would need to be reported to the health care provider?

The stoma is prolapsed

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

This test detects heme, an iron compound in blood within the stool

A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?

To rest the gastrointestinal tract and promote healing

A health care provider orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?

Total parenteral nutrition (TPN)

Use of an indwelling urinary catheter leads to the loss of bladder tone.

True

The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite?

Try to ensure that the client's food is attractive and sufficiently warm

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect?

Vitamin D

An older adult has developed occasional constipation despite having no such issues during their adult years. Which developmental factor is most likely related to this change?

Weakend pelvic muscles lead to constipation

A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect?

You won't have to endure any more needlesticks

The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk?

adolescent who is in the second trimester of pregnancy

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?

anuria

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

banana

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

cleansing enema

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60, PaCO2: 64 mm Hg, HCO3: 42 mEq/l

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and fatigue and the nurse's assessment reveals an irregular heart rate. The nurse should assess the client's levels of which electrolyte?

potassium

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress

The nurse prepares to administer large-volume cleansing enemas to a client scheduled for bowel surgery. For which client should the nurse stop administration of the enemas and notify the primary care provider?

the client who experiences severe abdominal pain

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

winged infusion needle