SS 10.13

A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take? A. Keep the formula cold until instillation. B. Withhold the feeding if the residual volume is 150 mL. C. Cleanse the top of the can of formula with an alcohol wipe. D. Flush the tube with 30 mL of sterile water before the feeding.

C. Cleanse the top of the can of formula with an alcohol wipe.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? Creatine kinase Troponin Total bilirubin Albumin

Albumin

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene Chlorhexidine Povidone-iodine Nonantimicrobial soap Alcohol-based hand rub

Nonantimicrobial soap

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? Urine output of 175 mL in the past 8 hr Urine output of 2,200 mL in the past 24 hr First-voided urine in the morning has a strong odor Urine is cloudy after sitting in the urinal for 6 hr

Urine output of 175 mL in the past 8 hr

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? "I will allow him to be in the position where he is most comfortable during the feeding." "I will elevate the head of the bed 10 degrees during the feeding." "I will turn him on his left side during the feeding." "I will have him sit in his chair during the feeding."

"I will have him sit in his chair during the feeding."

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (SATA) -After each medication -Before aspirating gastric contents -When the flow of the medication by gravity slows -Prior to administering each medication -After giving multiple medications

-After each medication -Prior to administering each medication -After giving multiple medications

A. nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? SATA -MSO4 -bid -30 mL -.2 mg -Q.D.

-bid -30 mL

A nurse is caring for a client who is post op following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer To the client (SATA) -broth -grape juice -nonfat milk -custard -lemon gelatin

-broth -grape juice -lemon gelatin

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? 6.0 4.0 7.0 8.0

4.0

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? A. Allow the AP to deliver the food tray to the client. B. Call the dietary department and ask for a kosher tray. C. Replace the nonfat milk with apple juice. D. Explain to the client that he needs the protein in the milk and the beef.

B. Call the dietary department and ask for a kosher tray.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? A. Keep the container of solution at a level to maintain client comfort. B. Hold the container of solution 30 cm (12 in) above the anus. C. Hold the container of solution level with the client's upper hip. D. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.

B. Hold the container of solution 30 cm (12 in) above the anus.

A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following laboratory values indicates the client needs a change in the formula? Hematocrit 42% Urine specific gravity 1.022 BUN 28 mg/dL Sodium 142 mEq/L

BUN 28 mg/dL

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders? Xerostomia Halitosis Bruxism Sordes

Bruxism`

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective? A. "My partner should cough while swallowing food." B. "My partner should place their food on the weaker side of their mouth when eating." C. "My partner should tilt their head forward when swallowing." D. "My partner should sit at a 30° angle while eating their meals."

C. "My partner should tilt their head forward when swallowing."

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? A. Request a prescription for a medication to ease the client's anxiety. B. Irrigate the NG tube with 100 mL of sterile water. C. Check to see if the suction equipment is working. D. Remove and reinsert the NG tube.

C. Check to see if the suction equipment is working.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? Lemon sherbet Plain yogurt Cranberry juice Carrot juice

Cranberry juice

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? A. Mix the three medications together prior to administering. B. Dilute each medication with 10 mL of tap water. C. Maintain the head of the bed in a flat position for 30 min following medication administration. D. Flush the NG feeding tube with 30 mL of water immediately following medication administration

D. Flush the NG feeding tube with 30 mL of water immediately following medication administration

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? A. The client who has a tracheostomy tube attached to humidified oxygen B. The client who has an indwelling urinary catheter to gravity drainage C. The client who has a chest tube to water seal D. The client who has a nasogastric (NG) tube to suction

D. The client who has a nasogastric (NG) tube to suction

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? A. The nurse initiates the feeding after aspirating 50 mL of gastric residual. B. The nurse irrigates the NG tube with tap water after feeding. C. The nurse administers the feeding through a syringe barrel by gravity. D. The nurse allows the client to rest in a supine position during feeding.

D. The nurse allows the client to rest in a supine position during feeding.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? A. To confirm the placement of the NG tube B. To remove gastric acid that might cause dyspepsia C. To determine the client's electrolyte balance D. To identify delayed gastric emptying

D. To identify delayed gastric emptying

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first? A. Disconnect the tube from the wall suction. B. Perform hand hygiene. C. Provide mouth care to the client. D. Verify the provider's prescription to discontinue the tube.

D. Verify the provider's prescription to discontinue the tube.

A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions? Electrolyte imbalance Diarrhea Constipation Delayed gastric emptying

Diarrhea

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? Symmetrical convex sphere shape Concave umbilicus Bilateral bowel sounds in lower quadrants Ecchymosis

Ecchymosis

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have? Grape juice Lemon sherbet Milkshake Vanilla ice cream

Grape juice

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? Weigh the second client. Obtain vital signs for both clients. Administer pain medication to the first client. Change the dressings of both clients.

Obtain vital signs for both clients.

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? After palpating the abdomen Prior to percussing the abdomen After assessing for kidney tenderness Prior to inspecting the abdomen

Prior to percussing the abdomen

A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take? Discontinue the enema. Slow the flow of enema solution briefly. Continue the enema and reassure the client. Pause the enema and administer oral pain medication.

Slow the flow of enema solution briefly.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? Warm the feeding solution to body temperature. Place the client in low Fowler's position. Discard any residual gastric contents. Test the pH of gastric aspirate.

Test the pH of gastric aspirate.

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? When the client has the urge to defecate Every 2 hr while the client is awake Immediately before the client has a meal After the client feels abdominal cramping

When the client has the urge to defecate

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching? Yogurt Popsicle Gelatin Broth

Yogurt

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take? a. aspirate the client's stomach contents b. hang the feeding bag 30 cm (12in) above the client c. label the feeding bag with the date and time of the start of the feeding d. warm the feeding to room temp

a. aspirate the client's stomach contents

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check? a. at the client's bedside before administration b. in the area where the nurse obtained the medication c. at the time of documentation d. at the nurses' station while reviewing the providers prescription

a. at the client's bedside before administration

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? a. excessive laxative use b. ignoring the urge to defecate c. inadequate fluid intake d. increased fiber in the diet e. increased activity

a. excessive laxative use b. ignoring the urge to defecate c. inadequate fluid intake

A nurse is caring for a client and observes that the client's urine is dark, amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? a. urinary tract infection b. urinary incontinence c. urinary frequency d. urinary retention

a. urinary tract infection

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take? a. put on sterile gloves b. assist the client to the left sims position c. hang the enama container 60 cm (24 in) above the anus d. insert the tubing about 15 cm (6 in) into the anus

b. assist the client to the left sims position

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? a. steatorrhea b. blood c. bacteria d. parasites

b. blood

a nurse is preparing to initiate a continuous enteral feeding through an open system to a client. which of the following actions should the nurse take? a. reconstitute the formula with tap water b. discard unused formula after 8 hr c. administer 200 mL of formula during the initial infusion d. give the initial feeding over 15 min

b. discard unused formula after 8 hr

A nurse in a long-term facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse? a. admission assessment of a new client b. scheduling a diagnostic study for a client c. evaluating changes to a clients pressure ulcer d. teaching a client inulin injection technique

b. scheduling a diagnostic study for a client

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take? a. use the tablet's packaging to pick it up form the counter b. wash the tablet off with alcohol and place it in a clean medication cup c. discard the tablet and obtain another dose of medication d. place the tablet directly into a medication cup

c. discard the tablet and obtain another dose of medication

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? a. bear down hard when defecating b. drink four to five glasses of water daily c. increase dietary intake of raw vegetable d. limit activity

c. increase dietary intake of raw vegetable

A nurse is caring for a client who is receiving continuous enteral feedings. The client is at risk for developing? a. dehydration b. absent gag reflex c. infection d. tube displacement e. fluid overload

c. infection

A nurse is assessing a client's abdomen who report stomach pain. Which of the following actions should the nurse take first? a. auscultate b. percuss c. inspect d. palpate

c. inspect

a nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? a. serve foods that have a hot/cold balance b. serve milk products separately from meals c. request a meal tray without pork d. remove tea and coffee from meal trays

c. request a meal tray without pork

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take? a. Request a prescription for an oral formulation of the medication b. administer the crushed medication though the NG tube c. dissolve the medication in water and give it thought he NG tube d. Administer the medication under the clients tongue

d. Administer the medication under the clients tongue

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge? a. clamps the NG tube during auscultation b. performs auscultation between meals c. auscultates bowel sound for 3 to 5 min d. palpates the abdomen prior to performing auscultation

d. palpates the abdomen prior to performing auscultation

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? a. deflate the catheter ballon using a sterile syringe b. measure and document the urine in the drainage bag c. remove the tape or device securing the catheter to the client's thigh d. position the client supine

d. position the client supine