Term 1 Unit 5 Exam Nutrition & Introduction to Fluids

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."

The health care provider has requested a urine sample from a female client for urinalysis. Which method should the nurse instruct the client to use to obtain a clean-catch urine?

"Begin to urinate while continuing to hold the labia apart. Allow the first urine to flow into the toilet."

A nurse is caring for an older adult client who was admitted for dehydration. Which instruction will the nurse give to the client's adult child to prevent this situation from happening again to the client?

"Encourage your parent to drink fluids throughout the day."

A school nurse is educating a class of middle school students on how to promote urinary system health. Which statement by one of the students indicates understanding?

"I will wipe from front to back after going to the toilet."

A client tells the nurse, "I increased my fiber, but I am still very constipated." Which information should the nurse share with the client about promoting bowel care?

"When you increase fiber in your diet, you also need to increase liquids."

A client is 6 weeks' pregnant and is in a clinic for her first prenatal exam. The client asks the nurse how her nutritional needs have changed now that she is pregnant. Which is the nurse's best response?

"You will need an increase in calories, protein, calcium, folic acid, and iron."

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

24-hour specimen

The nurse is caring for four clients. The nurse recognizes that which client's lifestyle choice contributes most highly to risk for development of cardiometabolic syndrome?

28-year old who eats fast food daily

Preliminary laboratory results of a client's urine culture suggest that the sample was contaminated. A clean-catch specimen has consequently been recommended. Why is a clean-catch specimen preferable to a randomly voided specimen?

A clean-catch specimen is more accurate because it is collected after the initial urine stream has cleansed the urinary structures.

A client comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. Which assessment techniques and diagnostic studies should the nurse use?

Bowel sounds and stool sample

Which instructions should the nurse give a client who needs to provide a urine sample for a pregnancy test?

Collect the first morning urine or urine that has been in the bladder for at least 4 hours.

A older adult client admitted for dehydration is being discharged. In which way should the nurse instruct the client to maintain proper hydration?

Drink six to eight 8-oz glasses of fluid (1,500 to 2,000 mL) per day.

A nurse is caring for older adult clients in an assisted living facility. The nurse encourages the clients to eat diets that are high in fiber to prevent constipation. In which way would the nurse assist the clients to plan a menu to ensure that their dietary intake is rich in fiber?

Eat fruits and vegetables daily.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?

Elevate the legs

A postsurgical client has been admitted to the unit with an indwelling urinary catheter that was inserted in the operating room and which is scheduled for removal the following morning. How can the nurse best avoid backflow of urine into the client's bladder and subsequent infection?

Ensure that the collection bag is always lower than the client's bladder.

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 following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, ten 8-oz glasses (2,500 mL) of fluids. What would the nurse tell the client to change?

Nothing; this is a good diet.

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

O negative

A nurse is caring for a client with an abdominal injury at a health care facility. The client informs the nurse about passing blood-stained stool. Which nursing action is appropriate at this time?

Perform a screening test on stool samples

A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?

Plans to eat a snack of fruit twice per day.

The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into toilet or bedpan. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.

The nurse is caring for a 70-year-old client with a body mass index (BMI) of 34.8. Which risk factor should the nurse discuss with this client?

Risk of heart disease

An elderly client has been experiencing urinary hesitancy, and this has resulted in the client's bladder becoming overdistended with urine. What intervention should the nurse attempt before resorting to the insertion of a urinary catheter?

Run water from the tap in the client's room to stimulate the urge to void.

A client with partial-thickness (second-degree) burns is encouraged to increase the proteins in the diet. Which food selection from the hospital menu indicates that the client understands how to choose foods high in protein?

Scrambled eggs with cheese

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?

Sims

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?

Stop the transfusion and notify the health care provider.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion.

A woman had a left mastectomy with axillary node dissection due to cancer. How would this affect placement of an intravenous line?

The left arm should not be used.

A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students?

The student should drink large amounts of water on practice days.

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

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

a slowing of client's heart rate

Accurate fluid volume assessment has been ordered for a client who has been acutely ill since the time of admission to the hospital. The nurse can best monitor this client's fluid balance by:

accurately measuring and recording the client's intake and output

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 client underwent surgical repair of a hernia and has been ordered on a clear fluid diet for the first 24 hours following surgery. The client's family members are eager to help with recovery and have asked the nurse about permissible food items to bring for the client. Which item is acceptable at this point in the client's recovery?

apple juice

The health care provider notifies a client of a diagnosis of glycosuria. Which assessment information will the nurse obtain from the client next?

blood sugar

What is fecal occult blood?

blood that cannot be seen

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, the dietitian informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy?

carbohydrates, protein, and lipid

A nurse is caring for a client who reports chest pain. Which test levels would indicate whether the client is at risk for cardiac and vascular disease?

cholesterol

The physician has asked the nurse to prepare a list of laboratory tests needed to assess an obese client's daily fat intake. Which test would the nurse include on the list?

cholesterol level test

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply.

client drinking milk · client's urination · vomiting · infusion of intravenous solution

The nurse cares for a client with a chronic neurologic condition that decreases the peristalsis. What concern will the nurse use to plan care for this client's most likely risk?

constipation

A client is admitted to the health care facility reporting pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as:

dysuria

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning

A nurse is caring for a client with a colostomy. What type of stools would the nurse expect to find in the colostomy bag?

formed

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

greater than normal urinary volume

What are two essential techniques when collecting a stool specimen?

hand hygiene and wearing gloves

A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?

inadequate intake of liquid

A nurse is preparing to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?

infection

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?

left side-lying

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

The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing:

oliguria.

A nurse is caring for a client with pseudoconstipation. What can cause pseudoconstipation in a client?

overuse of suppositories

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

phlebitis

Which term is most closely associated with an acute urinary tract infection?

pyuria

A nurse is caring for a client diagnosed with high risk for cardiovascular disease. Which item should the nurse make sure is not on the client's dietary tray?

red meat

A nurse is caring for a pregnant client who is a strict vegetarian. What type of diet should the client follow?

rich in protein

The nurse is helping a client, who wishes to increase Omega-3 fatty acids, to order breakfast. Which food will the nurse recommend?

salmon

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

skin turgor response 5 seconds

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate

Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly?

soft, watery