AH2: Exam 3

When a client develops steatorrhea, the nurse documents this stool as: 1. Dry and rock-hard 2. Clay colored and pasty 3. Bulky and foul smelling 4. Black and blood-streaked

3. Bulky and foul smelling

A client is instructed to avoid straining on defecation postoperatively. The nurse evaluates that the related teaching is understood when the client states, "I must increase my intake of: 1. Ripe bananas. 2. Milk products. 3. Green vegetables. 4. Creamed potatoes.

3. Green vegetables

A client is admitted to the hospital with a ureteral calculus. The nurse expects what urinary clinical findings? 1.Urgency and mild aching pain 2.Foul odor and dark urine 3.Hematuria with sharp pain when voiding 4.Frequency with small amounts of urine

3. Hematuria with sharp pain when voiding

To help prevent a cycle of recurring urinary tract infections, the nurse should plan to instruct a female client to: 1. Increase the daily intake of citrus juice 2. Douche regularly with alkaline agents 3. Urinate as soon as possible after intercourse 4. Wipe carefully from back to front

3. Urinate as soon as possible after intercourse

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zeroor is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart."

4, 2, 1, 3, 5, 6, 7

When teaching a community health class the nurse informs the group that the person at highest risk for developing prostate cancer is: 55 year old black male 45 year old white male 55 year old asian male 45 year old hispanic male

55 year old black male

A morbidly obese patient who had a laparoscopic sleeve gastectomy two days ago reports nausea and severe abdominal cramping....

Anastomotic leak

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client puts the call light on to report the need to urinate. What should the nurse do first?

Assess that the tubing attached to the collection bag is patent

The nurse manager in a long-term care facility plans nutritional assessments of all residents. Which nutritional assessment activity does the nurse delegate to unlicensed assistive personnel (UAP) at the facility? A. Assessing residents' abilities to swallow B. Determining residents' functional status C. Measuring the daily food and fluid intake of residents D. Screening a portion of the residents with the Mini Nutritional Assessment

C. Measuring the daily food and fluid intake of residents

Which is an example of a low-flow oxygen delivery system used for long-term therapy?

Nasal cannula

The nurse is performing an admission assessment on a patient with chronic obstructive pulmonary disease (COPD) who is admitted for treatment of pneumonia. The patient exhibits pursed-lip breathing. Which action by the nurse is correct?

Note the breathing pattern and continue the assessment.

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a."I must try to include at least 25 grams of fiber in my diet every day." b."I'll ride my bike or take a long walk at least three times a week." c."I will take a laxative nightly at bedtime to avoid becoming constipated." d."I should use my legs rather than my back muscles when I lift heavy objects."

c."I will take a laxative nightly at bedtime to avoid becoming constipated."

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination

d. Promote carbon dioxide elimination

Which statement by the client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction? A. "I don't need to use my oxygen all the time." B. "I don't need to get the flu shot." C. "I need to eat more protein." D. "It is normal to feel more tired than I use to."

"I don't need to get the flu shot."

The nurse is explaining testicular self-examination to a client. What does the nurse explain about the examination?

"Roll and feel each testicle between your thumb and fingers."

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)

- bloody drainage at site - foul-smelling drainage - urine draining from the site

As charge nurse, you would assign the nursing care of which patient to an LPN/LVN, working under the supervision of an RN? 1. 48-year-old with cystitis who is taking oral antibiotics 2. 64-year-old with kidney stones who has a new order for lithotripsy 3. 72-year-old with urinary incontinence who needs bladder training 4. 52-year-old with pyelonephritis who has severe acute flank pain

1. 48-year-old with cystitis who is taking oral antibiotics

A client has decided to become a vegan and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse instructs this client to: 1. Add milk to grains to provide complete proteins 2. Use eggs and plant foods to provide essential amino acids 3. Plan a careful mixture of plant proteins to provide a balance of amino acids 4. Add cheese to grains and beans to increase the quality of the protein consumed

3. Plan a careful mixture of plant proteins to provide a balance of amino acids

What two assessment findings are changes secondary to chronic obstructive pulmonary disease (COPD)?

Barrel chest and finger clubbing

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client's immediate nutritional needs? 1. Low in fat and vitamin D 2. High in calories and fiber 3. Low in residue and bland 4. High in protein and vitamin C

4. High in protein and vitamin C

The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? 1. Provide continuous pressure on the prostatic fossa. 2. Stimulate continuous formation of urine. 3. Facilitate the measurement of urinary output. 4. Prevent the development of clots in the bladder.

4. Prevent the development of clots in the bladder.

The client says, "I hate this stupid COPD." What is the best response by the nurse? A) "Then you need to stop smoking." B) "What is bothering you?" C) "Why do you feel this way?" D) "You will get used to it."

B) "What is bothering you?"

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse? A. 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula B. 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas C. 34-year-old who has questions about how to care for a newly created ileoanal reservoir D. 36-year-old with peritonitis who just returned from surgery with multiple drains in place

D. 36-year-old with peritonitis who just returned from surgery with multiple drains in place

A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. The nurse assesses the client for which primary subjective symptom?

Flank discomfort

Which sign/symptom is significant in diagnosing asthma in a nonsmoker?

Wheezing

A nurse assesses a client who presents with renal calculi. Which question should the nurse ask? a. "Do any of your family members have this problem?" b. "Do you drink any cranberry juice?" c. "Do you urinate after sexual intercourse?" d. "Do you experience burning with urination?"

a. "Do any of your family members have this problem?"

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? a. Review the hemoglobin and hematocrit as ordered. b. Take vital signs and notify the surgeon immediately. c. Release the traction on the three-way catheter. d. Remind the client not to pull on the catheter.

b. Take vital signs and notify the surgeon immediately.

A nurse teaches a client who has viral gastroenteritis. Which dietary instruction should the nurse include in this client's teaching? a."Increase your protein intake by drinking more milk." b."Drink plenty of fluids to prevent dehydration." c."Sips of cola or tea may help to relieve your nausea." d."You should only drink 1 liter of fluids daily."

b."Drink plenty of fluids to prevent dehydration."

A nurse cares for a client with ulcerative colitis. The client states, "I feel like I am tied to the toilet. This disease is controlling my life." How should the nurse respond? a."To decrease distress, do not eat anything before you go out." b."Let's discuss potential factors that increase your symptoms." c."If you take the prescribed medications, you will no longer have diarrhea." d."You must retake control of your life. I will consult a therapist to help."

b."Let's discuss potential factors that increase your symptoms."

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a.Liquid stool b.Pale and bluish stoma c.Blood-smeared output d.Ostomy pouch intact

b.Pale and bluish stoma

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

c. "Add vegetables such as broccoli and cauliflower to your new diet."

A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client that which medication is unlikely to cause epigastric distress? a. Ibuprofen b. Indomethacin c. Acetaminophen d. Naproxen sodium

c. Acetaminophen

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the client's pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump.

c. Ensure an adequate airway.

A patient undergoing a TURP returns from surgery with a three-way urinary catheter with continuous bladder irrigation in place. The nurse observes that the urine output has decreased and the urine is clear red with multiple clots. The patient is complaining of painful bladder spasms. The most appropriate action by the nurse is to a. administer the ordered IV morphine sulfate, 4 mg. b. increase the flow rate of the continuous bladder irrigation. c. give the ordered the belladonna and opium suppository. d. manually instill 50 ml of saline and try to remove the clots.

d. manually instill 50 ml of saline and try to remove the clots.