Elevate module 3

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order.

1) Elevate head of bed to Fowler's position. 2) Measure distal NG tube from nose tip to earlobe to xiphoid process. 3) Lubricate 2-3 inches (5.08-7.62 cm) of distal NG tube. 4) Insert NG tube into unobstructed naris. 5) Advance NG tube upward and backward. 6) Rotate catheter and pass the tube into nasopharynx. 7) Have client swallow ice as NG tube advances into stomach. 8) Secure NG tube.

A client is preparing to be discharged after a total hip replacement. Which client statement would indicate teaching has been successful regarding prevention of hip prosthesis dislocation? 1. "I should not cross my affected leg over my other leg." 2. "I should not bend at the waist more than 90 degrees." 3. "While lying in bed, I should not turn my affected leg inward." 4. "It is necessary to keep my knees together at all times." 5. "When I sleep, I should keep a pillow between my legs."

1. "I should not cross my affected leg over my other leg." 2. "I should not bend at the waist more than 90 degrees." 3. "While lying in bed, I should not turn my affected leg inward." 5. "When I sleep, I should keep a pillow between my legs."

The nurse is assessing a pregnant client who thinks she is in labor. Which statement by the client would alert the nurse that the client is likely experiencing true labor? 1. "The pain is in my back, and comes around to my abdomen." 2. "The contractions seem to increase when I begin walking around." 3. "The pain is in my lower abdomen and groin." 4. "My contractions are coming every 5 minutes." 5. "Changing my position does not help with the pain intensity."

1. "The pain is in my back, and comes around to my abdomen." 2. "The contractions seem to increase when I begin walking around." 4. "My contractions are coming every 5 minutes." 5. "Changing my position does not help with the pain intensity."

A client, scheduled for a total hysterectomy for advanced cervical cancer, is crying and states, "I want to have more children! I do not know if I should have this procedure." Which responses by the nurse are appropriate? 1. Allow the client to discuss her fears. 2. Tell the client that her health is more important than having children. 3. Explain to the client that cryotherapy may be an option for treatment. 4. Advise the client to delay surgery until she is absolutely sure. 5. Encourage client to discuss with surgeon again about the total hysterectomy.

1. Allow the client to discuss her fears. 5. Encourage client to discuss with surgeon again about the total hysterectomy.

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1. Alternating pressure mattress 2. Hospital bed 4. Suction equipment 5. Oxygen

A nurse is caring for a client with a suspected myocardial infarction (MI). What lab work or diagnostics should the nurse anticipate the primary healthcare provider prescribing to specifically confirm the diagnosis? 1. ECG 2. Troponin Level 3. PTT 4. Metabolic Panel 5. CPK-MB 6. CPK-BB

1. ECG 2. Troponin Level 5. CPK-MB

Which teaching points would the nurse include in a client's nutritional teaching plan to accomplish the goal of a gluten free diet? 1. Gluten is a protein found in wheat. 2. The main starchy foods that a person can eat are made with barley. 3. Fruits can be eaten on a gluten free diet. 4. Pure, non-contaminated oats are an acceptable grain food that the client can consume. 5. Accidentally eating food with gluten may result in abdominal pain and diarrhea.

1. Gluten is a protein found in wheat. 3. Fruits can be eaten on a gluten free diet. 4. Pure, non-contaminated oats are an acceptable grain food that the client can consume. 5. Accidentally eating food with gluten may result in abdominal pain and diarrhea. (the main starchy foods that a person can eat are made with rice, corn, potatoes, quinoa, and tapioca)

A client has been admitted with advanced Cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs.(2.71 kg) since yesterday's measurements. What further assessment findings would the nurse expect? 1. Hypotension 2. Cool extremities 3. Bradycardia 4. CVP readng of 8 mm/Hg 5. Radial pulses 4+/4+

1. Hypotension 2. Cool extremities (FVD/3rd spacing)

What sign and symptom should the nurse expect to find during the physical assessment of a client who has a history of rheumatoid arthritis? 1. Nodules over bony prominences 2. Reports of morning stiffness lasting over 1 hour 3. Reports of weight loss 4. Cool, swollen joints 5. Joint deformity

1. Nodules over bony prominences 2. Reports of morning stiffness lasting over 1 hour 3. Reports of weight loss 5. Joint deformity warm/swollen joints

Which statements should the nurse include when teaching a client about osteomyelitis? 1. Osteomyelitis is a risk factor for people with impaired immune systems. 2. Weight bearing activity is restricted to avoid stress on the affected bone. 3. Intravenous antibiotics will be administered for at least 3 to 6 weeks. 4. The affected extremity will be elevated. 5. Osteomyelitis requires subcutaneous administration of calcitonin.

1. Osteomyelitis is a risk factor for people with impaired immune systems. 2. Weight bearing activity is restricted to avoid stress on the affected bone. 3. Intravenous antibiotics will be administered for at least 3 to 6 weeks. 4. The affected extremity will be elevated.

Which assessment finding would the nurse expect in a client diagnosed with Paget's disease? 1. Severe back pain 2. Walking with a limp 3. Upper extremity grip weakness 4. A shuffled gait 5. Bow legged

1. Severe back pain 2. Walking with a limp 5. Bow legged

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? 1. When sitting, keep knees slightly lower than the hips. 2. Avoid movements that require spinal flexion with straight legs. 3. Squarely face the direction of anticipated movement. 4. Pivot to turn while holding an object. 5. Wear comfortable, low-heeled shoes.

2. Avoid movements that require spinal flexion with straight legs. 3. Squarely face the direction of anticipated movement. 4. Pivot to turn while holding an object. 5. Wear comfortable, low-heeled shoes. keep knees higher than hips when sitting

A client who is 34 weeks pregnant is admitted to the ob/gyn unit with a diagnosis of pregnancy induced hypertension. During the admission process, the client suddenly reports continuous abdominal pain and the nurse notes abdominal firmness. What interventions should the nurse implement? 1. Reassure client that the baby will be fine. 2. Evaluate fetal heart tones. 3. Monitor amount of vaginal bleeding. 4. Notify primary healthcare provider. 5. Prepare for vaginal delivery.

2. Evaluate fetal heart tones. 3. Monitor amount of vaginal bleeding. 4. Notify primary healthcare provider.

A client arrives to the emergency department after an altercation resulting in a knife wound to the abdomen. The nurse makes the following observation. Which intervention should the nurse perform? 1. Place the client in trendelenburg position. 2. Instruct the client to lie quietly in a low Fowler's position. 3. Apply abdominal binder to gently place the intestines back in the abdominal cavity. 4. Cover exposed intestine with sterile dressings moistened with sterile saline. 5. Notify the surgeon at once.

2. Instruct the client to lie quietly in a low Fowler's position. 4. Cover exposed intestine with sterile dressings moistened with sterile saline. 5. Notify the surgeon at once.

A child with a radial fracture reports itching below the casted area. What is the appropriate nursing action to relieve itching? 1. Allow the child to use a Q-tip to scratch the area. 2. Assess the fingers and areas above the cast to identify areas of irritation. 3. Apply an ice pack for 10-15 minutes. 4. Raise the cast above the level of the heart to reduce itching sensation.

3. Apply an ice pack for 10-15 minutes. (changes sensation, more common is cool setting on blow dryer) never stick anything down cast!

What information should a nurse include when preparing discharge education for a client diagnosed with gastroesophageal reflux disease (GERD)? 1. Foods that may trigger an attack include apple juice, cream cheese, and oatmeal. 2. Lose weight slowly at a rate of 1 kilogram per week. 3. Only eat three small meals per day. 4. Avoid tight-fitting clothing. 5. Wait at least 1 hour after eating to lie down.

2. Lose weight slowly at a rate of 1 kilogram per week. 4. Avoid tight-fitting clothing. (trigger foods: fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, caffeine wait at least 3 hours after eating 6 small meals a day)

A client who delivered a 9-pound 12-ounce (4.17 kg) baby 1 hour ago, has saturated 2 peri-pads in 15 minutes. Which nursing action should take priority? 1. Notify the primary healthcare provider. 2. Massage the fundus. 3. Obtain a blood pressure. 4. Begin an infusion of oxytocin.

2. Massage the fundus. (MUST stop the bleeding)

An elderly client with dementia is being admitted to a long-term care facility. When orienting the client to the environment, what is the most important action for the nurse to take? 1. Provide nurse's name upon entering client's room. 2. Show client how to use the call bell in the room. 3. Provide a tour of the facility and grounds. 4. Instruct client on the location of emergency exits.

2. Show client how to use the call bell in the room.

A client is seeing the obstetrician for a monthly checkup at 35 weeks. Vital signs are within normal limits but the nurse notes bilateral pedal edema. What statement by the nurse provides the most appropriate information to the client? 1. "Do not use any salt for your food." 2. "Cut your daily fluid intake in half." 3. "Sit and elevate feet above your heart." 4. "Request a prescription for a diuretic."

3. "Sit and elevate feet above your heart."

A client has been admitted with advanced cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs. (2.72 kg) since yesterday's measurements. Based on this data, what would be the nurse's priority assessment? 1. Stool for occult blood 2. Ammonia blood level 3. Blood pressure 4. Level of consciousness

3. Blood pressure (risk of FVD)

A client diagnosed with celiac disease has been prescribed a gluten-free diet. Which meal, if chosen by the client, would indicate to the nurse that the client understands this diet? 1. Cream based chicken soup 2. Breaded baked chicken with peas 3. Grilled catfish with mixed vegetables 4. Marinated talapia with green beans

3. Grilled catfish with mixed vegetables

Which postpartum client should the nurse assign to the last private room in the Women's Health Center? 1. Placenta abruption during delivery 22 hours ago 2. Boggy fundus five hours post-delivery 3. Pre-eclamptic prior to delivery 30 hours ago 4. WBC count is 12,000/mm3 (12 x 10^9​/L) at 24 hours postpartum

3. Pre-eclamptic prior to delivery 30 hours ago (stimulus can still induce seizures even after birth)

The house supervisor has sent an LPN to assist on a busy medical-surgical unit. Which client could the charge nurse assign to the LPN? 1. Being discharged with a new Hickman port. 2. With a deep vein thrombosis (DVT) on a heparin infusion. 3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home. 5. New transfer from post-anesthesia care unit (PACU) following a mastectomy.

3. Two-days post gastric bypass taking clear liquids. 4. With Alzheimer's disease awaiting transfer to nursing home.

Which client diagnosed with chronic peptic ulcer disease is at the highest risk for gastrointestinal bleeding? 1. 50 year old who consumes 4 ounces (120 mL) of wine at bedtime. 2. 55 year old who is positive for Helicobacter pylori (H. pylori). 3. 60 year old who requires corticosteroid inhalers for asthma. 4. 70 year old who takes clopidogrel daily for unstable angina.

4. 70 year old who takes clopidogrel daily for unstable angina.

The nurse has a prescription to calculate a client's body mass index (BMI). The client weighs 150 kgs and is 1.8 m tall. Determine the BMI to the whole number.

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