Final Prep 2

A client is scheduled to receive total parenteral nutrition (TPN). To administer TPN, which piece of equipment is important for the nurse to obtain?

Infusion pump

The nurse is caring for a client who reports having cloudy, foul-smelling urine. Which assessment question should the nurse ask the client?

"Are you experiencing burning and frequency?"

When a client reveals to a nurse during data collection that his stools are speckled, which appropriate question might the nurse ask the client?

"Do you frequently take antacids?"

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply.

"Do you use anything to help move your bowels?" "How often do you move your bowels?"

A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client makes which statement?

"I need to void after sexual intercourse to flush microorganisms away from my urethra."

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

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

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which scenario would she document?

"Ileostomy bag half filled with liquid feces."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"Let's review your medication history and whether you consume bladder irritants."

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

Which degree of edema will result in a 6-mm deep indentation upon pressure application? 4+ 3+ 2+ 1+

3+

The nurse is assessing several clients. Which client will require parenteral nutrition?

A client with severe malabsorption disorder

The client reports taking bisacodyl daily for several weeks and remains constipated. What are appropriate actions of the nurse? Select all that apply.

Ask the client about abdominal pain. Auscultate the abdomen for bowel sounds. Assess the client's diet and fluid intake. Question the client about the color, consistency, pattern, and shape of stools.

Which nursing intervention is the priority for client with stroke who is transitioning from the ED to other settings?

Assessing the level of consciousness

The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas buildup in the colostomy bag?

Baked beans

The nurse is caring for a client with frequent urinary tract infections (UTIs). What does the nurse include in the client's teaching plan to decrease the incidence of UTIs?

Be sure to urinate after sexual intercourse.

While obtaining the client's health history, which factor would the nurse identify that predisposes the client to type 2 diabetes?

Being 20 pounds overweight

Which treatment would the nurse suggest to an adolescent with type 1 diabetes if an insulin reaction is experienced while the adolescent is at a basketball game?

Buy a soda and hamburger to eat

A nurse is inserting an indwelling urethral catheter. Which action does the nurse take to prepare the client to cooperate during the insertion of a catheter?

Close the door and curtain and explain the procedure to the client.

The nurse cares for a client with a chronic neurologic condition that decreases the peristalsis. What nursing diagnosis is the most likely risk for this client?

Constipation

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

Contact the health care provider

The nurse assesses a clients intravenous (IV) site. Which clinical finding leads the nurse to conclude that the IV has infiltrated, rather than caused inflammation?

Coolness

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

Which is the action of anti diuretic hormine (ADH)?

Decreases water loss in urine

Which symptom is a known side effect of antibiotics?

Diarrhea

Which conclusion would the nurse make about the assessment finding of a client's very pale-yellow-colored urine?

Dilute urine

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply.

Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body.

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.

A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)?

Emptying a client's ileostomy appliance

A clients IV infiltrates. Which factor would the nurse recognise as the cause of the infiltration?

Failure to secure the catheter adequately

Which intervention would the nurse implement for a client who has type 1 diabetes and has an elevated blood glucose?

Give supplemental doses of regular insulin

Which hormone aids in regulating intestinal calcium and phosphorous absorption?

Glucocorticoids

The nurse performs dietary teaching for a client recently diagnosed with osteoporosis. Which lunch, chosen by the client, indicates to the nurse understanding of the teaching?

Grilled cheese sandwich on whole grain bread, spinach salad, milk

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching?

Having sexual relationships does not put a woman at risk for developing a UTI."

A client with terminal cancer is taking high doses of an opioid for pain. Which comfort measures should the nurse teach the client's family regarding how to manage elimination care?

Increase fiber in the diet.

Which assessment finding in a client signifies a mild form of hypocalcemia?

Numbness around the mouth.

A hospitalized child with type 1 diabetes becomes pale, diaphoretic, and shaky 2 hours after eating breakfast. Which action should the nurse take?

Obtain a current glucose level

A child is prescribed insulin glargine before breakfast. Which instruction is most appropriate for the nurse to give the parents regarding a bedtime snack?

Offer a snack to prevent hypoglycemia during the night

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 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium

Which cation regulates intracellular osmolarity?

Potassium

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?

The client returned from a foreign country 2 days ago.

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

The proliferation of Clostridium difficile causes:

antibiotic-associated diarrhea.

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

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.

black clay colored yellow

What is fecal occult blood?

blood that cannot be seen

A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume?

brown rice

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?

dark pink and moist

A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply.

hot tea with meals a turkey sandwich with whole-grain bread prune juice with breakfast

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L)

hypokalemia

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia.

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

inadequate intake of liquid

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency.

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

loses urine when a toilet is not readily available experiences accidental loss of urine when there is an urgent need to urinate urinates 20 times in 24 hours

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?

loss of urine without any identifiable pattern or warning

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping and tetany

A client has a prescription to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?

oral hygiene

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

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

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?

straight catheter

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention

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.

"The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care."

Which physiological alteration would be expected with a higher than normal red blood count?

Increased blood viscosity

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

Infants

The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply.

100 ml from melted ice chips serving of jello infusion of intravenous solution cup of ice cream

To be a universal recipient, a person must have which blood type?

AB

In which components of the nephron unit does furosemide decrease fluid reabsorption?

Loop of henle Distal tubules Proximal tubules

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

formed

A client is receiving furosemide to relieve edema. The nurse will monitor the client for which adverse effect?

Hypokalemia

The nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client. Which is the volume of solution that would be prepared?

Adolescents 500 -750ml 150-250 Infants 250-350 Toddlers 300-500 School age

Which gland is affected in aldosteronoma?

Adrenal cortex

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel?

Antidiarrheal agent

A home care nurse is visiting a client with renal failure 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.

Which collecting structure is collected at the end of the renal papilla?

Calyx

The nurse administers a parenteral preparation of potassium slowly to avoid which complication?

Cardiac arrest

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

The health care provider prescribes a blood transfusion for a client with esophageal varices. What should the nurse prioritize?

Check the clients vital signs Establish intravenous (IV) access with IV normal saline Verify the blood product with another nurse against the clients id bracelet Monitor the clients vital signs and status according to agency policy

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply.

Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily.

Upon removing the lid of a tray for a client who is lactose intolerant, the nurse discovers which food is not permitted in this client's diet?

Custard

A nurse is providing care to a client who has undergone a colonoscopy. What would be most appropriate for the nurse to do after the procedure?

Monitor for rectal bleeding.

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?

Muscle weakness, fatigue, and dysrhythmias

The nurse educator is providing information about different insulin types. Which type of insulin can be safely mixed with regular human insulin in the same syringe?

NPH

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.

Calcitonin actions are

Opposite to that of parathyroid hormone

An older adult client has a history of constipation and currently self-treats with over-the-counter laxatives. What education will the nurse provide the client regarding the use of laxatives? Select all that apply.

Oral laxatives take longer to work than laxatives administered rectally. Older adults are at a higher risk for laxative misuse and abuse. Rectal suppositories need to be retained in the rectum for at least 15 minutes. Incorporate high-fiber foods into the diet and increase fluid intake.

In which parts of the kidney are glucose and amino acids reabsorbed?

Proximal tubule

Which action is promoted by vasopressin?

Reabsorption of water

The nurse is educating a client about managing hypoglycemia unawareness. Which info will the nurse provide?

Refrain from alternative testing sites

A client who takes daily megadoses of vitamins is hospitalized with joint pain loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. Which toxicity would the nurse suspect?

Retinol (Vitamin A)

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?

Sacral area

The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edmea?

Shift of fluid into the interstitial spaces

The nurse is caring for an older adult client with diarrhea. Which finding is most important for the nurse to report to the health care provider?

Skin turgor response of 6 seconds

Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure?

Sodium

Which electrolyte deficiency triggers the secretion of renin?

Sodium

The nurse has assessed the client, analyzed the data, and identified constipation as a client problem. Which assessment data would support constipation? Select all that apply.

Stool is hard and has a consistency of small "marbles." Client reports frequency of daily bowel movements as every 3 to 4 days. Client states straining when having a bowel movement.

Twenty minutes after an infusion of packed red blood cells begins, the client complains of chest pain, difficulty breathing, and feeling cold. Which is the first action the nurse will take?

Stop the transfusion

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence?

Stress

A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise?

The client is dehydrated.

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 nurse is caring for a client who is being treated for bladder infection. The client reports to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition?

dysuria

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