Foundations Quiz 2 study practice problems

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?" Medications and food may affect the color of stools. Antacids may cause speckling or a white discoloration. Anticoagulants may cause the stools to be light pink to red to almost black. Consuming large quantities of red meats may cause the stool to be almost black. Stools are light brown when consuming large amounts of milk and milk products along with a diet low in meats.

A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention?

"My favorite drink is coffee with sugar." Foods containing added sugar as a major ingredient tend to supply calories but few, if any, other nutrients. A client monitoring carbohydrate intake should be mindful of the intake of extra sugar.

The nurse is caring for a client who reports constipation and is presently in the bathroom attempting to have a bowel movement. The client presses the call bell and tells the nurse that about feeling dizzy. What education should the nurse provide the client about this condition?

"This occurs when bearing down and decreasing blood flow to the heart; when you stop, the blood flow will return in a larger amount." When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may cause the heart rate to slow and result in syncope in some clients.

A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? Select all that apply.

- Diminished ability of kidneys to concentrate urine may result in nocturia. - Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. - Decreased bladder contractility may lead to urine retention and stasis. - Neuromuscular problems may interfere with voluntary control of urination. - Altered thought processes may cause urinary frequency.

As a nurse is aspirating the contents during a tube feeding, the nurse finds that the tube is clogged. What would be appropriate nursing interventions in this situation? Select all that apply.

- Use warm water and gentle pressure to remove clog. - If necessary, replace the tube. - Ensure that adequate flushing is completed after each feeding.

A 40-year-old man has consumed a breakfast consisting of cereal, milk, orange juice, and coffee. His blood sugar in 2 hours is likely to be in what range?

140-180 mg/dL Normal blood glucose should be between 80 mg/dL and 110 mg/dL. Blood glucose 2 hours after a meal can rise to between 140 and 180 mg/dL, depending on the person's age.

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3 year old in croup tent An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated.

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?

Acute bronchitis Acute bronchitis is caused by inflammation. Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. This process causes a sensation of pain as air travels over those nerve endings. Clients with pneumonia often experience pain with deep breathing because each breath increases pressure on pain receptors that are already compressed and irritated by swollen, inflamed lung tissue. Coronary artery disease should be ruled out in anyone reporting chest pain, but Martin's sensation of burning in his airway with each breath is more suspicious for a respiratory issue. Emphysema is a more chronic illness that causes a slow progression of increasing shortness of breath. Martin is definitely at risk for emphysema but it would not explain his worsening shortness of breath over the last 2 days.

When assessing an elderly client for constipation the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation?

Affects absorption of fat soluble vitamins . Elderly clients who use mineral oil to prevent or relieve constipation need to be informed that prolonged use affects the absorption of fat-soluble vitamins such as A, D, E, and K.

The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed?

Apply steady, firm pressure on the puncture site for 5 to 15 minutes. Because the artery has been punctured, there is an increased risk for puncture site bleeding compared to venous blood draws. The nurse should apply steady, firm pressure on the puncture site for 5 to 15 minutes or until bleeding has completely stopped. An adhesive bandage should not be placed before bleeding is stopped. The blood specimen should be properly labeled; however, the priority for the nurse would be to ensure bleeding from the puncture site has stopped. Pressure should be applied prior to any extremity elevation.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial Blood Gas Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in this situation? Select all that apply.

Ask the client if he needs to pause before continuing insertion. Continue to advance tube when the client relates that he is ready. Have the emesis basin nearby in case client begins to vomit.

A nurse enters a client's room to perform a tube feeding. Which nursing action should be performed first?

Aspirate stomach contents and check pH. Nasogastric tube placement should be checked before flushing, giving medications, or feeding. After placement has been ensured, the gastric residual should be checked, the nasogastric tube should be flushed as ordered, and the tube feeding administered.

Prior to allowing a client to eat, which action is most important for the nurse to take?

Assess the client's level of consciousness. The most important thing the nurse can do is to ensure the client is alert enough to safely eat without aspirating.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included?

Assist the client to a normal voiding position when possible. Maintaining a normal voiding pattern would involve having privacy whenever possible, voiding once the urge is felt, and not waiting to urinate. Being in a normal voiding position is important for men and women.

A nurse is caring for a client who has a decrease in appetite. Which actions by the nurse would be appropriate?

Assist with oral hygiene before serving the meal tray. The client should be assisted with oral hygiene before serving the meal tray. This helps with the taste of the food.

A client is deficient in found to be deficient in vitamin K. What complications should the nurse closely assess for related to this deficiency?

Bleeding Tendencies A deficiency in vitamin K will cause bleeding tendencies related to the inability for the blood to clot appropriately.

When education a breast feeding mother on the characteristics of the stool of her newborn, the nurse should inform her that the stool will be

Bright Yellow If newborns are fed breast milk, the stools will be bright yellow, soft, and unformed with an unobjectionable odor.

A nurse provides discharge education for a client diagnosed with ketosis. Which nutrient would be added to this client's diet?.

Carbohydrates Ketosis is the catabolism of fatty acids that occurs when an individual's carbohydrate intake is not adequate; without adequate glucose, the catabolism is incomplete and ketones are formed, resulting in increased ketones. Proteins, fats, and minerals breakdown does not cause ketosis.

The client with dysphagia has a regular meal tray delivered at breakfast. Which is the best action for the nurse to take?

Check the medical record for the client's prescribed diet. The nurse ensures the client has received the correct meal tray. Often a client on a dysphagia diet will have a special diet that includes softer or pureed foods and thickened liquids that aren't available on the regular diet tray.

A nurse is providing home care instructions for a client who is being discharged to his home with a tracheostomy in place. Which statement accurately describes a guideline for care that should be included in the teaching plan?

Clean, rather than sterile, technique can be used in the home setting. Clean, rather than sterile technique, can be used in the home setting. The client and home caregiver should be instructed on how to perform tracheostomy care. Sterile saline can be made by mixing 1 teaspoon of table salt in 1 quart of water and boiling for 15 minutes. There is no need for the client to avoid humid locations.

A nurse is administering a client's large-volume enema. What assessment finding would indicate to the nurse that the solution is being administered too quickly?

Decrease in heart rate Rapid administration of a large-volume enema can precipitate a vagal response, resulting in decreased heart rate.

The nurse is administering magnesium citrate to a client with constipation. What mechanism of action would the nurse expect from this drug?

Drawing water into the intestines to stimulate peristalsis Magnesium citrate increases intestinal bulk by drawing water into the intestine and stimulating peristalsis. Chemical stimulation of peristalsis is promoted by stimulants such as bisacodyl. The stimulant promotes peristalsis by irritating the intestinal mucosa or stimulating nerve endings in the intestinal wall. Emollients such as mineral oil lubricate the intestinal tract and retard colonic absorption of water, softening the stool, and making it easier to pass. Bulk forming agents, such as psyllium husk, increase intestinal bulk to enhance mechanical stimulation of the intestine.

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)?

Ensure that the catheter is removed as soon as possible. To prevent UTIs, the nurse should leave the catheter in place for as short a time as possible. Strict aseptic technique is used for insertion, not clean technique. Frequent irrigation increases the risk of UTIs. For most clients with intact immune systems, prophylactic antibiotics are not used.

T/F A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable.

False Hypertonic solution preparations are available commercially and are administered in smaller volumes (adult, 70 to 130 ml). These solutions draw water into the colon, which stimulates the defecation reflex. Oil retention enemas lubricate the stool and intestinal mucosa, making defecation easier. About 150 to 200 ml of solution is administered to adults.

A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. How should the nurse document this condition?

Fecal impaction The client has fecal impaction because the large, hardened mass of stool is interfering with defecation. Iatrogenic constipation occurs as a consequence of other medical treatment. Secondary constipation is a consequence of a pathologic disorder. Fecal incontinence is the inability to control the elimination of stool.

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:

Fluid and Electrolyte levels Total parenteral nutrition (TPN) is nutrition administered through a central venous access and is high in nutrients and electrolytes. It is important to assess fluid and electrolyte levels with TPN infusions.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this?

Having the client sign a consent form for the procedure The client would sign a consent form for the procedure since it is invasive. This would be completed after the procedural health care provider had explained the purpose, risks, and benefits of the procedure.

Which principle should guide the nurse's collection of a fecal occult blood test?

If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. In a woman who is menstruating, the test should be postponed until 3 days after her period has ended. Before stool testing, the client should avoid the foods (for 4 days) and drugs (for 7 days) that may alter test results; there is no need to assess for a 2-week window. Stool softeners do not confound the results of testing. Results indicate the presence of blood, but not its source.

The nurse is caring for a client who has recently had a gastrostomy placed. The nurse's assessment reveals a small amount of leakage from around the appliance. The nurse should choose interventions primarily based on which nursing diagnosis?

Impaired Skin Integrity Leakage from a gastrostomy site poses a significant threat to the client's skin integrity, due to the low pH of gastric contents.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client?

Impaired Skin Integrity related to urinary bladder infection and dehydration

A home care nurse visits a client diagnosed with depression who informs the nurse that he has been prescribed amitriptyline. What would the nurse include when educating the client about the effects of this medication?

It causes urine to turn blue-green The nurse should inform the client that amitriptyline turns the urine blue-green.

The nurse is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action?

Milk the tubing to strip it of clots. When stationary clots are noted, a process of compressing and stripping of the tubing (known as milking) can be done. This should never be done routinely because it can cause high negative intrapleural pressure. Other answers are incorrect.

A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?

Nebulizer For a client with decreased cognition, a nebulizer may be more appropriate because the client passively inhales the entire dose

The nurse is caring for a client with a gastrostomy tube and notes a patchy, red rash at the insertion site. Which action would be most appropriate to address this concern?

Notify the health care provider for a prescription to apply an antifungal powder. If the skin has a patchy, red rash, the cause could be candidiasis (yeast). The nurse should notify the health care provider for a prescription to apply an antifungal powder.

A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?

One signal of preparedness is when your child is dry for at least 2 hours." A child is typically 2 to 3 years old before beginning toilet training, although this does depend on the culture. The child signals readiness by staying dry for longer periods, usually at least 2 hours.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?

Oxygen Hood An oxygen hood is a delivery device for infants that can deliver oxygen concentrations up to 80% to 90%.

The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action?

Perform respiratory assessment. As the nurse enters the room, the respiratory assessment immediately begins by visualizing the client's skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter, report findings to the health care provider, and document.

The nurse is using a large syringe to administer an intermittent feeding to a client who has a nasogastric feeding tube. Which method should the nurse use to increase the flow rate of the formula?

Raise the height of the syringe. Syringe feedings are infused via gravity. Raising the syringe will increase the rate of infusion.

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces?

Sigmoid colostomy Irrigations are infrequently used to promote regular evacuation of some colostomies. Various factors, such as the site of the colostomy in the colon (preferably the sigmoid colostomy where constipation occurs) and the client's and physician's preferences, determine whether a colostomy is to be irrigated.

When reviewing data collection on a client with constipation, which factor identified by the nurse might suggest the causative factor?

The client takes bisacodyl every day. Overusage of bisacodyl may cause lazy bowel syndrome, leading to constipation.

The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted?

The novice nurse asks the client to urinate before palpating the bladder. The urinary bladder cannot be palpated when empty, so the client should not urinate before the nurse palpates or percusses it.

The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply.

The nurse gently palpates the client's symphysis pubis. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). The nurse adjusts the scanner head to center the bladder image on the crossbars. To correctly use the ultrasound bladder scanner, the nurse would gently palpate the client's symphysis pubis. Palpation identifies the proper location and allows for correct placement of scanner head over the client's bladder. The nurse would place a generous amount of ultrasound gel midline on the client's abdomen. The gel is necessary to conduct the ultrasound waves for an accurate reading. The nurse would aim the scanner head toward the bladder. Failure to point the scanner in this direction will give erroneous results. The nurse would adjust the scanner head to center the bladder image on the crossbars. This step is necessary to record the most accurate results.

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply.

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply. Light Brown, Dark Brown

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider?

Thrill and Bruit The client is experiencing decreased circulation to the left arm that has an AV graft for hemodialysis. There is increased risk for the AV graft to clot and create a circulatory emergency. Obtaining a full set of vital signs would be indicated to evaluate overall status of the client; however, the health care provider would need to know if thrill and bruit are present over the AV graft. Absence of thrill and bruit is a medical emergency.

A nurse teaches a student nurse about the role fats play in the human body. What is the major storage form of fat?

Triglycerides Triglycerides are the predominant form of fat in food and the major storage form of fat in the body, composed of one glyceride molecule and three fatty acids.

The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed?

Urine culture sensitivity - 100,000/mL 100,000 organisms per milliliter in a urine culture and sensitivity specimen is positive of a urinary tract infection.

A nurse is teaching a client how to change his ostomy appliance. Which instructions should be incorporated into the teaching plan?

Use toilet tissue to remove any excess stool from the stoma. Excess stool may be removed from the stoma using toilet paper.

A 16-year-old adolescent informs her nurse that she became a vegetarian 1 year ago. Lately she is reporting fatigue and has trouble concentrating. A quick blood test ordered by her licensed provider informs the nurse that she has pernicious anemia. This is a deficiency of what vitamin?

Vitamin B12 deficiency is most commonly found in vegetarians, particularly in strict vegans. Individuals who have such rigid dietary restrictions must take care to supplement this vitamin.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril. The nasopharyngeal airway length is measured by holding the airway on the side of the client's face. The airway should reach from the tragus of the ear to the tip of the nostril.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

A nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema?

draws fluid from body tissues into the bowel A hypertonic saline enema draws fluid from body tissues into the bowel. A retention enema lubricates and softens the stool. A tap water and normal saline solution has a non-irritating effect on the rectum but moistens the stool. Soap solution enemas cause chemical irritation of the mucous membranes.

A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate?

functional Functional incontinence takes place when attempting to overcome obstacles, such as transferring from the wheelchair to the bed. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.

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 urinates 20 times in 24 hours experiences accidental loss of urine when there is an urgent need to urinate Losing urine when a toilet is not readily available, urinating more than eight times in a 24 hour period, and experiencing accidental loss of urine with urgency reflect urge urinary incontinence. Other answers do not reflect assessment data associated with urge urinary incontinence.

A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather?

mineral oil The nurse will gather a mineral oil solution, which is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue; hypertonic saline irritates local tissue and draws water into the bowel.

Which is a sign of dyspnea specific to infants?

nasal flaring In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 high; PaCO2 high

The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will:

urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." The client accurately details the steps of the procedure except the nurse needs to further instruct the client that the client needs to void a small amount of urine into the toilet and then stop urination for a short time and then void around 3 to 5 mL into the cup.