Fundamentals of Nursing Care-Practice Test

The nurse is assessing for correct placement of a NG tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct placement with a pH of?

3.5 (should be 5.5 or lower)

On assessment of a patient with a colostomy, you note the stoma is located on the right lower quadrant. Due to its location, this is known as what type of colostomy?

Ascending colostomy

The nurse is caring for a client with cancer who is neutropenic. Which plan would be inappropriate?

Avoid any spicy foods.

Your patient is NPO and receiving continuous tube feeding via PEG tube. All of the following are appropriate nursing actions EXCEPT.

Check blood sugar AC/HS -It should be q6h

A nurse is caring for a client scheduled for a CT scan with contrast. Which action is most appropriate?

Checking the client's creatinine level

When assessing a client's skin, the nurse observes a deep purple discoloration on the heel. Skin is intact, how will the nurse document this finding?

Deep Tissue Pressure Injury

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding?

Deep tissue injury

Mrs. D returns from surgery with a new colostomy. The nurse assesses the stoma and note that it is red and edematous. What is the best nursing action based on this finding?

Document the findings

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

A patient with diabetes mellitus self monitors blood sugar at home. Now the primary care provider wants to assess the client's average blood sugar over a 3-month period. The best test for this would be:

Hemoglobin A1C

A client who is weak, dyspneic, and jaundiced has an elevated bilirubin level. With which problem are these clinical findings consistent?

Hemolytic anemia

The nurse is preparing to insert a NG tube into a client. What position should the client be in?

High fowlers

A patient with atrial fibrillation is receiving warfarin (Coumadin) 5 mg each day. His INR today is 2.4 (N= 0.8-1.2). What is the expected change in medication dosage?

His INR is within desired range. No change in warfarin dose is needed.

Thinking back to the patient with the ascending colostomy, what kind of stool would the stoma be excreting?

Liquid stool

The nurse is reviewing the arterial blood gas (ABG) values of a client and notes that the pH is 7.31, Pco2is 50 mm Hg, and the bicarbonate (HCO3) level is 27 mEq/L. The nurse concludes that which acid-base disturbance is present in this client?

Respiratory acidosis

What does the image indicate?

Stage 2 ulcer

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings

pH 7.25, Pco2 50 mm Hg

While a client is receiving TPN, it is MOST important for the nurse to monitor

serum glucose and electrolytes.

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter?

transparent film

Matching: 1) Protein responsible for osmotic/oncotic pressure 2) Breakdown of hemoglobin 3) Estimate of Renal function A) GFR B) Bilirubin C) Albumin

1) C 2) B 3) A

The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, "I'm upset because I know I won't be able to have children", which response is best?

"Having an ileostomy doesn't necessarily mean you cannot bear children. Let's talk about your concerns"

A client is admitted to the ER w/ a diagnosis of acute MI. The client tells the nurse, "I am scared I think I am going to die". What is the most appropriate response?

"It is normal to feel frightened. We are doing everything we can for you"

Prior to being transported to the surgery suite, the nurse asks the client whether the client has any allergies. The client responds, "Does anyone communicate with anyone? I've been asked that question over and over!" What is the nurse's best response?

"This question is asked for verification and safety with each new phase of treatment."

A pt is diagnosed with terminal cancer says to the nurse, "I am going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all I am the one who's dying." Which response by the nurse is therapeutic?

"You're feeling angry that your family continues to hope for you to be cured?"

An outpatient care nurse is providing instructions to a patient who is scheduled for a colonoscopy to remove a polyp. Which instructions are appropriate for client preparation for this procedure?

A bowel preparation will be required in preparation for the procedure.

A client is one day post-op following a transverse loop colostomy. Which assessment finding would be indicative of a complication?

A dusky color to the stoma

A Muslim female client has been stabilized after an assault in the parking lot of a local restaurant. The nurse manager is making assignments for the oncoming shift. Which action by the nurse manager is the most appropriate to ensure the client's comfort?

Assign the client a female nurse for every shift.

A nurse is planning care for an older adult with a pressure ulcer. What should the nurse do?

Cover with protective dressing, reposition q2h, request an alternating pressure mattress

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do?

Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client's CO2 level rises, what will occur with the blood pH?

Fall

The nurse is caring for a child with neutropenia. Which beverage is unsuitable for the client with a low neutrophil count?

Fresh squeezed lemonade

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer?

Full-thickness skin loss involving damage to subcutaneous tissue

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN?

Handle TPN using strict aseptic technique.

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses?

Increased blood viscosity (increased RBC->increased solute and decreased solvent)

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which action by the home health aide indicates understanding about the nursing team's responsibility in relation to pressure ulcers?

Inspecting the skin daily

How should the nurse determine the length of the NG tube to be inserted?

Measure from the nose to the earlobe to the xiphoid process

A client with diabetes mellitus has a blood glucose level on admission of 596 mg/dL. The nurse should anticipate that this client could be experiencing which type of acid-base imbalance?

Metabolic acidosis

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Metabolic alkalosis

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 86 mm Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which result?

Normal results

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

Partial-thickness skin loss of the dermis

NG or naso-enteric tubes are used for all of the following purposes EXCEPT

Permanently feeding patients

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to2 hours?

Prevent pressure ulcers

Sitz baths are prescribed for a client with an inflamed painful hemorrhoid. How do the sitz baths aid the healing process?

Promoting vasodilation

The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs?

Protruding stoma

A nurse reviews a client's arterial blood gas values and notes a pH of 7.50, a Pco2 of 30 mm Hg, and an HCO3 of 25 mEq/L. The nurse should interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema?

Sims

A 67-year-old man is admitted with an embolic stroke and is started on a heparin drip w/in 2 hours. Six hours later, the aPTT is greater than 120. The nurse should

Stop the Heparin

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving?

The patient's ammonia level decreased from 160 to 120 mg/dL.

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

This is a normal, expected event.

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions?

This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.

Before administering an intermittent enteral feeding through an NG tube, the nurse assess' for residual. Why is this important?

To evaluate absorption of the last feeding

A patient has had colon surgery as a result of an intestinal obstruction. Which is a method of delivering nutrition that avoids the gut?

Total parenteral nutrition (TPN)

True/False: Symptoms of hypoglycemia include excessive hunger, fatigue, excessive sweating, and shakiness

True

Which of following interventions would a nurse utilize for a patient with thrombocytopenia?

Use an electric razor when shaving and avoid taking rectal temperature