NSG 3100 Exam 3 Test Your Knowledge

7) The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information? 1. Fasting blood glucose 2. Capillary blood specimen 3. Glycosylated hemoglobin 4. GGT (gamma-glutamyl transferase)

Answer: 3. Rationale: A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options 1 and 2 will provide information about the current blood glucose, not the past history. Option 4 is used to assess for liver disease. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 34-2

7) An older client with renal insufficiency is to receive a cardiac medication. Which is the nurse most likely to administer? 1. A decreased dosage 2. The standard dosage 3. An increased dosage 4. Divided dosages

Answer: 1. Rationale: Due to renal insufficiency, the dose of the medication would need to be decreased in order to avoid accumulation of the medication and the risk of toxicity. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 35-12.

8) Proper administration of an otic medication to a 2-year-old client includes which of the following? 1. Pull the ear straight back. 2. Pull the ear down and back. 3. Pull the ear up and back. 4. Pull the ear straight upward.

Answer: 2. Rationale: To straighten the ear canal in children less than 3 years of age, the ear must be pulled down and back. In individuals over 3 years of age, the ear is pulled up and back. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-20c.

9) A primary care provider writes a prescription for 0.15 milligram of digoxin intravenously every day. The medication is available in a concentration of 400 micrograms per mL. How many mL will the nurse administer?

Answer: 0.375 or rounded to 0.38 mL. Rationale: After converting to like numbers, the formula would be set up as follows: 400 micrograms = 1 mL 150 micrograms = X mL Cross multiply (400 X = 150) Divide by 400 X = 0.375 Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-9.

6) During an assessment, the nurse learns that the client has a history of liver disease. Which diagnostic tests might be indicated for this client? Select all that apply. 1. Alanine aminotransferase (ALT) 2. Myoglobin 3. Cholesterol 4. Ammonia 5. Brain natriuretic peptide or B-type natriuretic peptide (BNP)

Answer: 1 and 4. Rationale: ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver. The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-2.

2) During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. 1. Perineal skin irritation 2. Fluid intake of less than 1,500 mL/day 3. History of antihistamine intake 4. History of frequent urinary tract infections 5. A fecal impaction

Answer: 1, 2, 4, and 5. Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1,500 mL/day and clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 48-4

9) Which nursing diagnoses is/are most applicable to a client with fecal incontinence? Select all that apply. 1. Bowel Incontinence 2. Risk for Deficient Fluid Volume 3. Disturbed Body Image 4. Social Isolation 5. Risk for Impaired Skin Integrity

Answer: 1, 3, 4, and 5. Rationale: Option 1 is the most appropriate. The client is unable to decide when stool evacuation will occur. In option 3, client thoughts about self may be altered if unable to control stool evacuation. In option 4, client may not feel as comfortable around others. In option 5, increased tissue contact with fecal material may result in impairment. Option 2 is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Diagnosis. Learning Outcome: 49-6.

3) The primary care provider prescribed 5 mL of a medication to be given deep intramuscular for a 40-year-old female who is 5′7″ tall and weighs 135 pounds. Which is the most appropriate equipment for the nurse to use? Select all that apply. 1. Two 3-mL syringes 2. One 5-mL syringe 3. A #20-#23 gauge needle 4. A 1-inch needle 5. A 1 1/2-inch needle

Answer: 1, 3, and 5. Rationale: Five milliliters is too large an amount to inject into one site. The nurse needs to divide the amount into two 2.5-mL injections. A 3-mL syringe could be used (option 1). The length of the needle will depend on the muscle development of the client. The nurse needs to assess the client. The presumption, based on the information provided, is that this client's muscle mass is within normal limits. The needle length would need to be 1 1/2 inches because the medication is ordered to be given "deep IM" (option 5). This also suggests that the medication should be given in the preferred site for IM injections—the ventrogluteal site—because it provides the greatest thickness of gluteal muscle. The gauge of the needle for an IM injection into the ventrogluteal muscle can range between #20 and #23 (option 3). The nurse needs to assess the viscosity of the medication. Smaller gauges (e.g., #23) produce less tissue trauma; however, viscous solutions may require a larger gauge (e.g., #20-#21). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-5.

5) The nurse is to administer a tuberculin test to a client who is 6 feet tall and weighs 180 pounds. Which is the most appropriate for the nurse to use? 1. A tuberculin syringe, #25-#27 gauge, 1/4- to 5/8-inch needle 2. Two 3-mL syringes, #20-#23 gauge, 1 1/2-inch needle 3. 2-mL syringe, #25 gauge, 5/8-inch needle 4. 2-mL syringe, #20-#23 gauge, 1-inch needle

Answer: 1. Rationale: A tuberculin test is given by intradermal injection. A tuberculin syringe is used because the dosage will most likely be 0.1 mL. A short, fine needle is needed to avoid entering the subcutaneous tissue. The needle should have a short bevel and usually be between #25 and #27 gauge. The needle should be between 1/4 to 5/8 inch long. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-18a.

1) Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? 1. Constipation 2. Diarrhea 3. Incontinence 4. Hemorrhoids

Answer: 1. Rationale: Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result—if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool (option 2). Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence (option 3). Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool (option 4). Cognitive Level: Understanding. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 49-1.

4) The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? 1. Leaves the catheter in place and gets a new sterile catheter. 2. Leaves the catheter in place and asks another nurse to attempt the procedure. 3. Removes the catheter and redirects it to the urinary meatus. 4. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

Answer: 1. Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 48-10b.

7) A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. 1. Limit fluids to avoid the burning sensation on urination. 2. Review symptoms of UTI with the client. 3. Wipe the perineal area from back to front. 4. Wear cotton underclothes. 5. Take baths rather than showers.

Answer: 2 and 4. Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of area to bacteria (option 5). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Implementation. Learning Outcome: 48-7.

10) Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. 1. Voids each time there is an urge. 2. Practices slow, deep breathing until the urge decreases. 3. Uses adult diapers, for "just in case." 4. Drinks citrus juices and carbonated beverages. 5. Performs pelvic muscle exercises.

Answer: 2 and 5. Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the BEST indicator of a successful program (option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4). Cognitive Level: Applying. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 48-6.

8) The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply. 1. Mixes the reagent with the stool sample before applying to the card. 2. Collects a sample from two different areas of the stool specimen. 3. Assesses for a blue color change. 4. Asks a colleague to verify the pink color results. 5. Asks the client if he has taken vitamin C in the past few days.

Answer: 2, 3, and 5. Rationale: The nurse should obtain the stool specimen from two different areas of the stool. The nurse should observe for a blue color change, which is indicative of a positive result. The nurse should assess for the ingestion of vitamin C by the client because it is ontraindicated for 3 days prior to taking the specimen. Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 34-5.

10) The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply. 1. Collect the specimen in the evening. 2. Send the specimen immediately to the laboratory. 3. Ask the client to spit into the sputum container. 4. Offer mouth care before and after collection of the sputum specimen. 5. Collect a specimen for 3 consecutive days.

Answer: 2, 4, and 5. Rationale: The sputum specimen should be sent immediately to the laboratory. The client should be provided mouth care before and after the specimen is collected. The sputum specimen should be collected for three consecutive days. Option 1 is incorrect because the sputum specimen is collected in the morning not in the evening. Option 3 is incorrect because the term spit indicates that saliva is being examined. The client needs to cough up or expectorate mucus or sputum. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-7.

3) The client has a urinary health problem. Which procedure is performed using indirect visualization? 1. Intravenous pyelography (IVP) 2. Kidneys, ureter, bladder (KUB) 3. Retrograde pyelography 4. Cystoscopy

Answer: 2. Rationale: A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cystoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-8

1) A client tells the nurse, "This pill is a different color than the one that I usually take at home." Which is the best response by the nurse? 1. "Go ahead and take your medicine." 2. "I will recheck your medication orders." 3. "Maybe the doctor ordered a different medication." 4. "I'll leave the pill here while I check with the doctor."

Answer: 2. Rationale: If there is any doubt, the medication administration process should be interrupted until the question is clarified. Listen to the client. Find out any other information the client may have about that certain medication. For example, does he know the dosage of the medication taken at home? Do not administer the medication (option 1). Inform the client that you will check the chart first. Review the chart to make sure there is no discrepancy between the physician's order and the MAR. Review the physician's progress notes because the medication may have been increased or reduced as part of the treatment plan (option 3). Check with the pharmacist because sometimes a pill may be a different color or shape based on the pharmaceutical company. Do not leave medications at the bedside. Medications should never be left unattended (option 4). Inform the client of your findings. The client will appreciate that you took the time to make sure that he received the correct medication. While it takes time to check out the client's statement, you will be glad that you avoided a potential medication error. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-11.

5) Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? 1. The client will wear a medical alert bracelet for antibiotic allergy. 2. The client will return to his or her previous fecal elimination pattern. 3. The client will verbalize the need to take an antidiarrheal medication prn. 4. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

Answer: 2. Rationale: Once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of overgrowth of bowel organisms not killed by the drug (option 1). Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock (option 3). Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not (option 4). Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 49-6.

1) The nurse would call the primary care provider immediately for which laboratory result? 1. Hgb = 16 g/dL for a male client 2. Hct = 22% for a female client 3. WBC = 9 × 103/mL3 4. Platelets = 300 × 103/mL3

Answer: 2. Rationale: Option 2 is very low and can lead to death. The client's red blood cells participate in oxygenation. Options 1, 3, and 4 are within normal range and should not be reported to the primary care provider. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-3.

6) A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? 1. Prepare to irrigate the colostomy. 2. After assessing the stoma and surrounding skin, notify the surgeon. 3. Assess bowel sounds and administer antiemetic. 4. Administer a bulk-forming laxative, and encourage increased fluids and exercise.

Answer: 2. Rationale: The client has assessment findings consistent with complications of surgery. Option 1: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option 3: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetics are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option 4: Administering a bulk-forming laxative to a nauseated postoperative client is contraindicated. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 49-6.

8) The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? 1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy

Answer: 2. Rationale: The ileal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 48-9.

3) Which action represents the appropriate nursing management of a client wearing a condom catheter? 1. Ensure that the tip of the penis fits snugly against the end of the condom. 2. Check the penis for adequate circulation 30 minutes after applying. 3. Change the condom every 8 hours. 4. Tape the collecting tubing to the lower abdomen.

Answer: 2. Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight. A 1-in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bag (option 4). An indwelling catheter is secured to the lower abdomen or upper thigh. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 48-10a.

9) A primary care provider is going to perform a thoracentesis. The nurse's role will include which action? 1. Place the client supine in the Trendelenburg position. 2. Position the client in a seated position with elbows on the overbed table. 3. Instruct the UAP to measure vital signs. 4. Administer an opioid analgesic

Answer: 2. Rationale: The puncture site is usually on the posterior chest. The client should be positioned leaning forward. This will allow the ribs to separate for exposure of the site. Option 1 is incorrect. The client should not be placed in the Trendelenburg position because the site would not be exposed. Option 3 is incorrect since changes in vital signs do not routinely occur with this procedure. Option 4 is incorrect. The client does not need to be medicated for pain with this procedure. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 34-10

2) Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1. "I need to drink one and a half to two quarts of liquid each day." 2. "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." 3. "If my bowel pattern changes on its own, I should call you." 4. "Eating my meals at regular times is likely to result in regular bowel movements."

Answer: 2. Rationale: The standard of practice in assisting older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults (option 2). In addition, a normal stool pattern for an older adult may not be daily elimination. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 49-3.

10) A nursing student is preparing to administer insulin to a client with diabetes. Indicate the correct order for the administration of this medication: 1. Cleanse the site with alcohol. 2. Insert the needle quickly into the subcutaneous tissue. 3. Mix the insulins. 4. Assess the skin for the injection. 5. Pinch the skin lightly. 6. Inject the medication. 7. Count to five. 8. Remove the syringe. Correct sequence: _______________

Answer: 3, 4, 1, 5, 2, 6, 7, and 8. Rationale: This is the correct order for this skill—first the nurse mixes the insulin, assesses the skin, and cleanses the skin. The nurse would then pinch the skin, insert the needle, inject the medication, count to five, and remove the syringe. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-18b.

4) The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? 1. The stoma extends 1/2 in. above the abdomen. 2. The skin under the appliance looks red briefly after removing the appliance. 3. The stoma color is a deep red-purple. 4. The ascending colostomy delivers liquid feces.

Answer: 3. Rationale: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink/red for a while after the adhesive is pulled off. Feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 49-9.

9) Which focus is the nurse most likely to teach for a client with a flaccid bladder? 1. Habit training: Attempt voiding at specific time periods. 2. Bladder training: Delay voiding according to a preschedule timetable. 3. Credé's maneuver: Apply gentle manual pressure to the lower abdomen. 4. Kegel exercises: Contract the pelvic muscles.

Answer: 3. Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 48-9.

8) Which of the following is most likely to validate that a client is experiencing intestinal bleeding? 1. Large quantities of fat mixed with pale yellow liquid stool 2. Brown, formed stools 3. Semisoft black-colored stools 4. Narrow, pencil-shaped stool

Answer: 3. Rationale: Blood in the upper GI tract is black and tarry. Option 1 can be a sign of malabsorption in an infant, option 2 is normal stool, and option 4 is characteristic of an obstructive condition of the rectum. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 49-2.

5) When assisting with a bone marrow biopsy, the nurse should take which action? 1. Assist the client to a right side-lying position after the procedure. 2. Observe for signs of dyspnea, pallor, and coughing. 3. Assess for bleeding and hematoma formation for several days after the procedure. 4. Stand in front of the client and support the back of the neck and knees.

Answer: 3. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-10

2) A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important? 1. Instruct the client to empty his bladder and save this voiding to start the collection. 2. Instruct the client to use sterile individual containers to collect the urine. 3. Post a sign stating "Save All Urine" in the bathroom. 4. Keep the urine specimen in the refrigerator.

Answer: 3. Rationale: Option 3 is the most important nursing measure. This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the first voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterile, and one container is needed—not individual containers. Option 4 is inappropriate because some 24-hour urine collections do not require refrigeration. Cognitive Level: Understanding. Client Need: Physiological Integrity.Nursing Process: Implementation. Learning Outcome: 34-6.

5) Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? 1. "I will keep the collecting bag below the level of the bladder at all times." 2. "Intake of cranberry juice may help decrease the risk of infection." 3. "Soaking in a warm tub bath may ease the irritation associated with the catheter." 4. "I should use clean technique when emptying the collecting bag."

Answer: 3. Rationale: Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (option 1). Intake of cranberry juice creates an environment that inhibits infection (option 2). Clean technique is appropriate for touching the exterior portions of the system (option 4). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Evaluation. Learning Outcome: 48-7.

4) The nurse is to administer 0.75 mL of medication subcutaneously in the upper arm to a 300-pound adult client. The nurse can grasp approximately 2 inches of the client's tissue at the upper arm. Which is the most appropriate for the nurse to use? 1. A tuberculin syringe, #25-#27 gauge, 1/4- to 5/8-inch needle 2. Two 3-mL syringes, #20-#23 gauge, 1 1/2-inch needle 3. 2-mL syringe, #25 gauge, 5/8-inch needle 4. 2-mL syringe, #20-#23 gauge, 1-inch needle

Answer: 3. Rationale: The type of syringe for subcutaneous injections depends on the medication to be given. This situation does not indicate that the medication is insulin and, thus, another syringe is needed. Generally a 2-mL syringe is used for most subcutaneous injections. Generally, a #20- to #23-gauge needle is used for IM injections. Needle size and length are based on the client's body mass, the intended angle of insertion, and the site of the injection. Generally, a #25-gauge, 5/8-inch needle is used for adults of normal weight and the needle is inserted at a 45° angle. Because 2 inches of tissue can be grasped or pinched at the site of the injection, the nurse should administer the medication at a 90° angle to ensure the medication reaches subcutaneous tissue. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 35-18b.

7) The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? 1. Soapsuds 2. Retention 3. Return flow 4. Oil retention

Answer: 3. Rationale: This provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage constipation and do not provide flatus relief. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 49-8.

6) The nurse is to administer 0.5 mL of a medication by intramuscular injection to an older emaciated client. Which is the most appropriate for the nurse to use? 1. A tuberculin syringe, #25-#27 gauge, 1/4- to 5/8-inch needle 2. Two 3-mL syringes, #20-#23 gauge, 1 1/2-inch needle 3. 2-mL syringe, #25 gauge, 5/8-inch needle 4. 2-mL syringe, #20-#23 gauge, 1-inch needle

Answer: 4. Rationale: If the nurse goes by the amount of the medication (0.5 mL) only, the deltoid muscle would be the site. However, knowing and assessing the client is critical. The muscles of an older, emaciated client will most likely be diminished or atrophied. The nurse should consider the ventrogluteal site because that site will have the most muscle mass. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcomes: 35-17c; 35-12.

2) The following medications are listed on a client's medication administration record (MAR). Which medication order should the nurse question? 1. Lasix 40 mg, po, STAT 2. Ampicillin 500 mg, q6h, IVPB 3. Humulin L (Lente) insulin 36 units, subcutaneously, every morning before breakfast 4. Codeine q4-6h, po, prn for pain

Answer: 4. Rationale: Options 1, 2, and 3 are written appropriately. Option 4 is incorrect because the dosage is missing from this order. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 35-6.

3) A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? 1. Oil retention 2. Return flow 3. High, large volume 4. Low, small volume

Answer: 4. Rationale: Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option 1). Return flow enemas help expel flatus (option 2). Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used (option 3). Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Planning. Learning Outcome: 49-8.

1) The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? 1. The bladder distends and its capacity increases. 2. Older adults ignore the need to void. 3. Urine becomes more concentrated. 4. The amount of urine retained after voiding increases.

Answer: 4. Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3). Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 48-2.

6) During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? 1. Stress Urinary Incontinence 2. Reflex Urinary Incontinence 3. Functional Urinary Incontinence 4. Urge Urinary Incontinence

Answer: 4. Rationale: The key phrase is "the urge to void." Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Diagnosis. Learning Outcome: 48-6.

4) Which noninvasive procedure provides information about the physiology or function of an organ? 1. Angiography 2. Computerized tomography (CT) 3. Magnetic resonance imaging (MRI) 4. Positron emission tomography (PET)

Answer: 4. Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-9

10) A student nurse is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site?

Answer: 5. Rationale: Option 5 is a sigmoidostomy site. Option 1 is an ileostomy site, option 2 is ascending colostomy, option 3 is transverse colostomy, and option 4 is descending colostomy. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 49-9.