NU 226 Exam 3 Practice Questions

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

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?

Sims

The primary extracellular electrolytes are:

sodium, chloride, bicarbonate

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus?

"Certain vegetables can cause flatus, as they are more difficult to digest."

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

Age 50 and older. A positive family history. A history of inflammatory bowel disease.

A client believes that the illness is caused by an imbalance of yin and yang. The nurse states, "You can call it whatever you believe, but you have a metabolic disorder." What is this nurse demonstrating?

Cultural blindness

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another spot.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound. Explanation: Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.

A nurse is reading a journal article about mood disorders in the older adult population. Which information about these conditions would the nurse expect to find? Select all that apply.

Depression is often misdiagnosed. Suicide is most serious consequence of depression. Symptoms often mimic those of other chronic cormorbidities of the older adult.

A 78-year-old woman is status post right hip fracture after a fall. She has stopped going to her church over the past few months. She has also asked her neighbor to help her and do her gardening, an activity she previously loved. The client tells the nurse "I just don't enjoy gardening like I used to. I am always worried about falling." What would most concern the nurse regarding the client?

Depression.

The nurse is caring for a client who does not speak the dominant language. In order to facilitate unencumbered communication with the client, the nurse will take which action(s)? Select all that apply.

Determine in which language the client communicates effectively. Review facility policy on communication with clients who do not speak the dominant language. Schedule a certified interpreter when collecting client health history.

A nurse is preparing to medicate an older adult client with an opioid analgesic. Which information will the nurse obtain first to decide about administering the medication?

Determining if the client is able to communicate pain verbally or nonverbally. Explanation: you can take vitals as a baseline or look for body ques.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site.

A client's spouse has asked that the client be cared for exclusively by female nurses. How should the nurse incorporate this request into the care plan?

Document the request and make all reasonable efforts to honor it

The middle adult is sometimes called the "sandwich generation". According to Erikson, the developmental task of the middle adult is what?

Generativity versus stagnation. Explanation: guiding the next generation, accepting their own changes and adjusting to need of aging parents, as well as evaluating their own goals and accomplishments.

The nurse is teaching a Black client about common health conditions. Which statement by the client most directly addresses a health problem with an increased incidence in this population group?

It is important to monitor my blood pressure

The staff nurse overhears the charge nurse, who is of Italian heritage, talking to the unlicensed assistive personnel. Which statement made by the charge nurse is an example of ethnocentrism?

Italians are best at everything

Which nursing action displays linguistic competence?

Learning pertinent words and phrases in the client's language

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?

Let me refer you to the blood bank so they can provide you with information

The nurse is reminiscing with a 72-year-old client with early onset dementia while providing care in a long-term care facility. How does the nurse implement this form of therapy to maximize the therapeutic value?

Listen to the client's stories and ask questions to facilitate ego integrity and provide companionship

A nurse is assessing middle-age adults living in a retirement community. What behavior would the nurse typically see in the middle-age adult?

Looks inward, accepts life span as having definite boundaries, and has special interest in spouse, friends, and community.

The nurse practitioner is examining a 55-year-old female client. Which of the following findings would be uncommon for this age group?

Lower extremity pulses are weak.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult

Which of the following assessment findings of a male client age 77 years should signal the nurse to a potentially pathologic finding, rather than a normal age-related change?

The client is oriented to person and place but is unsure of the month. Explanation: Age-related physiologic changes include a weakening of bladder emptying, presbycusis (hearing loss), and a slow gait that may be accompanied by stooped posture. Disorientation to time, however, should always prompt the nurse to perform further assessment

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

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess?

The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

A nurse is assigned to care for a client who does not speak the dominant language. An interpreter has been contacted and will be at the bedside shortly. Which action by the nurse would be most effective in reassuring the client until the interpreter arrives?

Using reassuring body language and making eye contact to assess needs

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

Very little scar tissue will form

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

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

brown rice

The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid?

brussel sprouts

Potassium is needed for neural, muscle, and:

cardiac function

A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct?

"I will administer enemas until the enema return is without stool."

Which statement best conveys the relationship between race and ethnicity?

Race denotes physical characteristics, while ethnicity is rooted in a common heritage

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?

As a stage I pressure injury

Which behaviors demonstrated by the client would the nurse consider reflections of the client's pride in ethnicity? Select all that apply.

Asking to wear unique clothing. Requesting native cuisine. Listening to folk music.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

Which behavior by the nurse is stereotyping?

Avoiding older adult clients because their care is time consuming

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

Banana

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 nurse is teaching a client with diarrhea about dietary management. Which teaching will the nurse include? Select all that apply.

Choose bland foods, such as cottage cheese. Bananas and applesauce are appropriate.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus. Explanation: Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching.

An older adult client who is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply.

Eat nourishing foods after surgery to promote healing. Monitor your moods after surgery. Depression after surgery is not normal. It may take you longer to heal than someone younger. Wound healing can take longer if you have been exposed often to the sun.

Erikson identified ego integrity vs. despair and disgust as the last stage of human development, which begins at about 60 years of age. Which intervention would best foster older clients' ego integrity?

Encouraging life review. Explanation: a way for an older adult to relive and restructure life experiences and is part of achieving ego integrity.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

Fish

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

Mineral oil enemas can interfere with absorption of fat-soluble vitamins.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

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

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?

Not wearing gloves when performing the intervention

A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take?

Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing

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

A family has immigrated and settled in a neighborhood that primarily speaks their native language. The nurse caring for this family recognizes that which family member will likely require the greatest amount of time to learn the dominant language?

The 45-year-old mother in the family who does not work outside the home

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway.

The nurse is caring for several clients of different cultures. Which client situation would the nurse recognize as the client with highest risk of culture shock?

The client from Ethiopia states, "All these machines attached to me scare me and I need to get them off."

A nursing student is studying the normal physiologic changes of older adults. The faculty member knows that the student comprehends the information when the student makes which statements? Select all that apply.

There is an increased sensitivity to glare. Fluids and electrolytes remain within normal findings. Height may decrease 1-3 in.

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

Wash it with a mild cleanser and water.

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

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

A nurse encourages residents of a long-term care facility to continue a similar pattern of behavior and activity that existed in their middle adulthood years to ensure healthy aging. This intervention is based on which aging theory?

identity-continuity theory. Explanation: theory assumes that healthy aging is related to the older adult's ability to continue similar patterns of behavior from young and middle adulthood.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

incision

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

intracellular

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?

left side-lying

A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the:

media

The nurse is caring for a client who is admitted for hypertension (HTN). The nurse notes that the client has not been eating the food provided, and family members have brought in homemade food. What would be the best response by the nurse?

Can you tell me what foods you prefer to eat and what your family is bringing you?

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside

The clinic nurse is obtaining demographic data from a client. The client states, "Why do you need to know what my ethnicity is?" How should the nurse respond?

Collecting this information allows us to develop a personalized plan of care to meet your needs.

A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response?

Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.

A nurse is preparing a presentation for a group of older adults about promoting safety while maintaining their mobility. Based on the nurse's understanding of factors placing the older adult at risk for falls, which area would the nurse most likely address? Select all that apply.

Environment hazards. Medication use. Diminished strength. Explanation: medications affecting balance, thinking, memory, and elimination; impaired vision; environmental hazards (e.g., slippery floors, throw rugs, poor lighting); decreased strength; loss of bone mass; and neurological and musculoskeletal problems.

A group of nursing students is reviewing information about the older adult and mobility. The students demonstrate a need for additional study when they identify which statement as accurate?

Falls are the leading cause of death due to injury in individuals who are over the age of 75 years. Explanation: This is FALSE because for people >65 years, falls are the leading cause of injury=death. Risk for falls= history of falls, fear, cognitive/ mood impairments, dizziness, functional impairments, and environmental hazards. Fear of falling and striving for independence. Medications and other complications.

A nurse is caring for an older adult client who has been confined to bed for several weeks following a fall. The client has been exhibiting symptoms of sundowner's syndrome. Which of the following are characteristics of sundowner's syndrome?

Feeling agitated and wakeful at night. Explanation: Awakening more frequently, requiring longer time to fall asleep, or napping during the daytime are a natural part of aging.

After graduation, if you especially want to care for the aged population, you would consider the nursing specialty that focuses on the health and illnesses of the aging. This specialty is:

Gerontologic nursing. Explanation: combines the knowledge and skills of nursing with specialized focus on the aging in both health and illness. Ex. hospice.

The nurse is assigned to care for a client age 87 years admitted to the medical unit for congestive heart failure. It is the fourth hospital day, and the response to treatment has been good. The client is no longer short of breath and the lung sounds are clearing. There is still a diet restriction of decreased sodium and fluids are limited to no more than 1000 mL per day. The nurse is preparing the client and family for discharge. The nurse's discharge education, in order to promote the older client's health, will include which instructions? Select all that apply.

Gradually increase activity as tolerated. Increased stress may interfere with recovery. Do not use the salt shaker at meals.

An older adult client is prescribed a sleep medication. When explaining the medication to the client, the nurse would emphasize which aspect of therapy?

Greatest effectiveness with short term use. Explanation: the medications may actually interfere with sleep and cause other adverse outcomes such as falls, confusion, and constipation

A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing?

Hemorrhoids

An older adult client comes to the health center reporting difficulty sleeping. Which statement by the client would the nurse need to address?

I find myself napping on and off throughout the day. Explanation: this can interfere with the client's ability to sleep at night. Avoiding activity after dinner, having a routine bedtime, and avoiding caffeine and alcohol are healthy sleep habits.

When describing the older adult's risk for infection, which aspect would the nurse most likely address? Select all that apply.

Inadequate nutrition. Lowered antibody responses. Decline in humoral immunity. Explanation: Humoral immunity declines because of changes in T-cell function, and older adults have lower antibody response to microorganisms that cause influenza and pneumonia. Inadequate nutrition and chronic illnesses adversely affect immunity.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?

Remove the IV catheter and reinsert another in a different location.

The spouse of a client asks the nurse whether the spouse may bring in a cream from home to apply to the client's skin. The spouse says, "Whenever anyone gets sick, we always use this cream." The nurse interprets this as:

Ritual

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

A client has been prescribed 2 units of packed red blood cells. A type and cross-match has been performed and the first unit has arrived on the floor from the blood bank. When administering this client's blood transfusion, the nurse should perform which actions? Select all that apply.

Start the administration slowly for the first 15 minutes of the transfusion.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes

The use of one's culture as a cultural standard is known as:

ethnocentrism

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?

foul-smelling drainage that is grayish in color

A nurse is performing a home assessment for a 90-year-old widower who lives in a third story apartment. The assessment reveals there are smoke alarm and carbon monoxide alarm systems; slip-proof surfaces in the bathtub and shower; no throw-rugs present; handrails on the steps; unlocked cabinets with potential poisons; adequate lighting; large flat screen TV on wall; and the water set at a safe temperature. As the nurse considers the client's home environment, what modification can be made to enhance safety for the client?

handrails in the bathroom

Persistent gaps between the health status of minorities and non-minorities are defined as:

health disparities

A client with renal disease requires IV fluids. It is important for the nurse to:

place the fluids on an electronic device

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing

The nurse is caring for a client admitted with an upper respiratory infection. The client tells the nurse about following the holistic belief of hot/cold. Which food items should the nurse provide to the client based on this information?

soup, hot tea and toast.

A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation?

stereotyping

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent