EAQ ~ Test 4 Practice

A client is admitted to the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery?

Whole bran

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client?

Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence.

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

A client with severe malabsorption disorder

A primary healthcare provider prescribes a urinalysis for a client with an indwelling catheter. To ensure that an appropriate specimen is obtained, the nurse would obtain the specimen from which site?

Tubing injection port

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?

Aspiration pneumonia

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

Constant bubbling in the water seal chamber

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response?

Invasion of privacy

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents?

Paralytic ileus

While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. The client also complains of urinary incontinence. Which nursing intervention is beneficial for the client?

Providing thorough perineal care after each voiding

A nurse is providing care to a client 8 hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon?

Urine output of 20 mL/hr

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?

"Wear cotton underpants."

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching?

Replace the drainage bag with a new bag once a week.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply.

Respiratory rate: 14 Blood pressure: 110/70 Oxygen saturation: 92%

A client has undergone pelvic surgery and the nurse removes the catheter in a week according to instructions. In the follow up within several hours, which finding in the client indicates a need for reinsertion of catheter?

Retention

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?

"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale."

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning?

"I will avoid draining urine from the tubing before ambulation."

A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. On physical examination, the nurse finds a smooth, firm, and enlarged prostate. The digital rectal examination report indicates enlargement of prostate tissue surrounding the urethra. Which condition does the nurse suspect in the client?

Benign prostatic hyperplasia (BPH)

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do?

Assess the client's condition per hospital protocol.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration?

Elevate the head of the bed between 30 and 45 degrees.

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention?

Oxygen Saturation: 89%

A client has a permanent sigmoid colostomy as a result of cancer of the rectum. The primary healthcare provider prescribes daily colostomy irrigations. What does the nurse explain is the primary purpose of these irrigations?

Establish a regular elimination schedule

A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery?

Limited water reabsorption caused by removal of intestine

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take?

Lower the height of the enema bag.

A client with colitis has had a hemicolectomy. Three days after surgery the nurse identifies that the client has abdominal distention and absent bowel sounds, and has vomited 300 mL of dark green viscous fluid. The nurse contacts the primary healthcare provider and recommends which intervention?

Nasogastric tube for decompression

The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI?

Prevent the development of clots in the bladder.

A client suspected to have a prostate disorder is encouraged to have a rectal examination. What position of the client will facilitate a rectal examination by the registered nurse (RN)?

Sims position

A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. What does the nurse include when teaching the client about the purpose of the antibiotics?

They are given to eliminate bacteria from the gastrointestinal (GI) tract.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

Tissue turgor