Foundations II: Review for Exam 1

The nurse is providing education about nutrition and feeding to the parent of a toddler. Which statement by the child's parent indicates understanding of the education?

"Boiled eggs and pieces of cheese are good snacks for my child."

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

At what period of life do nutrient needs stabilize?

Adulthood

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

__________ is used to screen for weight categories that can lead to health problems.

BMI

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. What education point follows recommended guidelines?

Be sure to shake the canister before using it.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. What guideline is recommended for this procedure?

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?

Blood from the fingertips shows changes in glucose more quickly than other testing sites.

A nurse is caring for an older adult client in the home. The nurse concludes that the client needs an X-ray to determine whether the client has pneumonia and requires oxygen for shortness of breath. The nurse calls to inform the physician of the client's status and then makes arrangements to carry out the physician's orders. In this scenario, what role does the nurse play?

Case manager

A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse?

Check oxygen saturation level.

Which nursing action associated with successful tube feedings follows recommended guidelines?

Check the residual before each feeding or every 4 to 6 hours during a continuous feeding.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?

Collect 15 to 30 mL of the client's liquid stool.

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

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

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

What dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure?

Ensure that the client fasts 6 to 12 hours before the test as per policy.

Mona Hernandez complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond?

Even short activities such as moving to the chair will help you cough mucus out of your lungs.

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. What action should the nurse recommend?

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. What suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

The nurse is irrigating a nasogastric tube attached to suction and finds that the flush solution is meeting a lot of force when the plunger is pushed. What would be the nurse's first intervention in this situation?

Inject 20 to 30 mL of free air into the abdomen in attempt to reposition the tube and enable flushing of the tube.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

The nurse titrates the patient's oxygen to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per the provider's orders. What is the rationale for this order?

Oxygen administration decreases respiratory and cardiac workload and offers increased oxygenation to meet metabolic demands.

A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?

Plans to eat a snack of fruit twice per day.

Mona Hernandez's blood gas results indicate respiratory acidosis. Her oxygen saturation is 95% per the pulse oximeter. Which interventions should the nurse provide? (Select all that apply.)

Promote voluntary coughing activities to clear secretions., Ensure the patient is well hydrated., Assist the patient with adequate ventilation., Provide supplemental oxygen as ordered.

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

Sims

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily.

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

The NG tube is in the client's airway.

A patient states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer?

The incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis.

An older adult client informs the nurse that foods don't taste or smell the same and eating is a chore. What suggestion can the nurse provide to the client to address this age-related change?

Try eating foods that are attractive and at the proper temperature.

The client reports to the nurse that she feels as if her eyes are persistently dry. This symptom is consistent with a deficiency in which dietary element?

Vitamin A

What factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet?

a diet lacking in fruits and vegetables

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:

apnea.

A client reports experiencing uncomfortable, frequent episodes of flatulence to the nurse. Which foods will the nurse recommend that the client avoid? Select all that apply.

cucumbers, lentils, onions, cabbage

What is the most common side effect of antibiotics?

diarrhea

Oxygen and carbon dioxide move between the alveoli and the blood by:

diffusion

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?

distilled water

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 patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up what test results?

hemoglobin Rationale: A pulse oximeter measures the oxygen saturation of hemoglobin. A patient's hemoglobin may be adequately saturated with oxygen, but if they have low hemoglobin, they might not have enough oxygen to meet demands.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

hypoxia

If your BMI is 30.0 or higher, it falls within the __________ range.

obesity

If your BMI is 25.0 to <30, it falls within the __________ range.

overweight

Anywhere from 44,000 to 98,000 people are estimated to die in U.S. hospitals each year as a result of __________.

preventable medical errors

A client whose neuropathic pain requires multiple doses of opioids each day would require interventions in order to maintain what?

regular bowel patterns

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

sigmoid colostomy

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?

the enema removing hardened fecal impactions from the rectum

If your BMI is less than 18.5, it falls within the __________ range.

underweight

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. What foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?

whole wheat spaghetti and broccoli

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be:

yellow.

A nurse is caring for a client recovering from abdominal surgery who is experiencing paralytic ileus. The client has a nasogastric tube connected to suction. How often should the nurse irrigate this tube?

Every 4-8 hours

Expected assessment findings of a patient with pneumonia may include which of the following? (Select all that apply.)

Fever, Malaise, Tachypnea, Use of accessory muscles

A client has a complex medical history related to the consequences of diabetes. As a result of having diabetic nephropathy, the client now participates in the local hospital's dialysis program and has been referred to an ophthalmologist by the primary care physician following the onset of vision problems. In addition, the client receives home care nursing for the treatment of a foot ulcer that is slow to heal. This client's situation characterizes what phenomenon?

Fragmentation of Care

A nurse recommends palliative care for a client who is being discharged following a diagnosis of cancer. What is the chief focus of this type of care?

Relief from physical, mental, and spiritual distress

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

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

fluid and electrolyte levels.

The nurse provides teaching to a client experiencing constipation. What food choice on the client's breakfast tray indicates effective teaching?

grapefruit

The Nursing Agenda for Health Care Reform (American Nurses Association [ANA]) identifies the recipients of health care. This reform's main focus is on:

health promotion.

Low oxygen saturation of the body, not enough oxygen in the blood

hypoxia

The nurse is caring for an older adult client with diarrhea. The nurse assesses that the client has a skin turgor response of 5 seconds. The nurse responds with...

immediate nursing intervention.

A patient demonstrates correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following?

inhales slowly and deeply

Which developmental consideration is a nurse assessing when determining that an 8-year-old child is not equipped to understand the scientific explanation of the child's disease?

intellectual development

What medication causes constipation?

iron supplements

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

left lateral

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation.

Mona Hernandez's laboratory work indicates an elevated white blood cell count with a left shift in the differential. The nurse interprets this to mean which of the following?

There is a high number of white blood cells and immature white blood cells present to fight the infection.

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

They are low-pitched, soft sounds heard over peripheral lung fields.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm.

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

After administering a tube feeding, the patient should remain upright for about __________ to reduce the risk of aspiration.

an hour

A nurse says, "We have so many drills and safety checks for everything. It is almost like we are preoccupied with the possibility of failure." How should the charge nurse respond to this statement?

"Highly reliable organizations think about the possibility of failure and what to do to avoid it."

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide?

"This test detects heme, a type of iron compound in blood in the stool."

The nurse is educating a client taking furosemide for heart failure about eating foods that are rich in potassium. What statement made by the client indicates that education was effective?

"When I take my medication, I will eat a banana or take it with a glass of orange juice."

A nurse is collecting a stool specimen from a client. Which measures are appropriate for this procedure? Select all that apply.

- The client should be asked to void first because the lab study may be inaccurate if the stool contains urine. - The client should be instructed not to place toilet tissue in the bedpan or specimen container. - Medical aseptic techniques are always followed. - Handwashing is performed before and after glove use when handling a stool specimen.

A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply.

- The nurse places the client in the supine position with the abdomen exposed. - The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. - The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft.

When conducting an education program for a group preparing for retirement, the nurse would include information about applying for Social Security benefits and Medicare insurance. The nurse would include in the education that Medicare is a federally funded insurance program which bases the fee for payment on what?

A prospective payment plan based on a predetermined fixed cost

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. What form of oxygen delivery should the nurse use for this client?

Ambu bag

A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk?

Assess the client's LOC

A nursing student is teaching healthy nutrition to a client who is vegetarian. What statement by the nursing student requires the nursing instructor to intervene?

"Obesity is closely linked with vegetarianism."

The nurse performs a respiratory assessment on a healthy client. While listening to the client's lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. What is the best way to document this respiratory assessment and lung sounds?

"Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%."

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (Cardiac output is determined by multiplying the stroke volume by the heart rate/min)

In which client should the nurse prioritize assessments for respiratory depression?

A client taking opiods for cancer

Identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? (Select all that apply.)

Acute pain, Ineffective respiratory gas exchange, Difficulty breathing, Not able to tolerate activity

Upon entering the room, the nurse observes Mona Hernandez slumped over in a semi-Fowler's position, struggling to catch her breath. What is the priority nursing action at this time?

Assist the patient into a high Fowler's position.

Which is the main focus of care for a school nurse?

Community care

The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. What should the nurse do?

Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure.

The nurse is preparing to discharge Mona Hernandez from the hospital. Which of the following instructions should the nurse include in the discharge education? (Select all that apply.)

Continue to focus on ambulating several times per day., Use the incentive spirometer every one to two hours to move secretions out of your lungs., Take your antibiotics as directed, even if you are feeling better., Quitting smoking will improve your recovery.

Nurses in various health care settings provide services to prevent the fragmentation of care that is occurring as a health care trend in today's society. What role of the nurse is most important in preventing this effect?

Coordinator of care

A nurse is assessing a patient with cystic fibrosis. Based on a diagnosis of cystic fibrosis, the nurse expects to find what common physical symptoms upon assessment?

Cyanosis or pallor, dyspnea, and arrhythmias

Why might someone with cystic fibrosis be told to eat a high-fat, high-protein, high-carbohydrate diet?

Cystic fibrosis interferes with the digestion of food and absorption of nutrients.

A patient complains of nausea after a tube feeding. What is the priority action of the nurse at this time?

Ensure the head of the bed remains elevated.

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?

Every 4 to 6 hours

A patient is concerned about a medication the nurse is administering. The patient states that the medication is not normally something that is administered. What is the best response by the nurse?

I will hold the medication and find out for you.

A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation?

Increased oral fluid intake

The nurse is caring for a client with an enlarged thyroid gland. Which nutritional deficiency will the nurse suspect is linked to the client's condition?

Iodine

The nurse is teaching a new mother who had decided to breastfeed her infant. What nutrient must be supplemented by the mother after the first four months of breast feeding?

Iron

Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. What is the best response by the nurse?

It helps prevent atelectasis or collapsing of the alveoli in the lungs.

The nurse encounters difficulty obtaining a large enough blood droplet for a capillary blood sample for glucose testing. What should the nurse's next action be?

Lower the hand below heart level and stroke the finger.

What methods are used to ensure that clients have continuity of care and cost-effective care during movement throughout the health care system?

Managed care, Case management, Primary health care

The nurse understands that a diagnostic-related group is one of the reimbursement strategies in a prospective payment system. The diagnostic-related group is a part of which health care system?

Medicare

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way?

Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

Monitor the amount of oxygen saturation in the blood.

During a visit to the pediatrician's office, a parent inquires about adding solid foods to the diet of a 6-month-old infant. What does the nurse inform the parent?

New foods should be introduced one at a time for a period of 2 to 3 days.

A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:

Niacin

During an annual physical examination the client reports feeling a lack of muscle energy when walking and doing simple chores around the house. When reviewing the client's diet, deficiencies in which vitamins would be associated with the symptoms reported?

Niacin and Thiamine Rationale: Vitamins in the B complex are associated with confusion and motor weakness.

During her hospitalization for pneumonia, the provider orders arterial blood gases for Mona Hernandez. What is the best explanation for why this is ordered?

Patient has shallow, ineffective breathing.

The average dietary nutrient intake level that meets the nutritional requirement of almost all healthy people in a selected age and gender group is the:

RDA level

A nurse has just inserted a nasogastric tube in a client. What method is most reliable for verifying the correct placement of the tube?

Radiographic confirmation of position

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

A nurse has received an order to suction an adult client's endotracheal tube. Which action is most appropriate when performing this intervention?

Use sterile saline to moisten the end of the suction catheter.

What guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

A nurse is conducting client education with a woman who meets the diagnostic criteria for metabolic syndrome. The nurse is teaching the client about the MyPlate tool for promoting healthy food intake. According to MyPlate, the highest proportion of food in each meal should consist of what?

Vegetables

As the nurse administers Mona Hernandez's prescribed medication, guaifenesin, the patient states: "I don't like this medication. It makes me cough too much." How should the nurse respond?

When you cough out secretions, oxygenation is more effective.

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion.

The nurse is caring for four clients. The client has a total cholesterol of 210 mg/dL and HDL 40 mg/dL. The nurse assesses that this client is at highest risk for __________ and __________ disease.

cardiac; vascular

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

clubbing

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 woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

coup.

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

cyanosis

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?

dark pink and moist

If your BMI is 18.5 to <25, it falls within the __________ range.

healthy weight

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?

nasal cannula

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

nasal cannula

An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of:

negative nitrogen balance

A nurse is working with a 45-year-old construction worker. The nurse obtains his height and weight and calculates that his BMI is 28. How would the nurse best classify James?

overweight

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

pleural effusion

When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?

rapid respirations

A client having a bowel surgery asks why being NPO after surgery is necessary. The nurse knows that the client is NPO after surgery to...

rest the gastrointestinal tract and promote healing.

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. What appropriate terminology would the nurse use to describe these lung sounds when documenting?

vesicular

A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?

vitamin K

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

warm the client's hands and try again

A client has received nursing teaching about proper skin care at a stomal site. The nurse's teaching has been effective when the client identifies what solution is used to clean the stoma?

water and mild soap

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

wheezing