fundamentals Exam #3

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

" I should lie on my back as much as possible to relieve the pain."

A nurse is teaching a client what to expect following a barium enema. Which client statement indicates a need for further teaching?

" I should limit my fiber intake for 1 to 2 weeks following the procedure."

Which statement indicates that the client understands the home care of a colostomy?

"I should be able to establish a regular pattern of elimination with my colostomy

The spouse of a terminally ill client asks the nurse, "Why is my spouse having frequent bowel movements if they are not eating?" What should the nurse tell the spouse?

"The intestines still produce some waste products even when a person is not eating."

A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information?

1 unit of gluclose

What is the maximum amount of medication (in milliliters) that can be administered into the deltoid muscle? Record your answer using a whole number.

2

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted

Following abdominal surgery, the nurse is auscultating the client's abdomen for bowel sounds. Which is the correct procedure?

Listen for 5 minutes in all four quadrants to confirm the absence of bowel sounds.

The nurse is observing a new graduate nurse instill eyedrops into a client's eyes. The nurse evaluates that the new graduate is using appropriate technique when which step is incorporated into the procedure?

The nurse's hand is stabilized on the client's forehead while instilling the drops.

The nurse is developing a care plan for a client who had abdominal surgery today. Which nursing action will be most important in preventing postoperative complications?

early ambulation

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's

adverse effects

The client who is in Buck traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?

an orange, raisin bran and milk, and wheat toast with butter

Which finding would indicate bowel functioning is returning after anesthesia and surgery for a client with a nasogastric tube?

auscultation indicates bowel sounds in all four quadrants

Which drug delivery system most effectively reduces the likelihood of medication errors?

automated

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?

laxative

A client complains of difficulty swallowing when the nurse tries to administer a medication in capsule form. What action should the nurse take next?

check for availability of a liquid preparation

A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects to prepare the client for which diagnostic study?

colonoscopy with biopsy

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown below. Which finding is expected when assessing this client?

dysfunction of bowel and bladder

Which are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply.

medical record number. name band.

What is the priority action that a nurse should take after omitting an ordered medication?

notify the perscriber

Which technique is correct when the nurse is inserting a rectal suppository for an adult client?

position the suppository along the rectal wall.

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

standing order

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which would be the most appropriate action for the nurse? You Selected:

strike out with a single line and place initials

A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base the next action on which understanding?

the nurse should clarify the order with the physician

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.

-to ensure efficient and accurate communication -to prevent medication errors -to ensure client safety

A nurse asks a client who had abdominal surgery 3 days ago if they have moved their bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

encourage the client to ambulate at least three times per day

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required?

independent

what is one disadvantage of using the rectal route?

it can result in incomplete drug absorption

A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error?

unauthorized entry