HA/BS Exam 3

A nurse is caring for a client who is having difficult with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral Cortex C. Pituitary D. Cerebellum

D. Cerebellum

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse first take? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum

D. Check the client's perineum The nurse must first collect adequate data before performing any plan of action. Assessment is the priority.

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include? A. Serve foods at warm or hot temp B. Offer the client low-density foods C. Make sure the client lies supine after meals D. Limit drinking liquids with food

D. Limit drinking liquids with food Drinking beverages with food leads to early satiety.

A nurse is performing a neuro assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A. Cranial Nerve XII B. Cranial Nerve X C. Cranial Nerve VIII D. Cranial Nerve V

A. Cranial Nerve XII The nurse is assessing the function of the hypoglossal nerve which innervates the tongue.

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

A. Daily weight

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A. Fats provide energy B. Carbs repair body tissue C. Fats regulate fluid balance D. Carbs prevent interstitial edema

A. Fats provide energy Fats provide 9 cal/g of energy

A nurse is caring for a client who has CKD. The kidneys regulate body fluids as well as assisting with with of the following functions? A. Regulation of acid-base balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temp D. Secretion of hormones needed for growth

A. Regulation of acid-base balance

A nurse is planning to perform passive ROM exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion 5 times during session B. Move the joint to the point of considerable resistance C. Sit ~2 ft from the side of the bed closest to the joint being exercised D. Exercise the smaller joints first

A. Repeat each joint motion 5 times during session To maintain the client's joint mobility, the nurse should repeat each motion 3-5 times.

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? Select all that apply. A. Gingivitis B. Dry, brittle hair C. Edema D. Spoon-shaped nails E. Poor wound healing

B,C,E B. Dry, brittle hair C. Edema E. Poor wound healing

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? A. Diminished B. Average C. Brisk D. Hyperactive

B. Average Diminished is 1+ or less Average is 2+ Brisk is 3+ or more Hyperactive is 4+

A nurse is preparing to administer a feeding via a g-tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the heads of the client's bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify that the client's gastric pH s above 4

B. Elevate the heads of the client's bed

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min. B. Fill the bag 2/3 with ice. C. Place the bag uncovered on the client's ankle. D. Tell the client that numbness is expected when the ice bag is in place

B. Fill the bag 2/3 with ice. Allows the bag to be molded around the client's ankle

As part of the neurological exam, a nurse instructs the client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia

B. Stereognosis The ability to identify an object's size, shape, and texture via tactile sensation

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A. "A lot of clients who are cared for at home have the same problem." B. "Don't worry about it. He will get a bath, and that will take care of the odor." C. "It must be difficult to care for someone who is confined to bed." D. "When was the last time he had a bath?"

C. "It must be difficult to care for someone who is confined to bed."

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide O2 B. Place the client in a side lying position C. Provide privacy D. Lower the client to the floor

D. Lower the client to the floor Use Maslow's hierarchy of needs. If a client begins to have a seizure, the nurse should first lower the client to the floor to protect them from injury.

A nurse is reviewing a client's lab report. The client's ABG levels are pH 7.5, Pa CO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

A. Respiratory alkalosis Normal pH range: 7.35-7.45 Normal PaCO2 range: 35-45 mmHg pH range is elevated, which indicates alkalosis. PaCO2 is below normal range, which indicates respiratory origin.

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside while feeding the client B. Order pureed foods C. Make sure feedings are provided at room temperature D. Offer the client a drink of fluid after every bite

A. Sit at the bedside while feeding the client Sitting at the bedside provides the client with the nurse's full attn during the feeding.

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium

A. Sodium Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities.

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A. Whole milk B. Chicken C. Oranges D. Dried peas

A. Whole milk

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following actions should the nurse take? A. Administer 0.9% sodium chloride until TPN is available from the pharmacy B. Check the client's capillary blood glucose level every 4 hr C. Obtain the client's weight each week D. Change the IV tubing every 3 days

B. Check the client's capillary blood glucose level every 4 hr The nurse should check the client's cap. blood glucose every 4 hr or according to facility policy due to the client's risk of hyperglycemia while receiving TPN.

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30 or 45 degrees C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temp before feeding

B. Elevate the head of the bed to 30 or 45 degrees Helps prevent gravitational reflux of gastric contents, decreasing the risk of aspiration.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises B. The client reports severe pain C. The client asks the nurse how often deep breathing should be done after surgery D. The client tells the nurse that this exercise will probably be painful after surgery

B. The client reports severe pain A client who is experiencing severe pain is not able to concentrate and is not ready to learn a new activity.

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? A. Assist the client into semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward

C. Advise the client to tuck his chin downward

A nurse is a provider's office is teaching a client about foods that are high in fiber. Which os the following food choices made by the client indicate an understanding of the teaching. Select all that apply. A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice

C. Black beans D. Whole-grain bread Dried pea and beans, including black beans, are high in fiber. Whole grains consist of the entire kernel and are also high in fiber.

A nurse is assisting a client who is eating a mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an O2 mask on the client B. Check the client's pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

C. Determine whether the client is able to breathe

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the head of the client's bed to 45 degrees before the feeding D. Flush the tubing with 15mL of water after the enteral feeding.

C. Elevate the head of the client's bed to 45 degrees before the feeding

A nurse is providing teaching to a client about protein intake. Which of the following foods should the nurse include as an example of incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt

C. Lentils Incomplete proteins: lentils, veggies, grains, nuts, seeds

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside? A. Vest restraint B. Tongue blade C. O2 equipment D. Neck brace

C. O2 equipment The nurse should be able to apply oxygen via mask or nasal cannula to a client who experiences a seizure.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2cm B. Wear sterile gloves to insert the tubing. C. Position the client on his left side. D. Hold the solution bag 91cm above the client's rectum

C. Position the client on his left side. Having the client lie on his left side facilitates flow of the enema solution into the sigmoid and descending colon.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

C. Pull the NG tube back slightly The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows.

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. Drink a minimum of 1000 mL of fluid daily B. Increase your intake of refined-fiber foods C. Sit on the toilet for 30 min after eating a meal D. Take a laxative every day to maintain regularity

C. Sit on the toilet for 30 min after eating a meal This action, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. The nurse should instruct the client to consume a minimum of 1,500 mL of fluid daily; increase consumption of coarse fiber; shouldn't take daily laxatives because it hinders natural defecation habits.

A nurse in the emergency dept is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HC03- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

D. Metabolic acidosis Normal pH range: 7.35-7.45 Normal PaCO2 range: 35-45 mmHg pH range is below normal range, which indicates acidosis. PaCO2 is WNL, which indicates metabolic origin.

A nurse is in a long-term care facility while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor. B. Perform an abdominal thrust. C. Open the airway with a head-chin tilt. D. Observe the client closely

D. Observe the client closely The nurse should observe the client closely. As long as the client is able to cough strongly, the nurse should not intervene.

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bad every 48 hours B. Chill the formula prior to administration C. Increase the infusion rate D. Request a prescription for an isotonic enteral nutrition formula

D. Request a prescription for an isotonic enteral nutrition formula

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? A. Use battery-operated equipment for personal care B. Apply mineral oil to protect the facial skin from irritation C. Remove the tv set from the bedroom D. Wear cotton clothing to avoid static electricity

D. Wear cotton clothing to avoid static electricity

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria

C. Diuresis Diuresis or polyuria is the excretion of a high volume of urine. Retention is the accumulation of urine in the bladder. Oliguria is diminishing urine output despite adequate fluid intake. Dysuria is painful or difficult urination.

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following lab values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001

C. Hct 55% BUN and capillary refill are WNL. Low urine specific gravity indicates hypervolemia.

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following lab values can cause confusion? A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 12g/dL

A. Sodium 123 mEq/L Normal Sodium range: 135-145 mEq/L Normal blood glucose range: 70-110 for fasting Normal potassium range: 3.5-5 mEq/L Normal hemoglobin range: 12-18 g/dL

A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following positions demonstrates an understanding of supination of the hand? A. The client holds the hand with the palm up B. The client holds the hand with the palm down C. The client points the fingers towards the floor. D. The client points the fingers towards the ceiling.

A. The client holds the hand with the palm up Palm down is pronation. Fingers towards the floor is flexion of hand. Fingers towards ceiling is extension of the hand.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep.

C. Raise the level of the bed. The nurse should raise the beed to allow the use of proper body mechanics.

A nurse is caring for a client who has a trach tube and requires suctioning. Which of the following actions should the nurse take? A. Hyperoxygenate the client before suctioning B. Insert the catheter during exhalation C. Apply suction during insertion of the catheter D. Apply suction for no more than 15 sec

A. Hyperoxygenate the client before suctioning The nurse should use a manual resus bag to hyperoxygenate the client for several minutes prior to suctioning

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? A. Inspection B. Auscultation C. Percussion D. Palpation

A. Inspection Always inspect first

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has CHF and is receiving 100% O2 via partial rebreather mask. B. A client who has emphysema and is receiving O2 at 3L/min via transtracheal oxygen cannula. C. A client who has an old tracheostomy and is receiving 40% humidified O2 via tracheostomy collar. D. A client who has COPD and is receiving O2 at 2L/min via nasal cannula

A. A client who has CHF and is receiving 100% O2 via partial rebreather mask. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify who risk poses the greatest threat. Rebreather masks need to be frequently checked to insure they inflate properly. If deflated, the client will rebreathe CO2 instead if O2.

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive heading loss of the left ear? A. Air conduction is less than bone conduction in the left ear. B. Air conduction is greater than bone conduction in the left ear. C. Sound is lateralizing to the right ear. D. Sound is lateralizing to the left ear.

A. Air conduction is less than bone conduction in the left ear.

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A lab result within the expected reference range for which fo the following substances indicates adequate protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium

A. Albumin Albumin levels measure protein status.

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A. Osteoporosis B. Scoliosis C. Kyphosis D. Lordosis

A. Osteoporosis Loss in height is often an early indication of osteoporosis. No other option precipitates a decrease in height of the client.

A nurse is planning to care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

A. Vitamin C and zinc The client's body needs both vitamin C and zinc to fight a wound infection. Th client should receive a multivitamin and a mineral supplement of both these substances. In addition, Vitamin E are also needed to promote skin and wound healing.

A nurse is teaching a client how to perform ROM exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. With your palm facing down, move your wrist sideways toward your thumb B. Move your palm toward the inner part of your forearm C. With your palm facing down, move your wrist sideways toward your little finger D. Bring the back of your hand as far back toward the wrist as you can

A. With your palm facing down, move your wrist sideways toward your thumb

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify the purpose of inflating the cuff includes which of the following? Select all that apply. A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of the secretions D. Preventing air leaks E. Preventing tracheal injury

B,C,D B. Stabilizing the position of the tube C. Preventing aspiration of the secretions D. Preventing air leaks Inflated cuffs help prevent movement of trach tube, reduce risk of aspiration, and keep air from leaking around the outer portion of the tube.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the admin of enteral feeding. Which of the following methods should the nurse use to verify the correct tube placement? Select all that apply. A. Auscultate injected air B. Verify the initial X-ray exam C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

B,C,D B. Verify the initial X-ray exam C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? A. Auscultate over the stomach while injecting air B. Request an X-ray of the client's abdomen C. Place the head of the client's bed in a flat position D. Administer the feeding if the pH of the aspirated contents is >6

B. Request an X-ray of the client's abdomen

A nurse is reviewing the lab data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

B. Sodium 150 mEq/L Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider.

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream

C. Gelatin Foods allowed on a clear liquid diet are clear and liquid at room temp. Cream of rice and ice cream are allowed on a full liquid diet; cottage cheese is allowed on a soft diet

A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when performing a tracheostomy care for the client? A. Perform trach care using asepsis B. Allow enough slack under the trach ties to insert 3 fingers C. Soak the inner cannula of the tube in normal saline D. Cut a sterile gauze pad to place between the neck and trach tube

C. Soak the inner cannula of the tube in normal saline Inner cannulas should be soaked in normal saline or a mixture of normal saline and H2O2 to loosen secretions. Trach care is performed using surgical asepsis; 1 or 2 fingers slack should be under trach ties; a cut gauze pad could cause the client to aspirate the loose threads.

A nurse is performing a neuro assessment for a client. Which of the following exams should the nurse use to check the client's balance? A. 2-point discrimination B. Glasgow coma scale C. Babinski reflex D. Romberg test

D. Romberg test When using the Romberg test, the nurse instructs the client to stand with feet together and arms at sides, first with eyes open and then with eyes closed. Inability to maintain balance is a positive Romberg test.