MCQ Exam #4
A nurse is teaching a patient about foods to eat when constipated. Which food selected by the patient from a list of foods indicates that the teaching was effective? 1. Peas 2. Apples 3. Cherries 4. Asparagus
Answer 1. A lot of fiber
A patient reports not having a bowel movement for several days. Place the nurse's actions in order of priority. 1. Obtain an order for an enema. 2. Request a prescription for a laxative. 3. Encourage the patient to drink more fluids. 4. Ask the patient when the last bowel movement occurred. 5. Explore with the patient how much fiber is being consumed in the diet.
4-5-3-2-1
A primary health-care provider orders blood glucose monitoring before meals and at bedtime for a patient. Place the following steps in the order in which they should be implemented. 1. Wipe away the rst drop of blood. 2. Cleanse the area with alcohol and let it dry thoroughly. 3. Place the hanging drop of blood gently on the end of the test strip. 4. Put the patient's finger in a dependent position in a cup of warm water. 5. Prick the site with the lancet while holding it perpendicular to the patient's nger. 6. Check the code number on the strip and ensure that it compares with the code on the monitor screen.
6-4-2-5-1-3.
A nurse is caring for a patient who is scheduled for a cystoscopy. Which information should the nurse include when teaching the patient about what to expect a er the procedure? 1. Urinary retention may occur after the procedure. 2. Urine may be dark red initially a er the procedure. 3. Bedrest is necessary for several days a er the procedure. 4. A clear liquid diet generally is ordered for a few days a er the procedure.
Answer 1.
A nurse is caring for a patient who is constipated. Which food is most appropriate for the nurse to teach the patient to eat? 1. Celery 2. Grapefruit 3. Bran cereal 4. Sun flower seeds
Answer
A patient reports concern about not having urinated in several hours. e patient reports the sensation of the need to void and has moderate abdominal distention. What should the nurse do rst? 1. Encourage the patient to drink more fluid. 2. Stroke the inner aspect of the patient's thigh. 3. Pour warm water over the patient's perineal area. 4. Have the patient assume an upright position for voiding.
Answer 4
A nurse is preparing to administer a fat emulsion intravenously to an adult. What should the nurse do when administrating this solution? 1. Run the lipid solution at a rate of 1.0 mL/minute for the first 30 minutes. 2. Administer the lipid solution within 15 minutes a er removal from a refrigerator. 3. Rotate the lipid solution bottle gently if the solution separates into layers or is cloudy. 4. Connect the lipid solution infusion set tubing to the port above the lter in the primary infusion line.
Answer 1.
A nurse is caring for a patient with an indwelling urinary retention catheter. The primary health-care provider orders a urine specimen for culture and sensitivity. What should the nurse do when collecting this specimen? 1. Place the urine specimen in a sterile urine container. 2. Obtain the urine specimen from the hourly urine chamber of the collection bag. 3. Collect the urine specimen from the drainage port at the bottom of the collection bag. 4. Take the urine specimen directly from the distal end of the catheter a er separating it from the tubing.
Answer 1.
A hospitalized 70-year-old adult has a computed tomography (CT) scan with contrast at 11 a.m. The patient has an IV running at 125 mL per hour and ingested 50 percent of lunch with a cup of coffee and 4 oz of soup at 12 noon. e nurse is going on a break at 1 p.m. and provides the following information to the nurse accepting responsibility for the patient. Which information about the patient is of most concern to the nurse accepting responsibility for the patient? 1. Urine output - 100 mL 2. Presence of slight nausea 3. Medicated for a mild headache 4. Blood pressure - 150/84 mm Hg
Answer 1
A nurse is caring for a 3-week-old infant. Which as- sessment regarding the number of diapers the infant soils daily should cause concern? 1. 7 2. 8 3. 9 4. 10
Answer 1
A nurse is caring for a patient who has a urinary retention catheter. The primary health-care provider orders a urine culture and sensitivity. Which step ensures that the collected specimen is sterile? 1. Swab the specimen port with an antiseptic swab. 2. Don sterile gloves when obtaining the specimen. 3. Use a urinalysis container to collect the specimen. 4. Collect the specimen early in the morning before breakfast.
Answer 1
A nurse is caring for a patient who just had surgery 6 hours ago to remove a portion of the intestine and the surgical creation of a stoma. Which action is important when caring for this patient? 1. Assess the color of the stoma. 2. Explain that bowel function will return in 24 hours. 3. Wait until the collection bag is full before it is emptied. 4. Clean the peristomal area with half-normal saline solution and peroxide.
Answer 1
A nurse is caring for a patient with a nasogastric tube to intermittent wall suction. What should the nurse do to ensure that it is functioning e ectively? 1. Verify that the tubing is intact and patent. 2. Position the patient below the level of the collection bottle. 3. Elevate the head of the patient's bed to a semi- Fowler position. 4. Ensure that the collection bottle is attached to a humidification adaptor.
Answer 1
A nurse is caring for an older adult female who says, "Why am I always getting bladder infections?" Which response by the nurse is most appropriate? 1. "Women have a shorter urethra than men do, and that makes women more susceptible than men to bladder infections." 2. "Older adults may experience retained urine, which becomes more acidic and promotes the development of bladder infections." 3. "It is hard for women to cleanse the urinary meatus, which increases the risk of bladder infections." 4. "Infrequent sexual intercourse predisposes women to bladder infection."
Answer 1
A nurse working in a nursing home identi es that a patient may have a fecal impaction. Which clinical manifestation is most speci c to this problem? 1. Passage of a small amount of brown liquid from the rectum 2. Lack of a bowel movement for several days 3. Distension of the abdomen 4. Feeling of rectal fullness
Answer 1
While all of the following clinical manifestations are important to report to a primary health-care provider, which is most important? 1. Anuria 2. Dysuria 3. Polyuria 4. Nocturia
Answer 1
A nurse is caring for a patient who has an indwelling urinary catheter. Which nursing actions are important to include in this patient's plan of care? Select all that apply. 1. Obtain the vital signs routinely. 2. Cleanse the perineal area several times a day. 3. Monitor the tubing for kinks and obstructions. 4. Assess the urine for color, cloudiness, and volume. 5. Attach the drainage collection bag to the bed railing. 6. Position the drainage bag above the level of the bladder.
Answer 1, 2, 3, 4.
A nurse identi es that a patient may be experiencing urinary retention. Which clinical indicators support this inference? Select all that apply. 1. Voiding small amounts of urine several times hourly 2. Abdominal palpation indicating bladder distention 3. Tenderness over the symphysis pubis on palpation 4. Dysuria on urination 5. Blood-tinged urine
Answer 1, 2, 3.
Which independent nursing actions are associated with caring for a patient with diarrhea? Select all that apply. 1. Suggesting eating the banana from the breakfast tray 2. Providing perineal care after each defecation 3. Monitoring the patient's hematocrit level 4. Administering intravenous fluids 5. Administering an antidiarrheal
Answer 1, 2, 3.
Which of the following is essential to ensure reliable bedside dipstick testing of urine? Select all that apply. 1. Use the correct reagent. 2. Ensure adequate lighting. 3. Ensure that the kit is not past the expiration date. 4. Avoid delegating the procedure to another nursing team member. 5. Read the test results one minute after dipping the test strip in urine.
Answer 1, 2, 3. Option 5 is incorrect because waiting time depends on the type of kit used.
A patient with a history of urinary tract infections asks the nurse for suggestions to limit their occurrence. Which should the nurse encourage the patient to ingest to inhibit the growth of microorganisms that can cause a bladder infection? Select all that apply. 1. Eggs 2. Meats 3. Apple juice 4. Cranberry juice 5. Whole-grain breads
Answer 1, 2, 4, 5.
What should a nurse do to prevent burns during meal time in patients with mental and physical impairments? 1. Assist patients with warm drinks. 2. Use plastic instead of metal utensils. 3. Serve unsteady patients only cold drinks. 4. Wait until the food is cool before serving.
Answer 1.
A home-care nurse is caring for a cognitively intact woman who has arthritis that affects her hands and slows her mobility. The patient tells the nurse about having a few episodes of urinary incontinence that were upsetting. The nurse identifies that the patient is experiencing functional incontinence. Which nursing interventions in the plan of care are speci c to limiting episodes of incontinence in this patient? Select all that apply. 1. Encourage wearing clothing with Velcro closures instead of buttons and zippers. 2. Suggest purchasing a lift chair if economics permit. 3. Encourage avoiding products with caffeine. 4. Teach to position a commode nearby. 5. Teach the patient Kegel exercises. 6. Suggest voiding every 2 hours.
Answer 1, 2, 4, 6.
A nurse is caring for a debilitated patient who is on bedrest and has been eating 50 percent of meals. What should the nurse plan to do to stimulate this patient's appetite? Select all that apply. 1. Serve small, frequent meals. 2. Provide oral care before meals. 3. Schedule procedures for after meals. 4. Provide adequate pain medication before meals. 5. Transfer the patient to a comfortable chair for meals.
Answer 1, 2, 4.
A nurse is caring for a group of patients with a variety of urinary retention catheters. Which of the following nursing interventions are common to all types of urinary catheters? Select all that apply. 1. Provide perineal care three times a day and whenever necessary. 2. Position the collection container below the level of the pelvis. 3. Ensure that the balloon is lled with sterile saline. 4. Hang the collection bag on the bed frame. 5. Tape the catheter to the inner thigh.
Answer 1, 2, 4.
A nurse is caring for a patient with a diagnosis of UTI. Which clinical indicators identified during a nursing assessment support the medical diagnosis? Select all that apply. 1. Dysuria 2. Hematuria 3. Urinary retention 4. Urgent sensation to void 5. Distended suprapubic area
Answer 1, 2, 4.
A patient comes to the clinic reporting abdominal bloating. The primary health-care provider identifies that the patient has slowed intestinal peristalsis. What should the nurse encourage the patient to do to minimize abdominal bloating. Select all that apply. 1. Eat a high fiber diet. 2. Increase fluid intake. 3. Use laxatives sparingly. 4. Drink prune juice every morning. 5. Raise the head of the bed 30° when sleeping
Answer 1, 2, 4.
An older adult who lives alone is experiencing slow but steady weight loss over the past year. What should the nurse encourage the adult to do to address this concern? Select all that apply. 1. Select nutrient-dense foods. 2. Eat foods high in protein first. 3. Purchase prepared frozen meals. 4. Eat an extra meal before bedtime. 5. Use bullion powder for added flavor
Answer 1, 2.
Which dependent nursing interventions are associ- ated with caring for a patient who is constipated? Select all that apply. 1. Administering Colace 100 mg twice a day 2. Assisting the patient with ambulation 3 times a day 3. Encouraging the intake of prunes from the meal tray 4. Encouraging the patient to turn from side to side in bed 5. Responding immediately to the patient's urge to defecate
Answer 1, 2.
A nurse is teaching a patient with diarrhea about foods that should be avoided. Which foods eliminated from the diet by the patient indicates that the teaching was effective? Select all that apply. 1. Graham crackers 2. Chicken breast 3. Kidney beans 4. Scallops 5. Yogurt
Answer 1, 2. Avoid fiber which can cause bulking only continuing the diarrhea.
A patient's specific gravity is 1.032. For what addi- tional clinical indicators should the nurse assess the patient? Select all that apply. 1. Presence of thirst 2. Peripheral edema 3. Decreased skin turgor 4. Rapid, weak pulse rate 5. Decreased blood urea nitrogen
Answer 1, 3, 4.
A nurse is caring for a patient who has high cholesterol. Which foods should the nurse teach the patient to avoid? Select all that apply. 1. Eggs 2. Celery 3. Asparagus 4. Calves liver 5. Baked custard
Answer 1, 4, 5.
A nurse is caring for a patient who is receiving par- enteral nutrition. Which nursing actions are essential when providing care for this patient? Select all that apply. 1. Use tubing with an in-line filter. 2. Obtain the vital signs every 8 hours. 3. Monitor blood glucose every 4 hours. 4. Compare the patient's daily weight to fluid intake and output. 5. Hang 5% to 10% dextrose solution if the infusion is interrupted.
Answer 1, 4, 5.
A nurse is teaching a patient with diarrhea about what foods to select from a menu. Which foods selected by the patient indicate that the teaching was effective? Select all that apply. 1. Shrimp 2. Chickpeas 3. Rye bread 4. Milk shake 5. Cottage cheese
Answer 1, 4, 5.
Aprimaryhealth-careproviderordersa24-hoururine test. Which actions should be implemented by the nurse when conducting this test? Select all that apply. 1. Have the patient void one last time at the end of the 24 hours and add it to the volume being collected. 2. Have the patient void one last time at the end of the 24 hours and discard the urine. 3. Collect the first voiding and then add the urine voided for the next 24 hours. 4. Discard the first voiding and then collect the urine for the next 24 hours. 5. Store the collected urine for 24 hours in a large collection container.
Answer 1, 4, 5.
A nurse is providing dietary teaching to a person with a low fixed income. What should the nurse encourage the person to do when making meals on a limited budget? Select all that apply. 1. Substitute eggs and beans for meat. 2. Purchase luncheon meats for sandwiches. 3. Buy fresh milk instead of powdered milk. 4. Read the nutrition facts labels on prepared foods. 5. Use store brand frozen meals over advertised brands.
Answer 1, 4.
Which information is essential for the nurse to include in a program supporting healthy eating habits? Select all that apply. 1. Drink 8 glasses of fluid daily. 2. Increase the intake of foods high in solid fats. 3. Make 25% of your plate fruits and vegetables daily. 4. Cream cheese and butter are included in the dairy circle on MyPlate. 5. Two servings of seafood rich in omega-fatty acids should be included weekly.
Answer 1, 5.
A nurse is caring for a patient who had a large portion of the stomach surgically removed due to stomach cancer and is now experiencing dumping syndrome. For which clinical indicator of dumping syndrome should the nurse assess the patient a er the patient completes a meal? 1. Hyperperistalsis 2. Bradycardia 3. Dyspnea 4. Hypoxia
Answer 1.
A nurse identifies that a patient may have perceived constipation. What specific question related to perceived constipation should the nurse ask the patient? 1. "How often do you take a laxative?" 2. "What is the consistency of your stools?" 3. "Do you have a sensation of rectal fullness?" 4. "When was the last time you had a bowel movement?
Answer 1. Option 2, 3, and 4 are common questions asked to all patients during physical assessment.
A nurse is caring for a group of patients. Which patient should cause the most concern about potential urinary retention? 1. Patient who is immobile in bed 2. Patient who just had a retention catheter removed 3. Patient who is disoriented to time, place, and person 4. Patient who just was placed on a fluid restricted diet
Answer 2
A nurse is caring for a patient receiving continuous bladder irrigation (CBI). Which nursing action is essential when caring for this patient? 1. Check the volume of the patient's output every hour to ensure tube patency. 2. Increase the irrigation solution flow rate until the return flow is pink and free from clots. 3. Irrigate the double-lumen catheter according to the primary health-care provider's orders. 4. Turn the patient from side to side to promote output, which minimizes clot formation in the urine.
Answer 2
A nurse is caring for a patient who has an order for a stool specimen. What should the nurse do when collecting this specimen? 1. Wear sterile gloves to maintain sterility of the specimen. 2. Send it to the laboratory promptly to avoid a degraded specimen. 3. Flush the toilet rst so that the water is clean and free from debris. 4. Collect several inches of formed feces to ensure an adequate sample.
Answer 2
A nurse is caring for a patient who is scheduled for a lower GI series. What information about this test should the nurse include in a discussion with the patient? 1. "You will have to implement a bowel prep at home the night before and the morning of the test." 2. "You will have chalky white colored stool for 1 to 2 days a er the test." 3. "You will remain in the supine position for the duration of the test." 4. "You will drink 8 ounces of barium just before the test."
Answer 2
A primary health-care provider orders a tap-water enema. The patient says, "How does this type of enema work?" Which rationale should the nurse include in words the patient will understand when answering the patient's question? 1. Water causes excessive interstitial fluid loss. 2. Instilled water stimulates a bowel movement. 3. Surface tension of water is reduced by soapsuds. 4. Hypertonic nature of the water irritates the intes- tinal mucosa.
Answer 2
A patient reports frequent episodes of constipation. Which should the nurse teach the patient to do to help relieve this problem? Select all that apply. 1. Use a prepackaged 4 oz enema once a week. 2. Drink at least 2 quarts of fluid every day. 3. Exercise at least 15 minutes every day. 4. Eat fresh vegetables two times a day. 5. Take a laxative three times a week.
Answer 2, 3, 4
A nurse is caring for a patient adjusting to a colostomy in the descending colon. The patient is concerned about eating foods that may cause a blockage. What foods should the nurse teach the patient to avoid? Select all that apply. 1. Cranberry juice 2. Green beans 3. Fresh pears 4. Popcorn 5. Rice
Answer 2, 3, 4, 5.
A nurse is caring for a patient who is recovering from abdominal surgery. e patient reports experi- encing "gas pains" and asks the nurse what can be done to prevent them in the future. Which should the nurse encourage the patient to avoid until intes- tinal function fully returns? Select all that apply. 1. Summer squash 2. Chewing gum 3. Onions 4. Lentils 5. Eggs
Answer 2, 3, 4.
A nurse is teaching a patient who is a vegetarian about what food combinations make a complete protein. What food combinations should the nurse include in the teaching? Select all that apply. 1. Lentils and tofu 2. Cereal with milk 3. Macaroni with cheese 4. Black-eyed peas and rice 5. Black and red bean soup
Answer 2, 3, 4.
A nurse is caring for a patient who is having urine collected for a 24-hour urine test. During the afternoon of the testing period, the patient forgets and accidentally voids into the toilet but tells the nurse right away. What should the nurse do? 1. Start the test again in the morning. 2. Identify the time and begin a new test. 3. Add the time since the previous voiding to the end of the test. 4. Notify the primary health-care provider about the delay of the test.
Answer 2.
A nurse is caring for a patient who is receiving continuous nutritional support via a nasogastric (NG) tube that is regulated by an enteral feeding pump. e nurse identifies that the patient is having difficulty breathing and is restless. What should the nurse do first? 1. Use a nasal cannula to provide oxygen. 2. Activate the hold button on the feeding. 3. Raise the bed to the high-Fowler position. 4. Immediately notify the primary health-care provider.
Answer 2.
A nurse is caring for a patient who was admitted to the hospital from home. Family members reported having difficulty getting the patient to eat. Which laboratory test should the nurse monitor because it is the best indicator of the patient's nutritional status? 1. Albumin 2. Transferrin 3. Blood urea nitrogen 4. Total lymphocyte count
Answer 2.
A nurse is planning a teaching program about the medication atorvastatin (Lipitor) for a patient who has high cholesterol. Which information is important for the nurse to emphasize? 1. Replace oils containing monosaturated fatty acids with oils containing polyunsaturated fatty acids. 2. Notify the primary health-care provider of muscle pain, weakness, or fever. 3. Avoid crushing and mixing this medication with applesauce. 4. Take this medication during a meal or with food.
Answer 2.
A nurse is providing a class about foods to include and avoid when following a calorie restricted 2-g sodium diet. A patient with which cultural heritage should the nurse be most concerned about adjusting to a 2-g sodium diet? 1. Indian 2. Chinese 3. Puerto Rican 4. Middle Eastern
Answer 2.
A nurse is teaching a patient about what constitutes a healthy diet. Which patient statement indicates that the teaching was effective? 1. "I must eat a protein food daily to meet my vitamin C requirement." 2. "I need to minimize my intake of foods containing trans fat." 3. "I should ingest foods rich in nonessential amino acids." 4. "I want one fifth of the foods on MyPlate to be grains."
Answer 2.
A nurse is teaching a patient what to expect regard- ing a colonoscopy. What information is most impor- tant to include in this discussion with the patient? 1. "You can expect flatus after the test because air is inflated into the bowel during the test." 2. "Report abdominal pain, fever, chills, or bleeding to the primary health-care provider." 3. "Avoid high fiber food for a week if a polyp or biopsy is taken during the procedure." 4. "Do not lift anything for a week if a polyp or biopsy is taken during the procedure."
Answer 2.
A nurse working in a primary care clinic is caring for a patient who was diagnosed with a low vitamin D level. e primary health-care provider prescribes 5,000 units of vitamin D daily and the nurse is teaching the patient foods that are high in vitamin D. e selection of which food by the patient indicates to the nurse that the patient can identify at least one food that is high in vitamin D? 1. Nuts 2. Eggs 3. Liver 4. Oranges
Answer 2.
A patient reports signs and symptoms associated with urge incontinence. Which action should the nurse teach the patient to employ to gain better bladder control? 1. Avoid lifting heavy objects. 2. Avoid products with caffeine. 3. Use the Credé maneuver when voiding. 4. Respond immediately to the sensation to void.
Answer 2.
A nurse is caring for a patient who has an order for a fleet enema to be self-administered at home the morning of ambulatory surgery. What is important for the nurse to teach the patient about this enema? 1. "Insert the tube 6 inches into the rectum to ensure it is beyond the internal rectal sphincter." 2. "Retain the enema solution as long as possible to promote evacuation." 3. "Lay on the right side as the solution is administered for best results." 4. "Warm it in the microwave for 1 minute to promote comfort."
Answer 2. Should be inserted within 3-4 inches. Lay on the left lateral side. Never warm the enema, may cause damage.
A postoperative patient has an indwelling catheter that has not drained urine in 3 hours. What should the nurse do first? 1. Ask the primary health-care provider for an order to irrigate the catheter. 2. Milk the tubing to dislodge any mucus or sediment in the catheter. 3. Palpate the patient's suprapubic area to assess for distention. 4. Recognize the patient's status is within expected limits.
Answer 2. Since normal urine output is 30 mL/h, the possible distention would not be noticeable through palpation as the total output would only be 90 mL. So, the best method to proceed is the milk in case of dislodging in the tube.
A nurse is teaching a patient about the best foods to eat to avoid constipation. Which vegetable selected by the patient from the hospital menu indicates that the teaching was effective? 1. Carrots 2. Spinach 3. Zucchini 4. Cabbage
Answer 2. The most amount of fiber among the 4.
A nurse is assessing a patient with the diagnosis of urinary tract infection (UTI). Which clinical indicator identified by the nurse supports this medical diagnosis? 1. Sweet, fruity odor to the urine 2. Dark amber color of urine 3. Cloudy urine 4. Foamy urine
Answer 3
A nurse is caring for a patient who was admitted to the hospital and is scheduled for surgery in the morn- ing due to a partial intestinal obstruction secondary to an intestinal mass. For which clinical indicator most associated with an intestinal obstruction should the nurse assess the patient? 1. Light-brown stool 2. Mucus in the stool 3. Ribbon shaped stool 4. Pungent odor to the stool
Answer 3
A nurse is teaching a patient how to test stool for the presence of occult blood. Which is important to teach the patient about this test to achieve accurate results? 1. Collect the specimen in the morning several days in a row. 2. Apply a thick layer of feces on the designated window of the test packet. 3. Avoid taking non-steroidal anti-inflammatory medications before the test. 4. Read the result as positive if a red color develops in response to the reagent.
Answer 3
A patient is scheduled for an esophagogastroduo- denoscopy. Which is most important to discuss when teaching the patient about this procedure? 1. Inform the patient that mild bloating and flatulence is common after the test. 2. Teach that a scope will be inserted via the nose and into the stomach and duodenum. 3. Instruct the patient to call the primary health- care provider if vomiting blood occurs after the procedure. 4. Explain that drinking a small amount of water a er awakening from the anesthesia is considered acceptable.
Answer 3
A patient self-administers a bowel prep consisting of sodium phosphate (Fleet Phospho-Soda), bisacodyl (Dulcolax), and an enema the night before a colonoscopy. For what serious adverse effect should the nurse assess the patient? 1. Deficient fluid volume 2. Intestinal cramping 3. Hyponatremia 4. Diarrhea
Answer 3
Which nursing intervention is most effective when assisting a patient to completely empty the bladder? 1. Place the patient's hands in warm water. 2. Stroke an inner aspect of the patient's thigh. 3. Encourage the patient to attempt to double void. 4. Turn a faucet on in the patient's room to produce sounds of flowing water.
Answer 3
A nurse is assessing a patient and is concerned that the patient may be experiencing urinary retention. Which clinical indicators support this conclusion? Select all that apply. 1. Blood-tinged urine 2. Amber colored urine 3. Reports of abdominal pressure 4. Lower abdominal distention on palpation 5. Voiding small amounts of urine at a time
Answer 3, 4, 5.
An older frail patient is admitted to the hospital because of malnutrition and an inability to maintain weight. e nurse reviews the results of biochemical laboratory tests. What laboratory results indicate a problem with nutrition? Select all that apply. 1. Hematocrit 42% 2. Hemoglobin 14 g/dL 3. Transferrin 190 mg/dL 4. Serum albumin 2.9 g/dL 5. Blood urea nitrogen 18 mg/dL
Answer 3, 4.
A nurse is caring for a patient who is receiving a high-calcium diet. Which foods should the nurse teach the patient to include in the diet? Select all that apply. 1. Tuna fish 2. Prune juice 3. Whole milk 4. Pinto beans 5. Broccoli spears
Answer 3, 5.
A nurse is caring for a patient who is weak and lethargic. Which action is most important when assisting this patient with meals? 1. Record the intake of food as poor, good, or excellent on the daily activities form. 2. Ask about preferences regarding the seasoning of food. 3. Check the mouth for pocketed food after the meal. 4. Encourage self-feeding.
Answer 3.
A nurse is caring for a patient with a history of expe- riencing residual urine a er voiding. e nurse uses a bladder ultrasound scanner (BUS) to detect the amount of urine that remains in the bladder a er the patient voids. What action should the nurse imple- ment that is essential to this test? 1. Give perineal hygiene before the procedure is initiated. 2. Position the patient in the left lateral position for the duration of the procedure. 3. Explain that no discomfort will be experienced as the transducer is moved on the surface of the skin. 4. Place the scan head on the abdomen, four inches midline above the pubic bone, aiming the scan head toward the coccyx.
Answer 3.
A nurse is teaching a patient about foods that should be avoided and foods that are acceptable on a lactose-free diet. Which food selected by the patient re ects an understanding of the teaching? 1. Yogurt 2. Sherbet 3. Fruit salad 4. Rice pudding
Answer 3.
A nurse is teaching a patient about nutrients that will increase the percentage of whole grains ingested daily. Which nutrient selected by the patient indicates that the teaching was effective? 1. Grits 2. Noodles 3. Wild rice 4. Corn bread
Answer 3.
A nurse receives an order to initiate continuous bladder irrigation. Which catheter should the nurse choose to perform the procedure correctly? 1. Straight catheter 2. Indwelling catheter 3. Triple-lumen catheter 4. Double-lumen catheter
Answer 3.
A patient has urinary retention and the primary health-care provider orders a straight catheterization. The draining volume reaches 750 mL without completely emptying the bladder. What alternative does the nurse have to help prevent bladder spasms? 1. Remove the catheter and reinsert a retention catheter. 2. Continue the complete emptying of the patient's bladder. 3. Release the remaining urine in the bladder slowly over 20 minutes. 4. Take the catheter out and then recatheterize the patient in 20 minutes.
Answer 3.
A patient is diagnosed with gluten intolerance. What food should the nurse encourage the patient to avoid when eating at restaurants? 1. White rice 2. Steamed eggplant 3. Veal cutlet parmesan 4. Fruit thickened with tapioca
Answer 3.
A primary health-care provider prescribes metformin (Glucophage) 500 mg PO bid for a patient newly diag- nosed with type 2 diabetes. What should the nurse teach the patient to do when taking this medication? 1. Increase the intake to three times a day when experiencing stress. 2. Drink a glass of orange juice if experiencing signs of hyperglycemia. 3. Be alert for nontherapeutic responses such as sleepiness, myalgia, and hyperventilation. 4. Explain that it is acceptable to double a dose if a dose is missed, as long as this occurs infrequently.
Answer 3.
A nurse is assisting a female patient who is experiencing numerous daily episodes of urge incontinence to gain better bladder control. Which outcome reflects achievement of a goal associated with this patient's urge incontinence? 1. Urinates every two hours while remaining dry between voiding 2. Wears an adult incontinence brief only when venturing outside the home 3. Empties the bladder every time before leaving the house, limiting incontinence 4. Uses deep, slow breathing until the sensation to void subsides, increasing intervals between voiding
Answer 4
A nurse is caring for a female patient who has a history of frequent urinary tract infections. What should the nurse teach the patient to do? 1. Wear nylon underwear. 2. Void before having intercourse. 3. Take a bubble bath rather than showering. 4. Urinate when the urge to urinate is perceived.
Answer 4
A nurse is caring for a patient who has an episode of diarrhea with frothy, odorous stool, containing an excessive amount of fat. Which word should the nurse use when documenting this type of stool? 1. Chyme 2. Melena 3. Meconium 4. Steatorrhea
Answer 4
A nurse is caring for a patient who is receiving bolus enteral feedings several times daily. Which nursing intervention is important to help prevent the patient from experiencing diarrhea? 1. Flush the tube a er every feeding. 2. Check the residual before each feeding. 3. Elevate the head of the bed during the feeding. 4. Discard the refrigerated opened cans of feeding formula a er 24 hours.
Answer 4
A nurse is caring for a patient who was admitted to the hospital with upper gastrointestinal bleeding. For which clinical indicator associated with gastrointesti- nal bleeding should the nurse assess the patient? 1. Pale, clay-colored stool 2. Yellow, greenish stool 3. Hard, dry brown stool 4. Black, tarry stool
Answer 4
A parent brings a child to the clinic because the child has been reporting rectal itching during the night. The primary health-care provider explains a specimen must be obtained so that the standard test for pinworms can be performed. What should the nurse instruct the parent to do? 1. Wash the anal area and then attempt to collect the specimen. 2. Insert a cotton-tipped swab into the anus and smear the specimen on a slide. 3. Pick up any worms found around the anus at night and put them in a sterile container. 4. Press clear scotch tape to the area around the anus rst thing in the morning and place it on a slide.
Answer 4
A patient is scheduled for thoracic surgery and is told by the surgeon that a er surgery a catheter will be placed in the bladder. A er the surgeon leaves, the patient asks the nurse, "Why am I going to have a tube in my bladder when I am having surgery in my chest?" Which response by the nurse is most appropriate? 1. "It is more convenient to control urine ow rather than having to clean a patient a er being incontinent." 2. "We want patients to rest a er your type of sur- gery. You will not be burdened with having to use a bedpan or urinal." 3. "A urinary catheter enables us to easily secure a urine specimen for laboratory tests that generally are ordered a er surgery." 4. "Hourly urine production is monitored with a urinary catheter. It is an effective way to assess kidney and circulatory function."
Answer 4
A patient reports a long-term problem with constipation. What should the nurse instruct the patient to do to help minimize this problem? 1. "Include more bananas in your diet." 2. "Drink a minimum of one quart of fluid a day." 3. "Hold your breath when bearing down to have a bowel movement." 4. "Attempt to have a bowel movement after drinking a warm liquid in the morning."
Answer 4
A nurse is caring for a patient receiving diphenoxylate HCl with atropine sulfate (Lomotil). Which is most important for the nurse to include when teaching the patient about nontherapeutic effects of this medication? 1. Monitor the pulse for a slow heart rate. 2. Suck on hard candy when experiencing a dry mouth. 3. Report abdominal cramps to the primary health- care provider immediately. 4. Avoid engaging in hazardous activity until the response to the medication is known.
Answer 4.
A nurse is caring for a patient with a colostomy who has a two-piece ostomy appliance. Which is impor- tant for the nurse to do when caring for this patient? 1. Tuck some gauze into the stoma after cleaning it until the new faceplate and bag is applied. 2. Cut an opening in the faceplate so that it is at least 1/2 inch away from around the stoma. 3. Empty the bag from the bottom, avoiding discon- necting the bag from the faceplate. 4. Change the faceplate of the appliance every 3 to 5 days or when necessary.
Answer 4.
A nurse is caring for a patient with gastroesophageal reflux disease. What nursing intervention is important? 1. Instruct the patient to chew food thoroughly. 2. Serve food that has different textures and aromas. 3. Offer fluids with food and at a preferred temperature. 4. Encourage the patient to avoid eating several hours before bedtime.
Answer 4.
A nurse is obtaining a health history from a patient. e patient states that she is embarrassed about episodes of incontinence when she sneezes or exercises and that she no longer attends an exercise program for this reason. She now walks several miles a day to lose the 50 lb she gained when pregnant with her h child. Based on this information, which nursing intervention will best help the patient to address the underlying cause of her lack of urine control? 1. Teach the patient foods to avoid that irritate the bladder mucosa. 2. Encourage the patient to return to her exercise class. 3. Engage the patient in a toileting program. 4. Teach the patient Kegel exercises.
Answer 4.
A nurse teaches a patient how to follow a prescribed 2-g sodium diet. What patient statement indicates that the patient understands the teaching? 1. "I can use as much salt substitutes as I want to season my food." 2. "I must limit my intake of salt to two teaspoons of table salt daily." 3. "I am allowed to drink diet cola because it has less salt than soda with sugar." 4. "I should read nutrition facts label for the amount of sodium that is in prepackaged foods."
Answer 4.
A primary health-care provider instructs a patient to limit the dietary intake of complex carbohydrates. The intake of which nutrient should the nurse teach the patient to limit? 1. Milk 2. Nuts 3. Eggs 4. Pasta
Answer 4.
A primary health-care provider prescribes the pro- ton-pump inhibitor omeprazole (Prilosec). e pre- scription states to take 20 mg once a day. Which instruction should the nurse give the patient regard- ing this medication? 1. "Take the capsule several hours before an antacid." 2. "Sprinkle the capsule contents in applesauce." 3. "Take the capsule with food." 4. "Swallow the capsule whole."
Answer 4.
