NR 226 Final Exam Practice Questions

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply. A. Warm the enema solution prior to installation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 2 inches. E. Hang the enema container 24 inches above the clients anus.

A, B, and C Enemas are rectal injections of fluid intended to cleanse or stimulate the emptying of the bowel. Enemas can be administered by a medical professional or self-administered at home. Enemas may also be prescribed to flush out the colon before certain diagnostic tests or surgeries. The bowel needs to be empty before these procedures to reduce infection risk and prevent stool from getting in the way.

Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply. A. Bowel incontinence B. Risk for deficient fluid volume C. Disturbed body image D. Social isolation E. Risk for impaired skin integrity

A, C, D, and E Incontinence is the inability to control feces of normal consistency. Fecal incontinence (FI) is the involuntary passage of fecal matter through anus or inability to control the discharge of bowel contents. Its severity can range from an involuntary passage of flatus to complete evacuation of fecal matter. Depending on the severity of the disease, it has a significant impact on a patient's quality of life

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? A. Constipation B. Diarrhea C. Incontinence D. Hemorrhoids

A. Constipation Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Functional constipation is a prevalent condition in childhood, about 29.6% worldwide. In the United States, it represents 3% to 5% of pediatric visits and a considerable annual health care cost. Most children do not have an etiological factor, and one third continue to have problems beyond adolescence.

A nurse determines that a fracture bedpan should be used for the patient who: A. Has a spinal cord injury B. Is on bedrest C. Has dementia D. Is obese

A. Has a spinal cord injury A fracture bedpan has a low back that promotes function of the patient's lower back while on the bedpan. The fracture pan has one flat end for ease of use with specific patient populations: i.e. hip fractures, hip replacements, or lower extremity fractures. Using the toilet may be a source of discomfort and embarrassment among all genders. Semi-private rooms or shared wards and hospital overcrowding are a challenge regarding patient privacy.

Nursing interventions that can help the patient to relax and sleep restfully include all of the following except: A. Have the patient take a 30- to 60-minute nap in the afternoon. B. Turn on the television in the patient's room. C. Provide quiet music and interesting reading material. D. Massage the patient's back with long strokes.

A. Have the patient take a 30- to 60-minute nap in the afternoon. Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep.

After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping, and muscle weakness. These symptoms probably indicate that the patient is experiencing: A. Hypokalemia B. Hyperkalemia C. Anorexia D. Dysphagia

A. Hypokalemia Fatigue, muscle cramping, and muscle weaknesses are symptoms of hypokalemia (an inadequate potassium level), which is a potential side effect of diuretic therapy. The physician usually orders supplemental potassium to prevent hypokalemia in patients receiving diuretics. Hypokalemia is more prevalent than hyperkalemia; however, most cases are mild. Although there is a slight variation, an acceptable lower limit for normal serum potassium is 3.5 mmol/L. Severity is categorized as mild when the serum potassium level is 3 to 3.4 mmol/L, moderate when the serum potassium level is 2.5 to 3 mmol/L, and severe when the serum potassium level is less than 2.5 mmol/L.

What does the nurse in charge do when making a surgical bed? A. Leaves the bed in the high position when finished. B. Place the pillow at the head of the bed. C. Rolls the patient to the far side of the bed. D. Tucks the top sheet and blanket under the bottom of the bed.

A. Leaves the bed in the high position when finished. When making a surgical bed, the nurse leaves the bed in a high position when finished. After placing the top linens on the bed without pouching them, the nurse fan folds these linens to the side opposite from where the patient will enter and places the pillow on the bedside chair. All these actions promote transfer of the postoperative patient from the stretcher to the bed.

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Passive prevention

A. Primary prevention Primary prevention precedes disease and applies to healthy patients. Primary prevention includes those preventive measures that come before the onset of illness or injury and before the disease process begins. Examples include immunization and taking regular exercise to prevent health problems from developing in the future.

A female patient undergoes a total abdominal hysterectomy. When assessing the patient 10 hours later, the nurse identifies which finding as an early sign of shock? A. Restlessness B. Pale, warm, dry skin C. Heart rate of 110 beats/minute D. Urine output of 30 ml/hour

A. Restlessness Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the patient restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool clammy skin. Shock is characterized by decreased oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization leading to cellular and tissue hypoxia. It is a life-threatening condition of circulatory failure and most commonly manifested as hypotension (systolic blood pressure less than 90 mm Hg or MAP less than 65 mmHg).

A female patient with a terminal illness is in denial. Indicators of denial include: A. Shock dismay B. Numbness C. Stoicism D. Preparatory grief

A. Shock dismay Shock and dismay are early signs of denial-the first stage of grief. Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. The other options are associated with depression—a later stage of grief.

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? A. Sims' B. Supine C. Dorsal recumbent D. Semi-Fowler's

A. Sims' Sims' position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler's positions without causing harm to the joint

A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply. A. Bradycardia B. Hypotension C. Fever D. Poor skin turgor E. Peripheral edema

B, C, and D Diarrhea is described as three or more loose or watery stools a day. Infection commonly causes acute diarrhea. Noninfectious etiologies are more common as the duration of diarrhea becomes chronic. Treatment and management are based on the duration and specific etiology. Rehydration therapy is an important aspect of the management of any patient with diarrhea. Prevention of infectious diarrhea includes proper handwashing to prevent the spread of infection

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? A. "I need to drink one and a half to 2 quarts of liquid each day." B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day." C. "If my bowel pattern changes on its own, I should call you." D. "Eating my meals at regular times is likely to result in regular bowel movements."

B. "I need to take a laxative such as milk of magnesium or if I don't have a BM every day" Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults. In addition, a normal stool pattern for an older adult may not be daily elimination. The cause of constipation is multifactorial. The problem may arise in the colon or rectum or it may be due to an external cause. In most people, slow colonic motility that occurs after years of laxative abuse is the problem. In a few patients, the cause may be related to an outlet obstruction like rectal prolapse or a rectocele. External causes of constipation may include poor dietary habits, lack of fluid intake, overuse of certain medications, an endocrine problem like hypothyroidism or some type of an emotional issue.

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? A. Prepare to irrigate the colostomy. B. After assessing the stoma and surrounding skin, notify the surgeon. C. Assess bowel sounds and administer antiemetic. D. Administer a bulk forming laxative, and encourage increased fluids and exercise.

B. After assessing the stoma and surrounding skin, notify the surgeon. The client has assessment findings consistent with complications of surgery. Providers and nurses should monitor stomas at regular intervals to look for the multiple complications of colostomies as an integrated team approach. Some complications are extremely troublesome to patients, and they come to the hospital with these presentations, but others may be more occult and have to be looked for.

When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients have adverse drug effects? A. Faster drug clearance B. Aging-related physiological changes C. Increased amount of neurons D. Enhanced blood flow to the GI tract

B. Aging-related physiological changes Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. ADEs are estimated to be indicated in 5% to 28% of acute geriatric medical admissions. Preventable ADEs are among one of the serious consequences of inappropriate medication use in older adults.

A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.D. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming: A. Fresh, green vegetables B. Bananas and oranges C. Lean red meat D. Creamed corn

B. Bananas and oranges Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Potassium is a mineral in the cells. It helps the nerves and muscles work as they should. The right balance of potassium also keeps the heart beating at a steady rate. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.

Which of the following blood tests should be performed before a blood transfusion? A. Prothrombin and coagulation time B. Blood typing and cross-matching C. Bleeding and clotting time D. Complete blood count (CBC) and electrolyte levels

B. Blood typing and cross-matching Before a blood transfusion is performed, the blood of the donor and recipient must be checked for compatibility. This is done by blood typing (a test that determines a person's blood type) and cross-matching (a procedure that determines the compatibility of the donor's and recipient's blood after the blood types have been matched). If the blood specimens are incompatible, hemolysis and antigen-antibody reactions will occur. If the donor is eligible to donate, the donated blood is tested for blood type (ABO group) and Rh type (positive or negative). This is to make sure that patients receive blood that matches their blood type. Before transfusion, the donor and blood unit are also tested for certain proteins (antibodies) that may cause adverse reactions in a person receiving a blood transfusion.

A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the: A. National League for Nursing (NLN) B. Centers for Disease Control (CDC) C. American Medical Association (AMA) D. American Nurses Association (ANA)

B. Centers for Disease Control (CDC) The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. CDC is responsible for controlling the introduction and spread of infectious diseases, and provides consultation and assistance to other nations and international agencies to assist in improving their disease prevention and control, environmental health, and health promotion activities.

A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation? A. Incontinence B. Dysrhythmias C. Fecal impaction D. Rectal hemorrhoids

B. Dysrhythmias Straining on defecation requires the person to hold the breath while bearing down. This maneuver increases the intrathoracic and intracranial pressures, which can precipitate dysrhythmias, brain attack, and respiratory difficulties; all of these can be life threatening. Strain at stool causes blood pressure rise, which can trigger cardiovascular events such as congestive heart failure, arrhythmia, acute coronary disease, and aortic dissection.

A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role? A. Manager B. Educator C. Caregiver D. Patient advocate

B. Educator When teaching a patient about medications before discharge, the nurse is acting as an educator. They provide educational leadership to patients and care providers to enhance specialized patient care within established healthcare settings. Assists patients and caregivers with educational needs, problem resolution, and health management across the continuum of care.

The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer? A. Position the head of the bed flat. B. Helps the patient dangle the legs. C. Stands behind the patient. D. Place the chair facing away from the bed.

B. Helps the patient dangle the legs After placing the patient in High Fowler's position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.

Exchange of gases takes place in which of the following organs? A. Kidney B. Lungs C. Liver D. Heart

B. Lungs Gas exchange is the transport of oxygen from the lungs to the bloodstream and the expulsion of carbon dioxide from the bloodstream to the lungs. It transpires in the lungs between the alveoli and a network of tiny blood vessels called capillaries, which are located in the walls of the alveoli.

The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessment B. Nursing diagnosis C. Planning D. Evaluation

B. Nursing diagnosis The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care

Vivid dreaming occurs in which stage of sleep? A. Stage I non-REM B. Rapid eye movement (REM) stage C. Stage II non-REM D. Delta stage

B. Rapid eye movement (REM) stage Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after falling asleep, and each of the REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour.

Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? A. Decreased plasma drug levels B. Sensory deficits C. Lack of family support D. History of Tourette syndrome

B. Sensory deficits Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Age-related decline of the five classical senses (vision, smell, hearing, touch, and taste) poses significant burdens on older adults. The co-occurrence of multiple sensory deficits in older adults is not well characterized and may reflect a common mechanism resulting in global sensory impairment.

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? A. The client will wear a medical alert bracelet for antibiotic allergy. B. The client will return to his or her previous fecal elimination pattern. C. The client verbalizes the need to take an antidiarrheal medication PRN. D. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

B. The client will return to his or her previous fecal elimination pattern. Once the cause of diarrhea has been identified and corrected, the client returns to his or her previous elimination pattern. Diarrhea is a common adverse effect of antibiotic treatments. Antibiotic-associated diarrhea occurs in about 5-30% of patients either early during antibiotic therapy or up to two months after the end of the treatment. The frequency of antibiotic-associated diarrhea depends on the definition of diarrhea, the inciting antimicrobial agents, and host factors.

Kubler-Ross's five successive stages of death and dying are: A. Anger, bargaining, denial, depression, acceptance B. Denial, anger, depression, bargaining, acceptance C. Denial, anger, bargaining, depression, acceptance D. Bargaining, denial, anger, depression, acceptance

C. Denial, anger, bargaining, depression, acceptance

The most important nursing intervention to correct skin dryness is: A. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection. B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear. C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. D. Avoid bathing the patient until the condition is remedied, and notify the physician.

C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas. Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient's skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing.

Which of the following symptoms is the best indicator of imminent death? A. A weak, slow pulse B. Increased muscle tone C. Fixed, dilated pupils D. Slow, shallow respirations

C. Fixed, dilated pupils Fixed, dilated pupils are a sign of imminent death. Death is a part of natural life; however, society is notorious for being uncomfortable with death and dying as a topic on the whole. Many caregivers experience a level of burden from their duties during end-of-life care

A scrub nurse in the operating room has which responsibility? A. Positioning the patient B. Assisting with gowning and gloving C. Handling surgical instruments to the surgeon D. Applying surgical drapes

C. Handling surgical instruments to the surgeon The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.

When bathing a patient's extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique: A. Provides an opportunity for skin assessment. B. Avoids undue strain on the nurse. C. Increases venous blood return. D. Causes vasoconstriction and increases circulation.

C. Increases venous blood return. Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care.

After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder? A. Lethargy B. Increased pulse rate and blood pressure C. Muscle weakness D. Muscle irritability

C. Muscle weakness Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems. Significant muscle weakness occurs at serum potassium levels below 2.5 mmol/L but can occur at higher levels if the onset is acute. Similar to the weakness associated with hyperkalemia, the pattern is ascending in nature affecting the lower extremities, progressing to involve the trunk and upper extremities, and potentially advancing to paralysis.

A terminally ill patient usually experiences all of the following feelings during the anger stage except: A. Rage B. Envy C. Numbness D. Resentment

C. Numbness Numbness is typical of the depression stage, when the patient feels a great sense of loss. Depression is perhaps the most immediately understandable of Kubler-Ross's stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia.

The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data? A. Vital signs B. Laboratory test result C. Patient's description of pain D. Electrocardiographic (ECG) waveforms

C. Patient's description of pain Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient's opinions or feelings about a situation. Subjective data provide clues to possible physiologic, psychological, and sociologic problems

After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates: A. Infection B. Infiltration C. Phlebitis D. Bleeding

C. Phlebitis Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Superficial phlebitis affects veins on the skin surface. The condition is rarely serious and, with proper care, usually resolves rapidly. Sometimes people with superficial phlebitis also get deep vein thrombophlebitis, so a medical evaluation is necessary.

Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal? A. Taking psychology courses related to gerontology. B. Reading books and other literature on the subject of thanatology. C. Reflecting on the significance of death. D. Reviewing varying cultural beliefs and practices related to death.

C. Reflecting on the significance of death According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient's feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured.

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated" . The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? A. Soapsuds B. Retention C. Return flow D. Oil retention

C. Return flow This provides relief of postoperative flatus, stimulating bowel motility. Options one, two, and four manage constipation and do not provide flatus relief. A return-flow enema, or Harris flush, is used to remove intestinal gas and stimulate peristalsis. A large volume fluid is used but the fluid is instilled in 100-200 ml increments. Then, the fluid is drawn out by lowering the container below the level of the bowel. This brings the flatus out with the fluid.

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? A. The stoma extends 1/2 inch above the abdomen. B. The skin under the appliance looks red briefly after removing the appliance. C. The stoma color is a deep red purple. D. An ascending colostomy just delivers liquid feces.

C. The stoma color is a deep red purple. An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. A stoma is the exteriorization of a loop of bowel from the anterior abdominal wall, done during a surgical procedure. It is done for diversion or decompression of the remaining bowel. It may be temporary or permanent, depending on the indication for which it was performed. Most stomas are incontinent, which means that there is no voluntary control over the passage of flatus and feces from the stoma.

When examining a patient with abdominal pain the nurse in charge should assess: A. Any quadrant first B. The symptomatic quadrant first C. The symptomatic quadrant last D. The symptomatic quadrant either second or third

C. The symptomatic quadrant last The nurse should systematically assess all areas of the abdomen, if time and the patient's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time? A. Impaired gas exchanges related to increased blood flow. B. Fluid volume excess related to peripheral vascular disease. C. Risk for injury related to edema. D. Altered peripheral tissue perfusion related to venous congestion.

D. Altered peripheral tissue perfusion related to venous congestion. Altered peripheral tissue perfusion related to venous congestion" takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. Deep-vein thrombosis is a common and important disease. It is part of the venous thromboembolism disorders which represent the third most common cause of death from cardiovascular disease after heart attacks and stroke.

To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test? A. Red blood cell count B. Sputum culture C. Total hemoglobin D. Arterial blood gas (ABG) analysis

D. Arterial blood gas (ABG) analysis All of these tests help evaluate a patient with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about a patient's oxygenation status. An acceptable normal range of ABG values of ABG components are the following,[5][6] noting that the range of normal values may vary among laboratories, and in different age groups from neonates to geriatrics: pH (7.35-7.45) PaO2 (75-100 mmHg) PaCO2 (35-45 mmHg).

Which pulse should the nurse palpate during rapid assessment of an unconscious male adult? A. Radial B. Brachial C. Femoral D. Carotid

D. Carotid During a rapid assessment, the nurse's first priority is to check the patient's vital functions by assessing his airway, breathing, and circulation. To check a patient's circulation, the nurse must assess his heart and vascular network function. This is done by checking his skin color, temperature, mental status and, most importantly, his pulse. The nurse should use the carotid artery to check a patient's circulation.

A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material? A. Whole wheat bread B. White rice C. Pasta D. Kale

D. Kale Kale is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale contains 6.6 g of dietary fiber. Fiber is a very important component of our diet and comes from plant-based food sources (fruits, vegetables, legumes and whole grains). Different food sources contain different types of fiber and resistant starches and the side effects depend on the individual's microbiome (gut bacteria). Instead of avoiding fiber altogether, you may want to identify the certain types of food that cause the distress.

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? A. Oil retention B. Return flow C. High large volume D. Low, small volume

D. Low, small volume Small volume enemas along with other preparations are used to prepare the client for this procedure. The small volume enema is used to clean the lower portion of the colon or the sigmoid. This type of cleansing enema is often used for the patient who is constipated but does not need cleansing of the higher colon. The amount used is less than 500 ml and the bag is raised no higher than 12 inches.

A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema the nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema? A. Lubricate the last 2 inches of the rectal tube. B. Insert the rectal tube about 4 inches into the anus. C. Raise the solution container about 12 inches above the anus. D. Lower the solution container after instilling about 150 mL of solution.

D. Lower the solution container after instilling about 150 mL of solution. Lowering the container of solution creates a siphon effect that pulls the instilled fluid back out through the rectal tube into the solution container. The return flow promotes the evacuation of gas from the intestines. This technique is used only with a return flow enema. This action is appropriate for all types of enemas.

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Acute pain related to surgery. B. Deficient fluid volume related to blood and fluid loss from surgery. C. Impaired physical mobility related to surgery. D. Risk for aspiration related to anesthesia.

D. Risk for aspiration related to anesthesia. Risk for aspiration related to anesthesia takes priority for this client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The gag reflex, also known as the pharyngeal reflex, is a reflex contraction of the muscles of the posterior pharynx after stimulation of the posterior pharyngeal wall, tonsillar area, or base of the tongue. The gag reflex is believed to be an evolutionary reflex that developed as a method to prevent the aspiration of solid food particles. It is an essential component of evaluating the medullary brainstem and plays a role in the declaration of brain death

Which organization's standards require that all patients be assessed specifically for pain? A. American Nurses Association (ANA) B. State nurse practice acts C. National Council of State Boards of Nursing (NCSBN) D. The Joint Commission

D. The Joint Commission The Joint Commission has developed assessment standards, including that all clients be assessed for pain.

Which human element considered by the nurse in charge during assessment can affect drug administration? A. The patient's ability to recover B. The patient's occupational hazards C. The patient's socioeconomic status D. The patient's cognitive abilities

D. The patient's cognitive abilities The nurse must consider the patient's cognitive abilities to understand drug instructions. If not, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The patient's ability to recover, occupational hazards, and socioeconomic status do not affect drug administration.

The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is: A. Flurazepam B. Temazepam C. Methotrimeprazine D. Tryptophan

D. Tryptophan Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products contain the sleep-inducing amino acid tryptophan. Having warm milk at bedtime is a good way to work towards reaching the recommended number of servings of Milk and Alternatives each day, and can be a comforting way to unwind. Tryptophan is an amino acid that promotes sleep and is found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter).