Skills Test 3 Ch. 14,29,38
Which type of feeding tube would be most appropriate for a client requiring enteral feeding for a long period of time?
gastrostomy tube
A client with nonhealing wounds requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
high-protein
A client is receiving enteral nutrition via an unvented nasogastric tube. Which suction settings will most likely prevent the tube from adhering to the wall of the client's stomach?
intermittent suction at 40 to 60 mmHg
A nurse is preparing to position a client who will be undergoing a pelvic examination. Then nurse will assist the client into which position for this type of procedure?
lithotomy
The nurse is preparing the client for a pelvic examination. What position would the nurse place the client in for the examination?
lithotomy
While preparing clients for bedtime, the nurse finds the visiting family members affected the environment. Which action by a family member will make the nurse determine that the family needs additional teaching?
lowered head of bed to 15° of client with nasogastric feeding tube
Which test does the nurse anticipate will be ordered for a client presenting to the emergency department that is suspected of having meningitis?
lumbar puncture
A client scheduled for a diagnostic test has an implanted pacemaker. Which test will have to be cancelled because of the pacemaker?
magnetic resonance imaging (MRI)
A nurse is reviewing the medical record of a client and notes that the client is scheduled for an electromyogram. The nurse identifies this procedure as evaluating the electrical activity of the:
muscles
Which type of tube feeding involves insertion of the tube through the nose into the stomach?
nasogastric
A health care provider will be performing a procedure to relieve abdominal pressure for a client with ascites. With what procedure does the nurse anticipate assisting?
paracentesis
The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care? Select all that apply.
prescription for warfarin diagnosis of periodontitis current chemotherapy treatment low platelet count
The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client asks for something to drink. Which criterion will determine when the nurse will allow the client to drink fluids?
presence of a cough and gag reflex
Replace all gastric contents following measurment of aspirate.
prevents electrolyte imbalance
After recieving results of a client's Papanicolaou (Pap) test, the nurse notes the cellular examination states class IV. The nurse anticipates client care planning will include which intervention by the health care team?
providing cancer treatment and management education
The nurse is reviewing results from a Papanicolaou (Pap) test which have returned from from the laboratory. The nurse notes a result of 5 on the 6-point scale used to determine degree of hormonal effects in the body. The nurse will plan client care to include which intervention?
provision of prenatal education
Nursing students are reviewing information about the advantages and disadvantages of the different types of feeding tubes. The students demonstrate understanding of the information when they identify which as an advantage of a nasointestinal feeding tube?
reduced danger for aspiration
Measure the length of the external tube.
reduces the risk of aspiration
A nurse is obtaining vital signs for a client who is being sent for an x-ray. Before leaving the nursing unit, which nursing action is essential?
removing all metal items from the client's body
A client is scheduled for a diagnostic test with contrast medium. For what allergy should the nurse be sure to question the client?
seafood or other foods containing iodine
A client with normal digestion and absorption requires a feeding tube. Which type of formula does the nurse anticipate will be ordered?
standard isotonic
The nurse cares for a client with an endotracheal tube. Before each tube feeding, the nurse will check the tube placement and residual volume with the goal of preventing which priorityconcern?
to prevent aspiration
Confirm pH of aspirate is less than 5.5.
useful in verifying correct placement
A client with a terminal illness has been placed in hospice care. Under which circumstance can hospice care be terminated?
when the client no longer meets the Medicare criteria
The nurse is preparing to administer a client's tube feeding. How should the nurse position the client prior to beginning the infusion?
with the head of the bed at least 30 to 45 degrees
A client is scheduled for a laboratory test. When explaining the test to the client, which would the nurse most likely include as being involved?
collection of a body fluid specimen
The nurse should begin the process of removing a client's nasogastric (NG) tube by:
confirming the health care provider's order to remove the tube.
A client has just been administered a barium contrast medium, and the nurse is providing postprocedural education on management of the medium's side effects. For which side effect will the nurse provide instruction?
constipation
Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?
coping strategies
A 20-year-old client phones a telehealth nurse and reports fever, headache, and sore throat. The client wants to know where to have a throat culture performed. What is the appropriate nursing response?
"A doctor's office or student health clinic can perform this test."
A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the mostappropriate statement by the nurse?
"Can you tell me about why you've made this decision?"
A client receives a copy of her Pap test results. She calls the nurse and asks, "What does Class I mean?" What is the best response by the nurse?
"Class I means that there are no abnormal cells and your results are negative."
The nurse is preparing a client for an angiography, when the client states, "I am not sure if I really need this procedure." What would be the most appropriate response by the nurse?
"Do you have any specific questions about the procedure?"
The nurse is preparing a client for a magnetic resonance imaging (MRI) of the brain. Which statement by the client would require immediate follow-up by the nurse?
"I have a mechanical aortic valve."
The nurse is teaching a client how to collect a blood glucose sample for a glucometer. Which statement by the client would indicate to the nurse that further teaching is required?
"I will puncture my finger directly on the pad of my finger."
The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?
"Please go away; I just want to be left alone."
The clinic nurse is reviewing a client's Papanicolaou (Pap) class I test results. How would the nurse explain the results to the client?
"The results show no abnormal cell changes."
The nurse is flushing a client's feeding tube with 50 mL of water after giving medications through it. When the client asks, "Why are you doing that?" what is the appropriate nursing response?
"Water helps keep the feeding tube free from obstruction."
An HIV-positive 34-year-old client asks the nurse how often she should have a Pap test. What is the best response by the nurse?
"You should have a Pap test more frequently than every 3 years."
A nurse is measuring a client's capillary blood glucose before dinner. Which result would the nurse need to report to the health care provider?
138 mg/dL
A client is receiving a continuous tube feeding using a commercially prepared formula at home. The nurse would instruct the client's caregiver to use the formula within which time frame once the container is opened?
24 hours
A 25-year-old female client is sexually active and has no history of abnormal Papanicolaou test results. The nurse should advise the client to have a Papanicolaou test every:
36 months.
A nurse administers a continuous tube feeding via an NG tube. The nurse must check for residual every:
4 to 6 hours.
The nurse is obtaining a capillary blood glucose level before lunch from a client with diabetes mellitus. What reading obtained would require immediate intervention by the nurse?
40 mg/dL
The nurse calculates the intake of a client who received a bolus tube feeding of 250 ml. The nurse administered 60 ml of water prior to the feeding and 60 ml of water after the feeding. The nurse administered crushed medications in 45 ml of water. Calculate the amount of fluid, in milliliters, the client received. Record your answer using a whole number.
415
A nurse is assisting a client with a Salem Sump tube. What is the standardized length of this device?
48 in (122 cm)
Which situation is most likely to warrant an autopsy?
A client's death involves an allegation of a medical error.
The nurse should include which action in the plan of care for the client receiving enteral feedings? Select all that apply.
Check placement of the tube before initiating feeding. Maintain the head of the bed elevated between 30 and 45 degrees for at least 30 minutes after feeding
A client is scheduled for a diagnostic examination. What would the nurse do first?
Check the client's understanding of the procedure.
Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?
Administer sedation and analgesia.
A client is scheduled for an office visit by a new provider at the clinic. The nurse contacts that client. Which information does the nurse provide?
Arrive 30 minutes ahead to complete necessary paperwork.
A client with a terminal diagnosis states, "I am so glad I had a good life. I am ready to die." How will the nurse assist the client to communicate this acceptance of death to the family?
Ask the client how the nurse can best support the discussion with family
Respiratory
Assess skin color.
The comatose client received a drug that promotes gastric emptying prior to a bolus tube feeding through a nasogastric tube. The total amount of formula and water was 600 ml. Approximately 30 minutes later, the client vomited. What recommendation to the health care provider will the nurse make to decrease the risk of vomiting again?
Change bolus feeding to a continuous feeding.
A client is scheduled to undergo radionuclide imaging. The day before the test is scheduled, the client calls the office and tells the nurse that she is pregnant. What should the nurse do?
Discuss the situation with the nuclear medicine department.
The nurse has assessed 100 mL of gastric residual after completing a tube feeding. What is the appropriate nursing action?
Document the assessment finding.
The nurse is assisting the health care provider with performing a Papanicolaou (Pap) test. When preparing for the examination, what action will the nurse take?
Ensure a sterile speculum is available by the examination table.
The nurse is caring for a client who requires an abdominal ultrasound. The client states," I do not really know anything about this test. I am not exactly sure why I am to having it." What action will the nurse take first when responding to the client?
Explore the client's understanding of the procedure and clarify misperceptions.
Neurologic
Gently touch the client.
A client who is receiving tube feedings develops diarrhea. What action(s) would be appropriate for the nurse to take? Select all that apply.
Hang no more than 4 hours' worth of formula for feeding at one time. Dilute the initial tube feeding to one-fourth to one-half strength.
A client is to undergo a throat culture. The nurse checks the client's chart and sees that the client is taking amoxicillin. What should the nurse do next?
Inform the client's health care provider.
The nurse is caring for a client with a nasointestinal tube that has become blocked. The nurse attempts to flush the tube with 60 ml of warm water; however, this attempt is unsuccessful in unblocking the tube. What action will the nurse take next?
Inform the health care provider.
A client has presented to the clinic for a scheduled diagnostic test. The nurse at the clinic is aware of the importance of client education for individuals undergoing diagnostic testing. What subject should the nurse prioritize when providing this client education?
a thorough description of the procedure that the client will undergo
In the United States, what belief is the hospice movement based on?
Meaningful living during terminal illness is best supported in the home.
A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which step should be performed as part of this procedure?
Measure the tube from the tip of the nose to the ear lobe and from the ear lobe to the xiphoid process.
cardiac
Provide verbal stimulation.
The nurse is preparing a client for a fasting blood glucose test when the client reports the last meal was eating 5 hours ago. What is the nurse's next action?
Report the error promptly.
A nurse is providing care to a client recently admitted to the health care facility for treatment of an infection. The client experienced a traumatic brain injury several months ago that resulted in paralysis of both lower extremities and difficulty swallowing and speaking. The client's spouse is the primary caregiver. The client's spouse says to the nurse, "It's been really tough this last month caring for my spouse. Even though I have an aide who comes in to help for a couple of hours a week, I'm just spent, physically and emotionally." A referral for which service would be appropriate?
Respite care
The family of a client who is terminally ill asks the nurse about respite care. What education should the nurse provide the family regarding respite care?
Respite care is often provided by volunteers.
The nurse is inserting a nasogastric tube and meets resistance with insertion. Which nursing action is most appropriate?
Rotate the tube slightly and ask the client to swallow.
A client requires gastric decompression. Which supply does the nurse anticipate gathering?
Salem Sump
The nurse is assessing the blood glucose of a client 1 hour after the client has eaten a meal. The client is not known to have diabetes. For which blood glucose level will the nurse take no further action?
Schedule the capillary glucose check 30 minutes before the client's next meal.
The nurse is preparing to obtain an adult client's capillary blood sample for glucose testing. Blood glucose monitoring has been prescribed before meals and at bedtime. Which action will the nurse include when performing this skill?
Schedule the capillary glucose check 30 minutes before the client's next meal.
A nurse is preparing to administer an enema to a client with severe arthritis. When positioning the client for administration of the enema, which position is appropriate for this client?
Sims
The nurse is preparing to administer a retention enema for a client. What would be the proper position to place this client in for optimal results?
Sims'
The nurse is caring for a client who is receiving feedings through a nasogastric tube. The client has developed diarrhea. Which action will the nurse take first in response to this finding?
Slow the rate of the feed and report the finding to the health care provider.
The client who is terminally ill has unrelieved and intractable pain. The nurse is administering hydromorphone intravenously. The client states, "I want you to give me additional medication so I will die. I cannot go on any longer." What action would the nurse take?
State, "This is not something I or any of the nurses can do."
The nurse is placing a nasogastric tube when the client becomes short of breath, coughs, and has difficulty breathing. What is the priority nursing action?
Stop placement and assess for signs of respiratory distress.
The nurse is caring for a client who has undergone abdominal surgery and has a history of dysphagia. A nasointestinal tube is in place for the client and a family member asks why this type of tube has been inserted. How will the nurse respond?
The client's condition places the client at a high risk for aspiration.
The nurse obtains a health history interview on a client with lung cancer. The client states, "I became too focused at work; I did not have time to rest. I usually work 8 hours per day but, for the past few months, I have been spending at least 12 hours per day at the office. That is probably the reason why I was diagnosed with cancer. Maybe when I try to go back to my usual schedule, the cancer will go away. I did not want to be here but my wife is insistent. I do not think medications work. My brother-in-law died of cancer. He took a lot of medicines and prayed really hard, but he died just the same."
The nurse determines that the client believes in the holistic cause of illness as manifested by believing one can be cured of cancer by limiting work hours
A client that has been shot in the chest is now deceased, and the nurse is delegated to provide postmortem care. In which situation should the delegating charge nurse intervene while the nurse is providing postmortem care?
The nurse is preparing to remove the IV lines from the deceased.
The nurse is checking placement of a nasogastric tube that has been in place for 2 days. The tube is draining green aspirate. What does this color of aspirate indicate?
The tube is in the stomach.
The nurse assesses that the drainage holes of a client's nasogastric tube are adhering to the gastric mucosal wall. What is the appropriate nursing action?
Turn off suction momentarily and reposition the client.
A nurse is providing end-of-life care to a client who spends most of the time praying and talking about a "spiritual connection." The nurse interprets this as indicating which stage of grief?
acceptance
The nurse is caring for an older adult client with Alzheimer disease. The client has just returned to the unit to begin supplemental tube feedings through a gastronomy tube. Which potential complication will be the nurse's priority?
aspiration
A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model?
bargaining
A client comes to the clinic reporting that it "feels like when I swallow my food, it gets stuck in my esophagus." What diagnostic test does the nurse anticipate arranging for the client?
barium swallow
The nurse is caring for a client who is 2 hours post colonoscopy. What would be a priority for the nurse to assess?
bowel sounds
The nursing instructor is teaching a nursing student about diagnostic terms. Which suffix will the nursing instructor teach that means "to puncture"?
centesis
A client is being prepared for a test to detect gallstones. For what test does the nurse anticipate preparing the client?
cholecystography
The client is to undergo an electroencephalogram in 24 hours. What should the nurse inform the client not to ingest for 8 hours prior to the test?
coffee, tea, and cola beverages with caffeine
The nurse is caring for a client with Parkinson disease who recently had a stroke and now requires a nasogastric tube for decompression. Which assessment finding does the nurse anticipate prior to inserting the tube?
depressed gag reflex
A nurse is obtaining the NEX measurement of a client before inserting a tube in the stomach. Which body part should the nurse measure to make the first mark on the tube?
distance from the nose to the earlobe
The nurse will be inserting an indwelling urethral catheter into a female client. What position should the nurse place the client in preparation for the procedure?
dorsal recumbent
In which position should the nurse place the client who is being prepared for an indwelling urinary catheter placement?
dorsal recumbent position
The nurse has just administered a high-carbohydrate bolus feed to a client through a nasointestinal feeding tube when the client reports gas, abdominal pain and dizziness. The nurse notes the client's blood glucose level is 60 mg/d (3.3 mmol/l). What do these symptoms likely indicate?
dumping syndrome
A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an):
durable power of attorney.
When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply.
expression of feelings management of pain use of coping strategies
Elevate the head of bed at least 30 degrees.
facilitates the flow of feeding to the gut
A client with significant nutritional deficits is being placed on tube feedings. The client's condition indicates that he will need these feedings for a minimum of 6 to 8 weeks and possibly longer. The nurse would anticipate the use of which tube?
gastrostomy
