Unit 6

The nurse is discussing ways to help prevent constipation. Which information is most important for the nurse to share? 1. Do not ignore the defecation reflex. 2. Plan to defecate prior to the next meal. 3. Decrease fluids if fiber is increased. 4. Use laxatives to better time defecation.

1

The nurse documents that a client has halitosis. Which conditions can the presence of halitosis indicate to the nurse? Select all that apply. 1. Stomach problems 2. Sinus infection 3. Leukemia 4. Poor hygiene 5. Pernicious anemia

1 2 4

The nurse is caring for a client admitted with a diagnosis of bulimia nervosa. Which assessment finding will the nurse expect? Select all that apply. 1. Evidence of dental caries 2. Verbal reports of indigestion 3. Statements about constipation 4. Frequent bouts of sore throat 5. Poor skin turgor and sunken eyes

1 2 4 5

A client tells the nurse of experiencing minor gastrointestinal pain, flatulence, and diarrhea several times after meals. Which possible cause should the nurse identify? 1. Anaphylaxis 2. Food intolerance 3. A food allergy 4. Food poisoning

2

The initial assessment of a client admitted with a gastrointestinal inflammatory disease reveals that the client has hyperactive bowel sounds. The follow-up assessment indicates that the bowel sounds are still hyperactive, but are now audible without a stethoscope. Which documentation will the nurse make on the client's medical record? 1. "Low-pitched bowel sounds" 2. "Borborygmus noted" 3. "High-pitched bowel sounds" 4. "Hyperactive bowel sounds"

2

The nurse assists a client to the bathroom, and notices that the client's stool is clay colored. The client tells the nurse that this has occurred off and on for the last month or two. Which condition does the nurse suspect? 1. Poorly balanced diet 2. Gallstones or liver problems 3. History of gastrointestinal (GI) bleeding 4. Poor fluid intake

2

The nurse is admitting a client and performs a focused assessment. Which techniques will result in the nurse acquiring objective data related to bowel function? 1. Ask when the client last had a bowel movement. 2. Use the diaphragm of a stethoscope to hear bowel sounds. 3. Inquire about the characteristics of feces. 4. Ask the client to describe past abdominal pain.

2

The nurse is assessing a client immediately after the placement of a colostomy. Which assessment finding does the nurse expect to see? 1. The presence of effluence in the colostomy appliance 2. A stoma that is red, shiny, moist, and beefy in appearance 3. A slight skin irritation found under the appliance wafer 4. Drainage of mucus and purulent liquid from the stoma

2

The nurse is performing an assessment of the client's eyes, and tells the client, "Focus on my pencil and follow it as I move it away from you and then back toward you." Which specific function is the nurse assessing? 1. Anisocoric pupil response 2. Accommodation response 3. Consensual pupil reflex 4. Direct pupil response

2

. The charge nurse notes a client's blood pressure at 8:00 a.m. was 124/80 mm Hg. It is now 12:00 p.m., and the client's blood pressure is 152/94 mm Hg. Which suggestion about the plan of care will the charge nurse make to the newly hired nurse? 1. The client's blood pressure should be rechecked in 15 minutes. 2. Any abnormal findings should be rechecked within 8 hours. 3. Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours. 4. Continue the current 4-hour assessment to determine if a pattern is being established.

3

A client has surgery that creates a pouch from his intestine. His ureters empty into the pouch, while a nipple valve allows him to perform self-catheterization to intermittently empty the pouch. Which type of urinary diversion does the nurse identify? 1. Orthotopic bladder substitution 2. Ileal conduit 3. Continent urostomy 4. Suprapubic catheter

3

A client has undergone diagnostic tests of the gastrointestinal (GI) system. The client, who has chronic constipation, tells the nurse the physician is concerned about peristalsis, and asks why it is important. Which information will the nurse include? 1. Peristalsis counteracts gravity to prevent food from being propelled through the GI tract too swiftly. 2. Peristalsis is movement triggered by enzymes causing food to digest quickly and prevent constipation. 3. Peristalsis is contractions of circular and longitudinal muscles that propels food through the GI tract. 4. Peristalsis is an abnormal movement of the bowel which causes intractable nausea and vomiting.

3

A client is prescribed isoniazid (INH), a medication that treats tuberculosis (TB). Which condition will prompt the nurse to remind the physician that the client will need a specific vitamin during the therapy? 1. Vitamin K is not absorbed when a client has TB. 2. Vitamin C will increase lung healing with TB. 3. Vitamin B6 excretion will increase with INH. 4. Vitamin B12 prevents nerve damage from INH.

3

A client with severe dehydration is experiencing minimal urine production. Which terminology does the nurse use to document the client's urinary output? 1. Anuria 2. Polyuria 3. Oliguria 4. Hematuria

3

The nurse provides care for a client who is one day postoperative. The client reports nausea and is refusing to eat. The nurse assesses the client by auscultating the abdomen. Which cause will the nurse suspect if assessment reveals hypoactive bowel sounds? 1. Peritonitis 2. Obstruction 3. Anesthesia 4. Paralytic ileus

3

When the nurse inserts a nasogastric (NG) tube, the client becomes cyanotic, coughs incessantly, and is unable to speak. Which action should the nurse take immediately? 1. Encourage swallowing. 2. Continue to insert the tube. 3. Remove the tube completely. 4. View the posterior pharynx.

3

The nurse is inserting a nasogastric (NG) tube. Which conclusion does the nurse make if a client coughs continually? 1. The client is resisting insertion. 2. The client has a strong gag reflex. 3. The client needs to have a break. 4. The client's airway is compromised.

4

The nurse is performing a physical assessment on an older adult client. Which is the best reason for the nurse to ask this client about experiences with constipation? 1. Older adult clients are known to overuse laxatives, which creates problems with constipation. 2. Older adult clients frequently have difficulty having a bowel movement while hospitalized. 3. In older adult clients, the rectal sphincter has lost elasticity and the sensation of urgency is decreased. 4. Older adult clients commonly experience slower intestinal peristalsis, creating issues with constipation.

4

The nurse receives a new order to start a 24-hour urine collection for a hospitalized client. Which is the most important intervention for the nurse to implement first? 1. Explain the purpose and length of the test to the client. 2. Get a bedside commode to assist the client in urine collection. 3. Tell the client to notify the nurse when a specimen is ready. 4. Instruct the client to void and dispose of the voided urine now.

4

The nurse wakes the client during evening shift for a focused assessment. The client, trying to rest, tells the nurse, "I really need to sleep. Can you tell me why you need to wake me up so often?" Which response by the nurse explains the purpose of the assessment? 1. "Most clients don't understand the schedule we keep in the hospital." 2. "I understand your frustration, but this has been ordered by your physician." 3. "I do a head-to-toe assessment so that I can determine if there are any changes in your condition." 4. "Because you were just started on a medicine, I need to check your blood pressure more frequently."

4

A ____________________ flush removes flatus, but not stool as with other types of enemas.

Harris

The nurse is administering a cleansing enema to a client in preparation for a diagnostic test. After inserting the rectal tube, the client becomes quiet and does not respond to verbal stimulus. The nurse stops the enema and discovers a pulse rate of 30 beats/minute. The nurse recognizes that the client is exhibiting a ________ response.

Vagal

The nurse is providing care for a client after the surgical removal of the colon. The nurse is aware that the client has a procedure in which the ____________________ does not drain into an external appliance.

effluent

When a client has an intact digestive system but has difficulty with swallowing, digestion, or the absorption of food, the nurse can expect the client to be ordered on ___________________ feedings.

enteral

A client's stomach contents will be removed by inserting a double-lumen nasogastric (NG) tube through the nose into the stomach and then connecting the tube to a suction. The nurse identifies this procedure as ____________________.

gastric decompression

The nurse is assessing an older adult client for safety issues. The client states, "I get up several times to urinate during the night." The nurse documents that the client has a risk for falling related to _____________________.

nocturia

The nurse is planning care for a client following surgery for a urethra blocked by recurrent infections. The nurse expects to see a _________________catheter when assessing the client.

suprapubic

The nurse is assigned to provide client care to multiple clients. Which client does the nurse recognize as being at greatest risk for a fecal impaction? 1. An older adult client with poor fluid intake and a history of laxative abuse. 2. A client who is four days postoperative receiving an opioid drug for pain. 3. A client admitted for dehydration related to vomiting, receiving IV therapy. 4. A client ordered on bedrest for a pulmonary embolus who eats a regular diet.

1

A physician has ordered "Clear liquids, advance as tolerated." Which factors indicate to the nurse the advancement of the client's diet should be delayed? Select all that apply. 1. Hypoactive bowel sounds 2. Nausea and vomiting 3. Reports of indigestion 4. Expression of hunger 5. Verbalizing thirst

1 2 3

The nurse is performing a focused assessment of the client's cardiovascular system every 4 hours. Which specific assessment will the nurse include? Select all that apply. 1. Skin color, moisture, and temperature 2. Blood pressure 3. Use of accessory muscles 4. Strength and equality of peripheral pulses 5. Capillary refill of extremities

1 2 4 5

A nurse is caring for a client with a kidney infection. Output is tallied at the end of the shift, and the nurse notes that the client has voided 240 mL in the past 8 hours. Which action should the nurse take next? 1. Notify the physician. 2. Document the output amount. 3. Take the client's temperature. 4. Evaluate the client's blood pressure.

2

The nurse is preparing to administer an ordered enema to a client. Which intervention by the nurse is correct for this procedure? 1. Warm the water to a temperature between 115°F and 125°F. 2. Insert the tip of the enema tube approximately 3 to 4 inches into the rectum. 3. Give the enema while the client is in a sitting position on the toilet. 4. Have the client lie on the right side to facilitate the instillation of fluid.

2

The nurse is caring for a client with incontinence who has an order for a catheterized urine specimen to evaluate the presence of a urinary tract infection. Which catheter will the nurse select to obtain the specimen? 1. An indwelling catheter 2. A three-way catheter 3. A straight catheter 4. A coudé catheter

3

The nurse is providing care for a female client who was admitted due to a stroke. The client becomes frustrated because of an inability to respond verbally to the nurse's questions. Which terminology should the nurse use to document this complication? 1. Dysphasic 2. Dysphagic 3. Aphasic 4. Dyspneic

3

A client has been vomiting without relief from medications. The physician orders the client on NPO status. Which action by the nurse violates the physician's order? 1. Maintains previously ordered IV fluids 2. Gives ice chips when the client indicates mouth dryness 3. Provides mouth swabs and lip balm for client comfort 4. Offers mouth care on a regular basis

2

A client is prescribed the medication lithium as a mood-stabilizing agent. Which laboratory report indicates the client may be retaining higher than prescribed levels of lithium? 1. Low sodium levels 2. High sodium levels 3. Low potassium levels 4. High potassium levels

1

The LPN/LVN is assigned to feed a client who was admitted with the diagnosis of a cerebral vascular accident (CVA). The client's ability to swallow is intact, but chewing remains difficult. Which type of food will most likely cause the LPN/LVN to consult with the RN? 1. Mechanical soft 2. Pureed 3. Full liquid 4. Thickened liquid

1

The LPN/LVN is caring for a client with diabetes mellitus and obtains a morning blood glucose level of 60 mg/dL. The LPN/LVN reports the finding to the RN. Which intervention does the LPN/LVN expect? 1. Provide the client with one-half cup of orange juice. 2. Cover the client with insulin using a sliding scale. 3. Chart the finding in the client's medical record. 4. Wait for fifteen minutes and repeat the assessment.

1

The home-care nurse is visiting a client who performs self-catheterization. The nurse observes the client's technique as a plan to decrease the possibility of urinary tract infection (UTI). Which observation of the client's techniques will the nurse correct? 1. The client puts on clean gloves without washing the hands. 2. The client reuses a cleaned catheter for each catheterization. 3. The client wears clean gloves when inserting the catheter. 4. The client denies sensation of bladder fullness prior to the process.

1

The nurse assesses a client just admitted from the emergency department with pain in the lower right quadrant of the abdomen. The physician's order reads, "Diet as tolerated." Which conclusion will impact the nurse's decision regarding the client's diet? 1. The client will be NPO due to the probability of surgery. 2. A clear liquid diet is appropriate to avoid possible nausea. 3. The client can have a regular diet until symptoms worsen. 4. A diet high in protein and vitamin C will promote healing.

1

The nurse is assessing the feet of an adult client who is hospitalized with uncontrolled diabetes mellitus. Assessment findings indicate an absence of cuts, cracks, or blisters. The client states, "I don't have as much feeling in my feet as I used to." Which condition does the nurse correctly identify for this client? 1. Paresthesia 2. Infection 3. Lentigines 4. Necrosis

1

The nurse is caring for a client who has an order for a 24-hour urine specimen collection. The client asks, "Why do I have to collect my urine for 24 hours?" Which answer by the nurse is best? 1. "This test is done to evaluate how your kidneys function." 2. "Is there something specific about the test I can explain to help you understand?" 3. "The test will determine if you have a urinary tract infection." 4. "I can call your doctor for a complete explanation if you like."

1

The nurse is caring for a client with urinary stress incontinence. Which statement by the client indicates that teaching has been effective? 1. "I need to do Kegel exercises to help strengthen the muscles that control the urine." 2. "I need to drink fluids with my meals but not in between meals." 3. "I should not do sit-ups because that will increase my abdominal pressure." 4. "I should avoid things and activities that make me sneeze or cough."

1

The nurse is leading orientation for a newly hired nurse. The newly hired nurse states, "I worry about getting all the information documented after an assessment. How do I remember everything?" Which advice by the orienting nurse will be most helpful? 1. "Document in the same order you gather data by working from head to toe." 2. "It is always best to write everything down as you go and reference it later." 3. "Just start with the information you remember and then try to recall the rest." 4. "If you forget any specific information, just go back and assess the client again."

1

The nurse is obtaining a health history from an older adult client. The client tells the nurse that a bowel movement occurs about every 2 to 3 days. Which question should the nurse ask to determine if this is normal functioning for the client? 1. What is the consistency of your stool? 2. Do you take laxatives to go more often? 3. What is a normal daily diet for you? 4. How do you feel if you don't go every day?

1

The nurse is preparing to collect a stool specimen ordered by the physician. Which client and reason defines the need for the specimen? 1. A client traveled outside the country and has lost weight since returning. 2. A client experiences bloating and flatus after consuming dairy products. 3. A client with hemorrhoids notices streaks of blood on the toilet paper. 4. A client is on iron therapy for anemia and the stools are dark in color.

1

The nurse performs a focused assessment. Which condition will provide the best information through the use of percussion? 1. Hyper-inflated lungs 2. An enlarged heart 3. Cardiac arrhythmia 4. Rebound tenderness

1

The nurse uses the five techniques for obtaining objective data when performing the physical assessment of a client. Which technique provides assessment information through the use of the nurse's hands? 1. Palpation 2. Auscultation 3. Observation 4. Olfaction

1

While inspecting a client's stool, a nurse notices a small amount of black, tarry blood with a distinctive old-blood odor that appears to have been partially digested. Which term does the nurses use to describe the client's stool? 1. Melena 2. Occult blood 3. Frank blood 4. Steatorrhea

1

While providing care for an older adult client, the nurse learns that the client has had only small, watery stools for several days. Which is the nurse's priority in providing care for this client? 1. Assess the client for an impaction. 2. Call the primary care physician and get an order for a laxative. 3. Administer medication to slow the diarrhea. 4. Collect a stool specimen for analysis.

1

A nurse explains to a client that it is wise to avoid taking a laxative every day because of the problems it can cause. The client demonstrates understanding by saying laxative abuse can result in which condition? Select all that apply. 1. Fluid and electrolyte imbalances 2. The need for increasing dosages of laxative 3. Loss of natural contractility in the bowel 4. Increased risk for an impaction 5. Development of irritable bowel syndrome

1 2 3 4

The charge nurse is presenting recently licensed nurses with information about the importance of accurately assessing and documenting clients' heart sounds. Which information does the charge nurse determine to include in the presentation? Select all that apply. 1. To listen to and compare the intervals between the heartbeats 2. To compare the radial and apical pulses simultaneously 3. To document "distinct" if both heart tones are clearly heard 4. To listen to the apical pulse for a full 30 seconds 5. To document the rate for the apical pulse

1 2 3 5

The nurse, working in a pediatric clinic, is caring for a preschool client. The client presents with vomiting and diarrhea. The client's parent reports poor appetite and sleeplessness. The nurse suspects a urinary tract infection (UTI). Which additional assessment will help confirm the nurse's suspicion? Select all that apply. 1. Ask which direction the client wipes after using the toilet. 2. Ascertain the method by which the client bathes. 3. Inquire if the client has fallen or injured the perineal area. 4. Determine if the client has recently been incontinent. 5. Evaluate the client's usual daily nutritional intake.

1 2 4

The nurse is providing care for a client with a newly placed ileostomy. Which comment by the client indicates a lack of acceptance for the alteration in body function? Select all that apply. 1. "I don't want to look at anything right now while it is so fresh." 2. "I know that you know what to do, so I will be quiet during care." 3. "I am still having some intense pain; I think that I need medication." 4. "I guess that I will need to ask about any dietary changes I need to make." 5. "Please teach my spouse how to perform all the care; I don't need to know."

1 2 5

The nurse needs to acquire a clean-catch midstream urine specimen from a female client. The client is capable of getting the specimen without assistance after the nurse provides instructions. Which instructions will the nurse provide? Select all that apply. 1. Place the open specimen container upright on a flat surface. 2. Hold labia open during cleaning and until the specimen is acquired. 3. Clean the midline from front to back using three wipes, one time each. 4. Begin voiding in the toilet until the bladder feels nearly empty. 5. Collect a specimen of urine by placing the cup in the urinary stream.

1 2 5

The nurse is caring for a client who is postoperative for abdominal surgery. On assessment, the nurse notes the presence of hypoactive bowel sounds. Which nursing intervention does the nurse need to include on the client's plan of care? Select all that apply. 1. Ambulation four times a day in the hall 2. Intake of 8 ounces of water four times a day 3. Movement to a chair for meals 4. Laxative administration at bedtime 5. Encouragement to pass flatus

1 3 5

After completing the initial head-to-toe shift assessment, the nurse determines that no changes are needed in the client's plan of care. Which evaluation process supports the nurse's decision? 1. Using the knowledge that the client received a comprehensive health assessment 2. Reviewing the effectiveness of previously initiated nursing interventions 3. Referring to the facility's general plan of client care for the current shift 4. Recognizing that the client may be discharged from the hospital during this shift

2

During a staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a client is exhibiting signs of illness or injury. Which description defines the assessment findings from these methods? 1. Subjective 2. Measurable 3. Reported by the client 4. Hidden

2

During an admission physical assessment, a nurse questions a client about bowel elimination habits. Which client care goal is the nurse attempting to identify? 1. Assessment about the need for a laxative. 2. Maintain the client's normal elimination habit. 3. Complete collection of all pertinent client data. 4. Determine if further gastrointestinal testing is necessary.

2

The LPN/LVN understands that alterations in the characteristics of urine can be an important indication of a client's condition. Which urine characteristic does the LPN/LVN expect an unlicensed assistive personnel (UAP) to report? 1. The urine is golden yellow in color. 2. The UAP notices a distinctly sweet odor. 3. The collected urine is clear in appearance. 4. The measurement container has a clean bottom.

2

The nurse is caring for a female client who has a new order for the insertion of an indwelling urinary catheter. The nurse notes that the client has a latex allergy. Which action will the nurse perform? 1. Notify the physician that the catheter cannot be placed. 2. Obtain a silicone catheter for the client. 3. Inform the client that a catheter cannot be used because of her allergies. 4. Switch the indwelling urinary catheter for a three-way catheter.

2

The nurse is caring for a male client with a recent total hip replacement who cannot ambulate to the bathroom without difficulty. The client has a urinal but reports a continued inability to void. Which intervention by the nurse will assist the client with toileting? 1. Ask the client every 2 hours about needing help to the bathroom. 2. Assist the client to stand at the bedside and void into the urinal. 3. Inquire if the client is experiencing fear or anxiety about falling. 4. Consider that the client may need an indwelling urinary catheter.

2

The nurse is caring for multiple clients with a variety of bowel conditions. Which client does the nurse consider at greatest risk for surgery to place a colostomy? 1. A client with traumatic injury to the abdomen 2. A client with a portion of bowel without circulation 3. A client with a cancerous tumor in the transverse colon 4. A client who has experienced a ruptured diverticulum

2

The nurse is evaluating the potential presence of a urinary tract infection (UTI). In which laboratory value will the nurse be most interested? 1. Urine specific gravity 2. Urine pH 3. Blood urea nitrogen 4. Creatinine

2

The nurse is providing care for a client after joint replacement surgery. The nurse delivers a lunch tray with a cheeseburger, French fries, slaw, and fresh fruit. After the meal, the nurse picks up an empty tray. Which comment is more important for the nurse to make if the client states, "My husband ate part of my lunch because I'm just not that hungry"? 1. "That's fine. Most of our clients do not eat all their meals." 2. "I will need to know which foods you actually ate." 3. "The trays are overfilled so clients have plenty to eat." 4. "Let's discuss what foods you would like for the next meal."

2

The nurse is working in the emergency department (ED). A client arrives stating the inability to empty the bladder for the past three days. An ultrasound reveals an extremely distended bladder, and the physician orders immediate placement of an indwelling urinary catheter. Which possible complication does the nurse associate with the urgency of the order? 1. A possible rupture of the bladder 2. The development of hydronephrosis 3. Shock related to a fluid deficit 4. Delay in treatment of intense pain

2

The nurse performs a physical assessment on a client who is just admitted for left lower-lobe pneumonia. The client describes experiencing an unproductive cough. Which assessment finding will support the nurse's suspicion of consolidation in the left lower lobe? 1. Scattered rales 2. Absent breath sounds 3. Stridor with expiration 4. Rhonchi cleared by coughing

2

The nurse receives a report on a client who just returned from surgery following a transurethral prostatectomy (TURP). The nurse is told that the client has a three-way urinary catheter. The nurse associates the catheter selection based on which client need? 1. Allows for direct installation of an anti-infective to the surgery site. 2. Provides continuous bladder irrigation to control clot formation. 3. Separates the irrigation drainage from the client's urinary output. 4. Controls surgery site bleeding better than a two-way catheter.

2

The nurse recognizes that teaching has been effective if a client selects which beverage while undergoing treatment for a urinary tract infection (UTI)? 1. Apple juice 2. Cranberry juice 3. Tea 4. Coffee

2

The nurse prepares a presentation for parents of adolescents with eating disorders. The parents have expressed an interest in understanding the causes and effects of the disorders. Which information will the nurse include? Select all that apply. 1. It is more prevalent in males than in females. 2. It can cause a client's health to be severely affected. 3. It generally occurs during adolescence or early adulthood. 4. It is evidenced by extreme disturbances in eating habits. 5. It may result from either physical or psychological causes.

2 3 4 5

A client is admitted with long-standing chronic obstructive pulmonary disease (COPD) and is at risk for respiratory failure. Every 4 hours, the nurse performs a focused respiratory assessment. Which assessment action will the nurse include during each reassessment? Select all that apply. 1. Neck vein distention 2. Color of nail beds 3. Presence of sternal retractions 4. Temperature of extremities 5. SpO2

2 3 5

The nurse is reinforcing teaching for a female client with a history of recurrent urinary tract infections (UTIs). Which behavior, if shared by the client, indicates the client understands the necessary behaviors to avoid another UTI? Select all that apply. 1. Acknowledging that a UTI can travel from the bladder to the kidneys 2. Using a method of birth control other than a diaphragm or spermicides 3. Drinking cranberry juice or take cranberry extract tablets 4. Limiting caffeine intake to just 32 ounces a day 5. Being sure to void after having sexual intercourse

2 3 5

A female client has been admitted with ulcerative colitis. Which appearance of the client's stools will the nurse expect with the exacerbation of this condition? 1. Be black, tarry, and odiferous 2. Float, and be odorless and bloody 3. Contain pus, mucus, and blood 4. Be soft, but ribbon shaped

3

The LPN/LVN is obtaining a blood glucose level on a client with diabetes mellitus, and notes that the blood glucose level is 280 mg/dL. Knowledge of which condition prompts the LPN/LVN to report the finding to the RN? 1. Hypoglycemia 2. Diabetic coma 3. Hyperglycemia 4. A normal value

3

The LPN/LVN is working in a long-term care facility. A client is having difficulty managing urinary continence, and the LPN/LVN begins a program of bladder training with the client. Which part of the bladder training program should the LPN/LVN reconsider? 1. Have the client void every 2 hours during the day, even without an urge. 2. Incorporate the routine of voiding in the morning, after meals, and at bedtime. 3. Provide the client's favorite beverages, which are coffee and iced tea. 4. Shorten time between voiding if the client is incontinent before 2 hours.

3

The nurse brings a dinner tray to a client on a regular diet. The nurse notes that the client has been blind since birth. Which intervention by the nurse is most helpful in assisting this client to eat? 1. Ask the client how they would like their dinner tray arranged. 2. List and describe the foods that are present on the client's tray. 3. Compare the location of the food on a plate with the face of a clock. 4. Inquire if the client wants anything added or removed from the tray.

3

The nurse is admitting a client diagnosed with congestive heart failure. Although the client is sitting in a semi-Fowler position, the nurse is unable to auscultate distinct heart tones. Which action should the nurse perform first? 1. Document that the heart tones are muffled. 2. Count the radial pulse and document it as the heart rate. 3. Assist the client to lean forward and toward the left side. 4. Report the findings to the admitting physician.

3

The nurse is attempting to insert a standard urinary catheter in a female client who is unable to separate her legs because of severe contractures. Which adjustment will the nurse make? 1. Get another nurse to help separate the client's legs. 2. Have the client stand on the floor with her legs apart. 3. Try to insert the catheter with the client lying on her side. 4. Notify the physician for an alternate order.

3

The nurse is caring for a client who has fecal incontinence. The symptoms include intermittent periods when small amounts of liquid stool are passed, followed by periods of severe constipation requiring the use of enemas to resolve. Which intervention should the nurse perform first? 1. Assess for readiness to participate in a bowel training program. 2. Teach the client about increasing fiber and fluids in the daily diet. 3. Examine the client and check for the possibility of fecal impaction. 4. Inform the client of the multiple types of incontinence products available.

3

The nurse is completing the placement of a nasogastric (NG) tube. Which is the most reliable way for the nurse to initially confirm the placement of the tube? 1. Quickly instill 10 mL of air into the tube and listen for a "whoosh" in the epigastric area. 2. Withdraw some of the stomach contents and check for a pH between 1 and 4. 3. After placement of a radiopaque tube confirm the location of the tube by x-ray. 4. Check a line marked on the tube for location at the entrance of the nares.

3

The nurse is performing a physical assessment at the change of shift on an older adult client. Assessment indicates a breathing rate of 30 breaths per minute, breath sounds are clear to auscultation in all five lobes, and the client denies dyspnea. Which finding does the nurse expect with assessment of the client's capillary refill? 1. Nail beds dusky, capillary refill 10 seconds 2. Nail beds cyanotic, capillary refill 4 seconds 3. Nail beds pink, capillary refill 5 seconds 4. Nail beds blanched, capillary refill 3 seconds

3

The nurse is preparing teaching for a client ordered on long-term treatment with corticosteroids. As part of the teaching about side effects, the nurse should inform the client that which body function is primarily affected? 1. Absorption 2. Appetite 3. Metabolism 4. Excretion

3

The nurse is providing care for multiple clients in the hospital who are ordered on intake and output (I&O) measurement. Which client does the nurse anticipate will need extra assistance in obtaining accurate data? 1. The client with an indwelling urinary catheter who is bedridden 2. The client who is NPO for surgery with a preoperative IV 3. The client who is vomiting with an intake only of ice chips 4. The adult client who is ambulatory but mildly confused

3

The nurse is teaching a client newly diagnosed with diabetes mellitus about the eating and nutrition parameters required with the client's diagnosis. Which comment by the client indicates that teaching is understood? 1. "I will need to eat 3 meals and 2 snacks daily." 2. "I can plan for a special dinner if I skip my lunch." 3. "I will find a new method for cooking besides frying." 4. "Once a week I can splurge and eat whatever I want."

3

A client with a known history of diverticulosis who is experiencing severe cramping and diarrhea is admitted to the hospital during the night with a diagnosis of diverticulitis. The client's pain increases, and the abdomen is distended and hard. The client has spiked a fever of 102.4°F. The nurse concludes the client may be developing a life-threatening complication and notifies the physician. Which possible complication concerns the nurse? 1. Crohn disease 2. Irritable bowel syndrome (IBS) 3. Fecal incontinence 4. Peritonitis

4

A nurse is caring for a client who is being evaluated for urinary retention. Approximately 10 minutes after the client voids, the nurse uses the bladder scan and determines that the client has 80 mL urine remaining in the bladder. Which is the best statement for the nurse to make? 1. "Your bladder is still pretty full. Do you think you can void again?" 2. "You have a large amount of leftover urine in your bladder, so I will notify the doctor." 3. "You must have really great kidneys to make so much urine so quickly." 4. "There is still some urine in your bladder, but it is an amount considered normal."

4

After an initial assessment, a nurse documents that a client, admitted for abdominal pain, has hyperactive bowel sounds. Which type of bowel movement will the nurse expect this client to have? 1. Hard and shaped in small balls 2. Fluffy, with a tendency to float in the toilet 3. Ribbon-shaped and soft 4. Liquid or semi-liquid

4

An emergency department nurse admits an adult client for a drug overdose. The physician writes an order for the nurse to instill charcoal through a nasogastric (NG) tube. Which size tube will the nurse select? 1. 4 French 2. 8 French 3. 12 French 4. 16 French

4

An older adult client is admitted to the hospital for a bowel obstruction, and part of the client's duodenum was surgically removed. Which condition does the nurse recognize as a potential problem for the client? 1. Limited stomach capacity 2. Duodenum-produced enzymes are not available 3. Poor absorption from shortening of the colon 4. A decreased ability to absorb nutrients

4

In response to a nurse's question about bowel function, a client shares that sometimes the feces are greenish black in color. Which answer by the nurse is correct? 1. "Large amounts of dairy products can cause your stools to turn green." 2. "If you take iron tablets, your stools can become greenish black." 3. "Typically our diet has very little to do with the color of our stools." 4. "Eating green foods, such as spinach, can cause your stools to have greenish black streaks."

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The RN provides teaching to a client with newly diagnosed diabetes mellitus. Which method will the LPN/LVN reinforce as the best indicator of long-term glycemic control? 1. Creatinine level 2. Urine glucose level 3. Blood glucose level 4. Glycosylated hemoglobin

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The nurse assesses a client 24 hours after abdominal surgery. The client is experiencing nausea, anorexia, and is vomiting foul-smelling emesis. Physical assessment reveals an extended abdomen and hypoactive bowel sounds. Which order does the nurse expect from the client's physician? 1. A nasogastric tube inserted to provide enteral nutrition 2. A prescription for anti-nausea and anti-emetic medication 3. A schedule for six small liquid meals to be given daily 4. A nasogastric tube inserted for gastric decompression

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The nurse documents that the client is eupneic in regard to the client's respiratory status. Which interpretation of the nurse's documentation is correct? 1. Breathing requires the use of costal, sternal, and sub-clavicular muscles. 2. Respirations are very shallow and at a rate between 8 and 12 per minute. 3. Client is using thoracic muscles to breathe at 20 to 24 breaths per minute. 4. Respiratory function is normal in depth and rate with abdominal muscle use.

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The nurse is admitting a client for a diagnosis unrelated to nutrition; however, the client states, "I don't eat gluten, but I don't have celiac disease." Which meal will the nurse expect the client to order? 1. Bean soup, cornbread with butter, and tapioca pudding 2. Ham and cheese sandwich on whole wheat bread, and fruit 3. Spaghetti with meat sauce, salad, and cake with butter frosting 4. Baked chicken breast, mashed potatoes with butter, and ice cream

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The nurse is caring for a client in the hospital. On assessment, the nurse discovers the client's hands and feet are swollen. A review of the client's past medical history reveals a history of cardiac problems. Which diet does the nurse expect the physician to order for this client? 1. A fat-restricted diet 2. A carbohydrate-restricted diet 3. A calorie-restricted diet 4. A sodium-restricted diet

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The nurse is performing an initial physical assessment on a client. Which sequence does the nurse apply to correctly assess a client's abdomen? 1. Inspection, palpation, and auscultation 2. Palpation, inspection, and auscultation 3. Palpation, auscultation, and inspection 4. Inspection, auscultation, and palpation

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The nurse is providing care for a client admitted to the hospital due to a renal stone. The physician orders that all urine be strained. Which reason does the nurse recognize as the primary purpose of straining the client's urine? 1. To verify that the stone has definitely been passed 2. In order to determine if the client can be released 3. So that pain medication can be adjusted accordingly 4. For analysis to help identify cause and treatment

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The nurse plans additional time to build a relationship and establish rapport with a client admitted for surgery. Which is the most important reason for the nurse to promote this level of familiarity? 1. The client may not be willing to fully cooperate with the nurse otherwise. 2. The nurse can use the relationship to assure the client cooperates after surgery. 3. The client feels more relaxed if the nurse is perceived a friend. 4. The nurse understands the importance of establishing feelings of trust from the client.

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The nurse who is performing a physical assessment is preparing to auscultate breath sounds. Which position is most favorable position for performing the assessment of breath sounds? 1. Supine position 2. Low Fowler position 3. Semi-Fowler position 4. High Fowler position

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When positioning a client to listen to breath sounds, the nurse is correctly aware that which lobe can only be heard by anterior or lateral auscultation? Select all that apply. 1. Left upper lobe 2. Left lower lobe 3. Right upper lobe 4. Right middle lobe

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