Week 5 Practice Questions

Minerals

Which are nutrients that are inorganic elements found in nature? Vitamins Minerals Proteins Carbohydrates

Catabolism

Which metabolic process breaks larger particles into smaller ones and releases energy? Micronutrients Anabolism Catabolism Glycogenolysis

Sodium

Which mineral can contribute to heart disease, hypertension, and stroke if consumed in large amounts? Iron Magnesium Sodium Calcium

Proteins

Which nutrients are needed to repair and maintain cells? Proteins Carbohydrates Lipids Vitamins

1, 2, 3

Which objective measures can a nurse use to assess a person's dietary history. Select all that apply. 1. Food questionnaire 2. 3-day food record diary 3. 24-hour memory recall 4. Ask about diet 5. Measure body composition

Semi-Fowler's position

Which position is described as the client lying in a semi-recumbent position, with the head of the bed elevated to 30 degrees? Fowler's position Semi-Fowler's position Prone position Lateral position

1, 3, 5

Which precautions and considerations should a nurse take when bathing a client with dementia? Select all that apply. 1. The client may experience fear and loss of control. 2. The client must have a bath every day. 3. Clients who are agitated during a bath my stay agitated for hours. 4. Restraints can be applied if the client is resisting. 5. Prepackaged bathing products can help complete the bath faster and more comfortably.

Lipid

Which source of energy is butter? Simple carbohydrate Lipid Complete protein Incomplete protein

2, 3, 5

The nurse is teaching a patient about the importance of reducing saturated fats in a cardiac diet. Which oils should the nurse recommend as options? Select all that apply. 1. Palm oil 2. Peanut oil 3. Cottonseed oil 4. Coconut oil 5. Olive oil

2, 3, 4 XXXXXX

The nurse is teaching nutrition counseling to a client with cholecystitis and discussing the need to avoid fatty foods. What foods should be avoided? Select all that apply. 1. Oranges 2. Bread 3. Avocados 4. Beans 5. Salmon

Use Velcro fasteners instead of buttons and zippers.

A 70-year-old client has a nursing diagnosis of Self-Care Deficit: Dressing r/t decreased strength and endurance and loss of muscle control and coordination. What is an appropriate nursing intervention for the client? Use Velcro fasteners instead of buttons and zippers. Push the client to reach goals of self-care. Provide self-help devices: extensions with hooks for picking things up from the floor. Create a plan for visual deficits that are present: Place clothing on bed.

1, 2, 3, 4

A student nurse is bathing an obese client for the first time. What intervention could be suggested for bathing this client? Select all that apply. 1. Offer a handheld shower with a long-handled brush. 2. Apply moisture barrier creams after bathing. 3. Separate skin folds with towels. 4. Rinse and dry the skin well. 5. Use breathable materials including bed linens.

The body converts food into complex forms of chemical energy and then into usable energy; therefore, extra food intake must have equal energy exertion in order to not gain weight.

A client blames recent weight gain on his or her metabolism. Which is the best information that the nurse can provide to the client about how metabolism works? The body converts food into complex forms of chemical energy and then into usable energy; therefore, extra food intake must have equal energy exertion in order to not gain weight. Metabolism encompasses all the ways in which the body changes and uses nutrients for vital processes and bodily functions, so metabolism is unable to cause weight gain. The metabolic process involves exerting energy from foods to provide basal metabolic rate, or energy needed for the body to sustain function at all times. The body uses metabolism to release energy, allowing us to engage in bodily functions that do not cause weight gain.

Brush teeth with a foam or cotton mouth swab.

A client has a high risk of gum bleeding due to painful mouth lesions. What might the nurse consider as a precaution? Brush teeth very quickly to avoid bleeding. Instruct the client to brush his or her teeth and be prepared with gauze. Brush teeth with a foam or cotton mouth swab. Avoid brushing teeth and only use mouth rinse.

Fowler's

A client is admitted to the hospital with chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen via nasal cannula. Which position will best assist his breathing? Lateral Supine Fowler's Sims'

Explain the procedure to the client.

A client is being transferred from the bed to a stretcher for surgery using a transfer board. What should be the nurse's first action? Explain the procedure to the client. Place the client in the prone position. Lower the stretcher below the level of the bed. Place the bed in the lowest position.

Gastroesophageal reflux

A client is given the instructions to avoid eating before bedtime, keep the head of the bed elevated at 30 to 40 degrees, and to avoid fatty foods, chocolate, and smoking. Which impaired digestive function is most likely for this client? Gastroesophageal reflux Decreased gastric secretions Glucose intolerance Decreased intestinal peristalsis

Use an electric razor.

A client is providing A.M. care to a client who is on anticoagulation therapy. When assisting the client with shaving, which consideration should be taken? Shave with a straight razor in an up-and-down motion. Use a one-time only razor, then dispose. Use an electric razor. Use surgical clippers.

1, 4

A client reports performing intense cardiovascular workouts every day for 45 minutes. Which information should the nurse include to prevent dehydration in the client? Select all that apply. 1. Drink 8 ounces of fluid prior to exercise. 2. Sports drinks provide better thirst relief. 3. Rely on your thirst reflex to determine needs. 4. Continue to drink water throughout exercise. 5. Refrain from drinking excessive water after exercise.

1, 3, 4

A client reports that he follows a strict vegetarian diet. What recommendations should the nurse give? Select all that apply. 1. Sun exposure can help compensate for lack of dietary vitamin D. 2. The client should add meat to the diet; a vegetarian diet is not advised. 3. Increase intake of food fortified with vitamin B12 and B12 supplements. 4. Eat foods containing vitamin C to improve iron absorption. 5. The client should use nonstick cookware to prepare food.

Maceration

A client that has urinary incontinence is susceptible to what type of skin issue? Maceration Dry skin Abrasions Pressure injuries

Isometric

A client who is bedridden asks the nurse what exercises can be included to prevent muscle atrophy. What is the nurse's best response? Isometric Isotonic Aerobic Anaerobic

D

A client with a calcium deficiency also should be tested for a deficiency in which vitamin? A B C D

Encourage family members to bring foods the client likes to eat.

A client with a nursing diagnosis of Imbalanced Nutrition, Less Than Body Requirements r/t diagnosis of colon cancer and depression has no desire to eat. What is one method of assuring the client receives the needed nutrition? Encourage family members to bring foods the client likes to eat. Refer the client for appropriate counseling. Suggest community resources for access to food. Recognizes factors contributing to being underweight.

Wait for the patient to calm down, then give him a towel bath.

A client with dementia becomes belligerent and combative when the nurse attempts to give him a tub bath. How should the nurse proceed? Allow the patient to go without bathing for a day or two. Call for assistance to help the patient into the bathtub. Wait for the patient to calm down, then give him a towel bath. Ask another staff member to attempt the tub bath.

Do your exercise in the afternoon or evening.

A client with rheumatoid arthritis (RA) informs the nurse he or she wants to begin an exercise program to prevent the disease from getting worse. What should the nurse instruct the client? Use hand weights for strengthening. Include a rest period prior to exercising. Do your exercise in the afternoon or evening. Plan on doing exercises after taking autoimmune medications.

Self-care deficit

A new client on the medical-surgical unit has not bathed in several days although she is fully capable of engaging in personal hygiene practices and ADLs. Upon investigation, the nurse learns she is homeless and typically utilizes the services of the homeless shelter once a week for her bathing and other hygiene needs. What is an appropriate nursing diagnosis for this client? Self-care deficit Ineffective hygiene maintenance Disturbed body image Unilateral neglect

The nutritional quality of breast milk remains consistent regardless of dietary intake so that infants will receive all needed nutrients.

A new mother asks the nurse about the importance of breastfeeding her infant. What is the best response that the nurse can provide as the primary reason? The nutritional quality of breast milk remains consistent regardless of dietary intake so that infants will receive all needed nutrients. Natural immunity is transferred from mother to infant through antibodies so there is less risk for developing illness. The infant needs folic acid to prevent neural tube defects, and breast milk is the best method of administration. Breast milk provides more kilocalories than formula to aid in growth and development.

"Cow's milk can cause gastrointestinal bleeding and stress on the kidneys, and it can lead to iron-deficiency anemia."

A new mother comments on the expense of formula and asks the nurse why she cannot feed the baby the same milk that the rest of the family drinks. Which is the best response that the nurse can provide to the mother? "Cow's milk can cause gastrointestinal bleeding and stress on the kidneys, and it can lead to iron-deficiency anemia." "It is okay to give cow's milk as long as honey or corn syrup is added for the needed carbohydrates." "Cow's milk must be boiled prior to allowing an infant to ingest it to remove any potential for E. coli." "Providing the infant is of healthy weight, it is okay to give cow's milk, but it must be mixed with boiled or purified water to create a 50/50 mixture."

1, 2, 3, 4

A nurse is assigned a client who is temporarily nonambulatory and with a nursing diagnoses including Self-Care Deficit: Bathing and Self-Care Deficit: Toileting. What information should be provided when delegating assistance? Select all that apply. 1. Limitations and restrictions 2. Specific safety precautions 3. Presence of obstacles 4. Observations to make during the procedure and why they are important. 5. Scheduled care time and length of time needed

Activity intolerance

A nurse is assisting a client to a standing position. The client requires frequent breaks and is unable to catch his or her breath. After standing for a few seconds, the client states he or she is exhausted and needs to lie down again. Which is an appropriate priority nursing diagnosis for this client? Impaired physical mobility Activity intolerance Risk for injury Risk for disuse syndrome

Place all hygiene items on the client's right side and assist with what the client cannot reach.

A nurse is assisting a client who has had a stroke that caused the loss of use of the left side with activities of daily living. What actions can the nurse take to encourage self-care and as much independence as possible? Instruct the client to allow the nurse to help with bathing, as the client cannot do this activity alone. Place all hygiene items on the client's right side and assist with what the client cannot reach. Instruct the client to do as much as possible and not to worry about the rest. Place all hygiene items on the left side to encourage the client to use that side.

1, 3, 4

A nurse is assisting a morbidly obese client with bathing. Which specific considerations should be taken? Select all that apply. 1. Pay special attention to drying skin folds. 2. Instruct the client that a complete bath cannot be given. 3. Provide a trapeze to assist with movement. 4. Provide a long-handled shower head or brush. 5. Do not completely dry the skin.

Passive ROM

A nurse is caring for a 25-year-old client who is quadriplegic. Which treatment would be a priority to decrease the risk of joint contracture and promote joint mobility? Applying a trochanter roll Turning every 2 hours Active ROM Passive ROM

Use a padded tongue blade.

A nurse is performing oral care on an unconscious client. How should the nurse hold the mouth open? Use a padded tongue blade. Use fingers to open the mouth. Use a toothbrush to open the mouth. Use gauze to hold the teeth.

Chocolate milk

A nurse is teaching a client with heart disease about following a low-fat diet. Which foods would a nurse include in a list of high-fat foods to avoid? Chocolate milk Avocados Salmon Cashews

Complete bath

A nurse provides a bath in which the nurse washes the client's entire body. The client is unable to assist. Which type of bath is this? Partial bath Assist bath Therapeutic bath Complete bath

Popsicle

A postoperative client has been placed on a clear liquid diet. Which item should the nurse offer the client? Popsicle Milk shake Orange juice Yogurt

"Your son had a major injury, and his immobility might be causing him to feel isolated and depressed."

A teenage client was hospitalized 3 weeks ago after a motor vehicle accident in which he crushed his pelvis. He remains on bedrest. His parents tell the nurse, "Our son is just staring off into space and won't talk to us. He doesn't want to listen to his music or watch television. That is so unlike him." What is the nurse's best response? "I will inform his doctor and see whether we can get your son started on an antidepressant medication." "He is bored because he has been in the hospital for 3 weeks; I'll try to find something new for him to do." "He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse." "Your son had a major injury, and his immobility might be causing him to feel isolated and depressed."

1, 2, 3, 4

A young female client reports fatigue, feeling foggy, muscle cramps, constipation, and headaches, and states that her heart feels like it is "fluttering." During assessment, she states she has been on a high-protein, no-carb diet. Which information should the nurse give the client to educate her about the importance of eating healthy carbohydrates? Select all that apply. 1. Complex carbohydrates supply energy to muscles, organs, and the brain. 2. Without carbohydrates, the body has to resort to using protein for energy, which then cannot rebuild tissue or maintain/repair body tissue. 3. Healthy carbohydrates aid in the absorption of sodium and the excretion of calcium. 4. Healthy carbohydrates enhance insulin secretion, which is needed for cellular use of glucose. 5. Healthy carbohydrates regulate fluid balance so the body does not become dehydrated.

138 (220-57=163x0.85=138)

The nurse is working with a 57-year-old client who is worried about exercising too hard. What would be this client's maximum heart rate for high-intensity exercise?

Tub bath

An elderly client is ambulatory but requires assistance with bathing. The client has episodes of incontinence and his or her bed and gown is soiled. Which type of bath would be most appropriate? Complete bath Tub bath Partial bath Towel bath

Weakened immune system and hormonal imbalance

An individual who suffers from anorexia nervosa is at risk for what type of disruptions in the body? Weakened immune system and hormonal imbalance Obesity, diabetes, and hypertension Equal balance of kilocalories and energy expended Altered fluid balance leading to dehydration

4, 5

An older adult client suffered left-sided paralysis from a stroke. Which are the best actions for this client? Select all that apply. 1. Encourage taking deep breaths frequently to hyperinflate the lungs. 2. Monitor for constipation. 3. Encourage an even gait when walking in place. 4. Assess the extremities for swelling and muscle atrophy. 5. Teach the use of a two-point crutch technique for ambulation.

Strive to burn at least 500 to 1000 calories more than consumed each day.

An overweight client wants to lose weight. What is one realistic goal that the client should understand and set for himself or herself? Strive to burn at least 500 to 1000 calories more than consumed each day. Plan to lose 3 to 4 pounds per week. Set outcome goals that can be reached. Review goals daily and adjust as needed.

1, 2, 3, 4, 5

As a nurse working in a bariatric clinic, you are conducting a presurgery assessment for a 24-year-old client. Which anthropometric measurements should be taken? Select all that apply. 1. Skinfold measurements 2. Hydrodensitometry 3. Abdominal circumference 4. Waist-to-hip ratio 5. Body mass index 6. Blood glucose levels

1, 2, 3, 5

As the days slowly pass, Mariam begins to develop psychological effects of immobility. What should the nurse be assessing for? Select all that apply. 1. Apathy toward self-care 2. Depression 3. Sleep disturbances 4. Restlessness 5. Disorientation

1, 2, 3, 5

The nurse is working with an older client who wants to begin an exercise regimen. The client asks the nurse about the benefits of moderate walking 30 minutes per day. What would be the nurse's best response? Select all that apply. 1. Prevents falls 2. Improves memory 3. Reduces depression 4. Decreases appetite 5. Lowers risk of Alzheimer's

1, 3, 5

Which are functions of water in the body? Select all that apply. 1. Solvent 2. Nutrient 3. Lubricant 4. Carries oxygen 5. Body structure and form

1, 2, 3, 4

Her first walk in the hallway went well with the assistance of two staff members. Which statements should the nurse include upon returning Miriam to bed? Select all that apply. 1. "Do not try to get up by yourself." 2. "Perform active range-of-motion [AROM] activities hourly when in bed." 3. "That was good; we'll try again before discharge." 4. "Tell me about the severity of the pain you are having now." 5. "I'll bring the bedpan if you need it."

97 ((4x4)+(18x4)+(1x9)=16+72+9)

How many kcal would be available if a client has just eaten a food consisting of 4 grams of protein, 18 grams of carbohydrate, and 1 gram of fat?

112 (28x4)

How many kilocalories (energy) are released from metabolism of 28 g of carbohydrates?

1, 3, 5

Which are guidelines for good body mechanics? Select all that apply. 1. Wide base of support 2. Head facing down 3. Abdominal muscles tight 4. Shoulders dropped forward 5. Chest high

Somatic nervous system

If a person makes a conscious decision to bend the elbow, which nervous system is applied? Autonomic nervous system Somatic nervous system Reflex mechanism Synovial movement

1, 2, 3

In which position should the nurse place the client with chronic obstructive pulmonary disease (COPD) who is short of breath? Supine Orthopneic Semi-Fowler's High-Fowler's

Orthopneic

In which position should the nurse place the client with chronic obstructive pulmonary disease (COPD) who is short of breath? Supine Orthopneic Semi-Fowler's High-Fowler's

1, 2, 5

Which are included as part of the USDA dietary guidelines? Select all that apply. 1. Food safety 2. Adequate exercise 3. Immunization schedules 4. BMI chart 5. Choosing a nutritious diet

"Let me see you use the crutches to walk around the nurses' station."

The client is being educated about the use of crutches after a cast was applied to his left ankle. What directions by the nurse are most important before discharge? "Don't lean or swing on the crutches." "Be careful of slippery floors and puddles." "Let me see you use the crutches to walk around the nurses' station." "Keep the crutches close to you during the night in case you need to get up."

Single-ended cane w/ straight handle

The nurse is evaluating the mobility of a client with rheumatoid arthritis and good balance. Select the cane which is the best option for this client. Single-ended cane w/half circle handle Single-ended cane w/ straight handle Multiprong cane

Obtain additional assistance

Mariam has returned from surgery and is prescribed to begin increasing activity. Peter is prepared to help her get up for the first time. What is the most important action before beginning? Obtain a walker Obtain a gait belt Remove all obstacles Obtain additional assistance Determine level of motivation

2, 5

Mariam is an active 69-year-old. She leads the pool aerobic exercise group in the senior retirement community that she and her husband moved to 3 years ago. She walks 2 miles each morning and eats a healthy, balanced diet. She is from a family with longevity and trusts she will have good health well into her 90s.As Mariam is walking to her exercise class, she steps off the curb and falls. She is taken to the emergency room and diagnosed with a fractured hip. She must be on bedrest and in traction for a week before surgery is scheduled. During that time, the pain is significant and she requires a large amount of pain medicine. Which factors contribute to her immobility? Select all that apply. 1. Age 2. Injury 3. Nutritional status 4. Abuse of body 5. Stress

1, 2, 3

Miriam is excited to go home. Which of the following are key elements of discharge planning? Select all that apply. 1. Include her husband during instructions. 2. Arise from bed slowly to prevent or reduce dizziness. 3. Remove loose rugs and obstacles that may cause problems. 4. Stop using the walker when she's feeling strong enough. 5. Walk around the block several times a day independently.

Complete bed bath

The nurse is preparing to give a bath to an older adult who is unconscious and has had a fever and night sweats. Which type of bath would be the best option? Assist bath Tub bath Complete bed bath Partial bath

1, 3, 4, 5

Peter develops an immobility plan of care for Mariam. What should be included? Select all that apply. 1. Position to allow for lung expansion 2. Massage calves and legs each shift 3. Encourage visitors 4. Eat a healthy balanced diet 5. Turn every 2 hours

An orange with fortified cereal

The nurse is teaching a client who has iron-deficiency anemia about foods that should be included in the diet. The nurse can determine that the client understands these instructions if the client chooses which of the following foods from a sample menu? An orange with fortified cereal Nuts and seafood Bacon and eggs Avocados and figs

2, 3, 4 XXXXXXX

The nurse is teaching a group of school-age children about diet and nutrition. What recommendations should the nurse make about the USDA dietary guidelines? Select all that apply. 1. Eat until you are full and don't overeat. 2. Wash hands before and after meals. 3. Eat six meals a day. 4. Avoid empty calorie snacks. 5. Eat equal amounts of fruits, vegetables, protein, grains, and dairy.

1, 4, 5

The basal metabolic rate is impacted by which factors? Select all that apply. 1. Body temperature 2. Disease process 3. Muscle mass 4. Environmental temperature 5. Sleep patterns

1, 2, 3, 5

The nurse asks the unlicensed assistive personnel to complete morning care for an older adult. What is included with this request? Select all that apply. 1. Bathing 2. Oral care 3. Hair care 4. Back massage 5. Toileting

The UAP answers the telephone while wearing gloves.

The nurse assists unlicensed assistive personnel in providing morning care to a comatose client who is bowel and bladder incontinent. The nurse should intervene if which action is observed? The UAP answers the telephone while wearing gloves. The UAP logrolls the client to provide back care. The UAP places an incontinence pad under the client. The UAP performs oral care with suction attached.

Requires assistive person

The nurse is assigned a 39-year-old client who is temporarily nonambulatory due to a car accident that resulted in a fractured pelvis and femur. One nursing diagnosis is Self-Care Deficit: Bathing. Using the NOC ranking system for self-care, which category would this client fall into? Dependent, does not participate Requires assistive person and device Requires assistive person Independent with assistive device Completely independent

Morning care

The nurse is assigned a 39-year-old client with the nursing diagnoses Self-Care Deficit: Bathing and Self-Care Deficit: Toileting. When would be the most appropriate scheduled care time to address the bathing needs of this client? Hourly rounds PM care Early morning care Morning care

2, 5

The nurse is bathing a client with a raised red rash on the shoulders and back. What should be the nurse's next actions? Select all that apply. 1. Moisturize the skin to prevent drying. 2. Ask whether the client has any allergies. 3. Discuss the body image problems created by the presence of the rash. 4. Wash the skin thoroughly each day with hot water and soap. 5. Assess for further inflammatory reactions.

Use a quiet, calm manner, allowing for choices.

The nurse is bathing a client with senile dementia. What action will optimize the chance of cooperation? Use a quiet, calm manner, allowing for choices. Complete the bath quickly. Avoid bathing more often than necessary. Have other people present to assist.

Ask about hygiene customs in the client's native land.

The nurse is caring for a client who has recently immigrated to this country. The interpreter shares that the client usually bathes once a week. When your assessment is finished, the nurse plans to have the client shower. What additional information needs to be gathered? Find out when the client last bathed. Ask about hygiene customs in the client's native land. Explain the importance of showering daily. Tell the client the shower schedule for patients of the facility.

2, 3, 5

The nurse is directing unlicensed assistive personnel in providing morning care to a comatose client. Besides a bed bath, what care should be provided? Select all that apply. 1. Irrigating nose 2. Brushing teeth 3. Cleaning fingernails 4. Shaving legs 5. Moisturizing skin

"It is healthier for your heart to exercise than to be sedentary."

The nurse is discussing the benefits of exercise with a client who has a history of hypertension and atherosclerosis. The client expresses hesitancy about beginning an exercise program while having heart disease. What is the nurse's best response? "Why are you hesitant to begin an exercise program?" "It is healthier for your heart to exercise than to be sedentary." "You must begin an exercise program to prevent further cardiac damage." "Let me speak to your health-care provider prior to beginning an exercise program."

1, 2, 3, 5

The nurse is educating a group of nursing assistants regarding proper body mechanics. Which key concepts should the nurse include in the presentation? Select all that apply. 1. Balance 2. Coordination 3. Joint mobility 4. Base of support 5. Body alignment 6. Center of gravity

1, 2, 3

The nurse, Peter, knows that Mariam is at a higher risk for injury as a result of her immobility. Which assessment changes indicate a potential complication of immobility? Select all that apply. 1. Crackles in both lung bases 2. Edema of the feet 3. Reddened areas on the coccyx 4. Increased appetite 5. Diarrhea Check Answer

1, 3, 4

The occupational health nurse is educating a group of workers who do heavy lifting. Which safety aspects should be included in the session? Select all that apply. 1. Squat to lift objects. 2. Keep elbows to the side. 3. Spread legs apart when lifting. 4. Use thigh muscles when lifting. 5. Stand on tiptoes to reach objects.

1, 2, 4

To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. Which foods are incomplete proteins that should be consumed with a complementary protein? Select all that apply. 1. Refried beans 2. Peanut butter 3. Cheese 4. Whole grain bread 5. Turkey

Transfer board

Two nurses are planning to transfer a comatose client from the bed to a stretcher. Which device should be used? Transfer board Scoot sheet Footboard Transfer belt

Move your weaker leg forward as your walker moves forward.

Upon discharge, Miriam is instructed to continue using a walker until the follow-up visit with her surgeon in 2 weeks. What instructions need to be included with the use of the walker? Advance the walker far ahead of your body and walk toward it. Slide the walker with each step. Move your weaker leg forward as your walker moves forward. Stand well behind the back legs. Size does not matter; any size walker will work.

Isotonic

Weight training with free weights is an example of which type of exercise? Isometric Isotonic Isokinetic Aerobic

1, 2, 4, 5, 6, 7

What are some common problems of the mouth? 1. Stomatitis 2. Halitosis 3. Loose teeth 4. Oral malignancies 5. Cracked lips 6. Dental caries 7. Gingivitis

10, 5, 1, 6, 2, 7, 4, 9, 8, 3

What are the appropriate procedural steps for administering parenteral nutrition? 1. Examine the PN container for leaks, cloudiness, and floating particles 2. Connect the IV tube to the PN and place the IV tubing in the infusion pump 3. Trace tubing from the client back to the bag, then label the tubing with the date and time of change 4. Clamp the catheter and the old PN administration set if still connected and remove/discard gloves 5. Wash hands, don gloves, and position the client in supine position 6. Compare the PN bag to the client's identification 7. Identify the correct IV catheter and lumen for PN 8. Attach the infusion tubing to the designated PN port and turn the luerlock to secure the connection 9. Don sterile gloves (or clean gloves) and inspect the patency of line 10. Gather supplies and explain the procedure to the client

2, 3, 5

What are the most important considerations when performing oral hygiene for an unconscious critical client? Select all that apply. 1. Avoid the use of mouthwash. 2. Perform oral hygiene at least twice a day. 3. Moisturize lips every 2 hours. 4. Use hydrogen peroxide to oral mucosa. 5. Use a padded tongue blade when providing oral care.

1, 2, 3, 5

What are the parts of a comprehensive nutritional assessment? Select all that apply. 1. Body composition 2. Dietary history 3. Laboratory findings 4. Body surface area 5. Physical assessment

1, 2, 3, 4

What benefits can the client experience from bathing? Select all that apply. 1. Stimulates depth of respirations and provides sensory input. 2. The warmth and friction dilate blood vessels near the surface of the skin, increasing the circulation. 3. It can be a time to strengthen the nurse-client relationship. 4. It promotes relaxation and comfort, enhances well-being, and improves self-image. 5. The approach, method, and time can be adapted to suit the client.

Take a 20-minute walk on a break.

What can the nurse include in the day at work to minimize stress and maintain health? Vent frustrations to coworkers. Sit alone in a conference room. Play video games during a break. Take a 20-minute walk on a break.

Toxicity

What could potentially occur if a client takes Vitamin A, D, E, and K supplements daily? Toxicity Dehydration Impaired iron absorption Impaired metabolism

1, 2, 3

What eye care interventions should a nurse make for a comatose client? Select all that apply. 1. Keep eyes lubricated every 2 to 4 hours with saline. 2. Use a protective eye shield to keep eyes closed. 3. Instill eye ointment on lower lids as prescribed. 4. Use warm water to cleanse the eye area every 2 to 4 hours. 5. Eyes appear clean and without redness or drainage.

1, 2, 4, 6, 7

What factors influence hygiene practices? 1. Personal preference 2. Culture 3. Employment status 4. Economic status 5. College education 6. Developmental level 7. Knowledge level

2, 3, 4

Which are interventions used to manage and minimize the symptoms of dry mouth? Select all that apply. 1. Increase salt intake. 2. Use hard candy or gum. 3. Take frequent sips of water. 4. Use lip moisturizer. 5. Eat acidic foods.

1, 2, 3, 4

What factors regarding nutrition should the nurse consider when working with an older adult? Select all that apply. 1. Tooth loss and gum disease limit chewing ability. 2. It is not unusual for older adults to lose interest in eating and for the thirst sensation to decrease. 3. The ability to taste and smell diminishes with age, and many clients find some diets unappealing. 4. Arthritic hands may create difficulty preparing and eating food. 5. Dietary patterns are not a consideration for aging adults who tend to eat what they want when they want.

Decreased circulation to lower extremities

What is a contributing factor to foot problems in elderly clients? Obesity Decreased circulation to lower extremities Taking multiple medications Increased pressure on the feet

Drape the client appropriately to protect modesty.

What is important to remember when conducting perineal care for a client? Drape the client appropriately to protect modesty. A nurse/NAP of the same gender should conduct perineal care. Clients should be facing the opposite direction to avoid embarrassment. A family member must be present to ensure client comfort.

1, 2, 3

What must the nurse consider in regards to the integrity of the aging adult's skin? Select all that apply. 1. Skin is thinner and more fragile. 2. Glandular activity decreases. 3. Collagen and elastin fibers weaken and become less elastic. 4. Skin is susceptible to bacterial infections such as MRSA. 5. Keratin production causes skin to become tough in areas.

1, 2, 3, 4

What should be assessed when monitoring a client receiving parenteral nutrition? Select all that apply. 1. Swelling, redness, drainage of insertion site 2. Rate and amount infused hourly 3. Blood glucose levels every 4 to 6 hours 4. Intake and output 5. Nutritional assessment every other day

Dangle the client's legs off the side of the bed.

What should the nurse do for a client with orthostatic hypotension who is preparing to get out of bed to walk for the first time in several days? Use a standing frame to promote stability. Dangle the client's legs off the side of the bed. Employ the mechanical lift to transfer the client. Have the client place his or her arms around the nurse's neck.

1, 2, 3

What should the nurse educator include when giving a presentation to a group of nurses about ways to prevent nurse back injuries while transferring a patient? Select all that apply. 1. Use electric or mechanical lifts for transfers. 2. Obtain assistance from other staff members. 3. Lock wheels and furniture and equipment before moving clients. 4. Move clients around equipment and furniture. 5. Transfer the client first, then move any tubing.

2, 3, 5

What should the nurse include when trying to motivate a group of adolescents to include exercise in their daily regimen? Select all that apply. 1. Set long-range goals. 2. Recognize barriers to exercise. 3. Reward yourself when goals are met. 4. Find one exercise activity and stick with it. 5. Tailor the exercise regimen to meet needs.

A transfer belt

What should the nurse use prior to moving a client who needs an assist device to help move from the bed to a chair? A transfer belt A hydraulic lift A standing frame A transfer roller sheet

1, 2, 3, 4

What skin conditions should be monitored for in a client with Risk for Impaired Skin Integrity? Select all that apply. 1. Dampness 2. Dehydration 3. Inadequate circulation 4. Nutritional status 5. Wound healing

1, 2, 4, 5, 7

What types of scheduled hygiene are provided in healthcare facilities? 1. Hour of sleep care 2. Hourly rounds 3. Mid-day care 4. Early morning care 5. Morning care 6. Before dinner care 7. Afternoon care 8. Middle of the night care

Use of ultraviolet light in the room

When addressing the needs of a nonambulatory client with severe Vitamin D deficiency, what might be an appropriate intervention? Use of ultraviolet light in the room Have client spend time outside Administer multivitamin as prescribed Monitor for skin integrity

Pale without underlying tones of pink

When assessing pallor in a light-skinned client, how does the skin appear? Pale without underlying tones of pink Ashen gray or yellow in appearance Redness, often in patches Slight bluish color

2, 1, 5, 6, 3, 4

When conducting a basin and water bath, in what order is the client washed? 1. Chest 2. Eyes 3. Back and buttocks 4. Rectum and perineal 5. Abdomen 6. Legs and feet

1, 2, 3

When educating a client on nail care of the feet, what important aspects should be included? Select all that apply. 1. Inspect nails daily. 2. Trim with clippers, or file if diabetic. 3. File nails straight across, slightly rounding edges. 4. Cut cuticles back with a cuticle clipper. 5. Remove ingrown nails with a cuticle clipper.

H.S. care

When is a back massage typically offered as part of scheduled care? Morning care Early morning care Afternoon care H.S. care

189 (21x9)

When teaching a client about the concept of metabolism and energy from foods, how much energy would the nurse explain is released from 21 g of lipids?

180 (45x4)

When teaching a client about the concept of metabolism and energy from foods, how much energy would the nurse explain is released from 45g of protein?

Distal to proximal

When washing a client's legs, which direction is correct? Proximal to distal Short, circular motions Distal to proximal Gently patting the limb

1, 2, 5

Which are appropriate client teaching topics for nurses to provide to clients regarding nail care? Select all that apply. 1. Inspect nails daily. 2. Clip toenails straight across. 3. If cuticles are rough, the client should bite them until they are flush with the skin. 4. Sharp nail scissors should be used for cutting toenails. 5. Use moisturizing lotion to soften cuticles.

1, 4, 5

Which are care and hygiene challenges nurses must consider when providing care for morbidly obese clients? Select all that apply. 1. Pressure 2. Dry skin 3. Dry mouth 4. Friction and shear 5. Moisture

1, 3, 4

Which are functions of body fat? Select all that apply. 1. Protection of vital organs 2. Produces blood cells 3. Essential to cell metabolism 4. Enables nerve-impulse transmission 5. Helps eliminate wastes

2, 3, 5

Which are the recommendations from the Centers for Disease Control for use of water in caring for contact lenses? Select all that apply. 1. Contact lenses should be washed daily with soap and water. 2. Contact lenses should be removed before showering or swimming. 3. Water can cause soft lenses to swell and stick to the eye. 4. Users should store lenses in water. 5. If water touches the lens, the user should discard them.

Standing on one foot, then the other, to improve balance

Which aspect of the exercise regimen should the nurse refrain from including when developing an exercise program for an older client with arthritis? Exercise that makes you breathe hard Heavy weights to improve resistance Stretching every other day to improve flexibility Standing on one foot, then the other, to improve balance

Skinfold measurements

Which assessment provides an estimate of a person's body fat content? Weight Percussion Skinfold measurements Basal metabolic rate

1, 2, 5

Which chronic diseases or conditions can have a direct impact on nutritional needs? Select all that apply. 1. Traumatic injury 2. Alcoholism 3. Degenerative joint disease 4. Viral illness 5. Cognitive function

1, 2, 5

Which describe types of muscle? Select all that apply. 1. Skeletal 2. Smooth 3. Articulating 4. Diarthrosis 5. Cardiac

Fitness

Which describes the ability to carry out activities of daily living with vigor and alertness, without undue fatigue, and with enough energy for leisure pursuits or to respond to emergencies? Mobility Fitness Exercise Endurance

Point of origin

Which describes the attachment of a muscle to a more stable bone? Point of origin Point of insertion Articulation Synovial point

Metabolism

Which describes the body breaking down nutrients into chemical energy and then into usable energy? Intake Conversion Metabolism Synthesis

Basal metabolic rate

Which describes the measure of energy used while at rest in a neutral temperature environment that is required for the heart, lungs, and brain to function optimally? Body mass index Calorie Basal metabolic rate Body composition analysis

Sprain

Which describes the stretching of a ligament that causes the ligament to tear? Sprain Strain Fracture Degeneration

Assist bath

Which describes the type of bath in which a client does as much as possible, but the nurse assists with hard-to-reach areas, such as the back, feet, and legs? Assist bath Complete bath Partial bath Deferred bath

Recommended Daily Allowance

Which describes the updated revision of vitamins, minerals, proteins, and total calories that are thought to meet the needs of about 98% of a particular group? Daily Reference Intake Recommended Daily Allowance Adequate Intakes Standards

1, 2, 3

Which environmental factors could prevent a person from exercising on a consistent basis? Select all that apply. 1. Weather 2. Pollutants 3. Financial strains 4. Medical diseases 5. Congenital disorders

1, 2, 5

Which factors can affect a person's hygiene practices? Select all that apply. 1. Culture 2. Developmental level 3. Career choice 4. Tolerance for cold 5. Economic status

1, 2, 4, 5

Which findings in the immobile client are complications related to immobility? Select all that apply. 1. Constipation 2. Decreasing appetite 3. Muscle growth 4. Bladder infection 5. Lung fluid

1, 3, 5

Which health factors affect a person's self-care ability? Select all that apply. 1. Pain 2. Socioeconomic status 3. Limited mobility 4. Family involvement 5. Cognitive impairment

Perform AROM each hour.

Which intervention in the immobile client's plan of care best helps develop muscle strength? Consume a diet high in protein. Use overbed trapeze to pull self up in bed. Log-roll client every 2 hours. Perform AROM each hour.

1, 2, 5

Which interventions should the nurse include in the plan of care for a postmenopausal client with osteoporosis? Select all that apply. 1. Refrain from cigarette smoking. 2. Perform weight-bearing exercises. 3. Consume 2 to 3 alcoholic beverages daily. 4. Take 1,000 mg per day of calcium supplements. 5. Include vitamin D and phosphorus in daily intake.

Risk for disuse syndrome

Which is an appropriate nursing diagnosis for a client who has had a stroke and has left-sided hemiparesis? Impaired physical mobility Sedentary lifestyle Risk for disuse syndrome Risk for injury

Gout

Which is an inflammatory response to high levels of uric acid in the blood, resulting in severe pain and limited activity levels? Ankylosing spondylitis Rheumatoid arthritis Gout Osteoarthritis

Bacteria

Which is the cause of body odor? Perspiration Bacteria Dry skin Inadequate drying

Weight in kg ÷ (height in meters)^2

Which is the correct formula for calculating body mass index? Weight in pounds ÷ (height in meters)^2 Weight in kg ÷ (height in inches)^2 Weight in pounds ÷ (height in inches)^2 Weight in kg ÷ (height in meters)^2

Radiography

Which is the most accurate method of verifying correct feeding tube placement when a tube is initially placed? Auscultation Visualization Aspiration Radiography

Periodontal disease

Which is the most common cause of tooth loss in adults over 35? Stomatitis Cheilosis Dental caries Periodontal disease

Client's needs

Which is the most important factor a nurse should consider when planning a client's hygiene care? Policies of the facility Family instruction Nurse's scheduled tasks Client's needs

Shower

Which is the most preferred method of bathing for ambulatory clients? Tub bath Partial bath Shower Complete bath

Osteoarthritis

Which is the most prevalent type of degenerative disease that can severely limit a person's ability to perform physical activity? Osteoarthritis Rheumatoid arthritis Gout Osteomyelitis

"I don't even care if I get cleaned up or not."

Which statement by the client indicates emotional distress from immobility? "There's nothing good on television." "I'm looking forward to being out of bed." "I don't even care if I get cleaned up or not." "I'm getting 6 to 7 hours of sleep each night."

1, 2

Which statements about bed making are correct? Select all that apply. 1. Draw sheets are used to help lift and turn heavier patients. 2. A poorly made bed can contribute to the development of pressure ulcers. 3. Making the bed in a hospital is like making a bed at home. 4. The bed linens should be changed before the bath occurs. 5. When making an occupied bed, the rails should be up on the side where the nurse is working.

1, 4, 5

Which statements about nutrition are correct? Select all that apply. 1. Carbohydrates raise blood glucose levels. 2. Fats are unhealthy and should be avoided. 3. Vitamin supplements are recommended for everyone. 4. Vegetables can be eaten with other vegetables to make a complete protein. 5. Micronutrients are foods that are consumed in small amounts.

1, 4, 5

Which structures are involved in physical coordination? Select all that apply. 1. Cerebral cortex 2. Frontal lobe 3. Spinal cord 4. Cerebellum 5. Basal ganglia

2, 3, 4, 5, 7, 8

Which techniques are beneficial in bathing a client with dementia? 1. Play loud music as a distraction 2. Let the client know what you are going to do before touching him or her with out spraying water 3. Do not rush 4. Provide choices 5. Provide privacy 6. Bathe the client only once a week 7. Use a gentle shower head for rinsing 8. Explain the procedure simply

Bed bath

Which term describes a type of bath in which a client is in bed but able to bathe himself or herself? Bed bath Tub bath Therapeutic bath Bag bath

1, 2, 3, 5, 7

Which terms are commonly used to describe types of baths delivered in healthcare? 1. Towel bath 2. Assist bath 3. Therapeutic bath 4. Ocean bath 5. Partial bath 6. Sauna bath 7. Bed bath 8. Foaming bath

Therapeutic bath

Which type of bath is most likely to be a medical order? Bed bath Tub bath Therapeutic bath Assist bath

Flexibility

Which type of exercise program does a nurse recommend to an older adult to prevent injury and muscle strain? Intensity Duration Flexibility Resistance

2, 4, 5

Which type of exercises should the nurse recommend to an obese client to reduce pain and increase compliance? Select all that apply. 1. Jogging 2. Swimming 3. Playing tennis 4. Using a rowing machine 5. Riding a recumbent bike

The knee joints

Which type of joint is a synovial joint? The cranium The vertebrae The knee joints The pubic bones

High-density lipids (HDLs)

Which type of lipid removes cholesterol from the bloodstream? High-density lipids (HDLs) Low-density lipids (LDLs) Glycerides Sterols

D

Which vitamin should be suggested as a supplement to a client who chooses a vegetarian diet? D A C K

Mechanical lift

Which would be the most appropriate way of moving a client who is very obese and immobile? Trapeze Transfer board Mechanical lift Transfer belt

Stop the feeding, assess the client, flush the tube, wait an hour, then measure gastric contents and restart the feeding at a slower rate.

While receiving nutrition through a gastric tube, the client complains of feeling full and nauseated. What should the nurse do at this point? Stop the feeding, assess the client, flush the tube, wait an hour, then measure gastric contents and restart the feeding at a slower rate. Cuff the tracheostomy tube and keep inflated for at least 15 minutes afterward to prevent aspiration. Remove any enteral feeding solution remaining in the tube. Try instilling 5 mL of warm water into the tube and clamping the tube for 5 minutes. Turn the client onto his or her left side.