course point

A hospice nurse is discussing spirituality and faith with a client and the client's family member. The client asks the nurse what is the difference between spirituality and faith. How will the nurse describe faith?

"A trust and belief in a higher power or something you cannot see"

During a nutritional assessment, the nurse measures a woman's waist at 38.5 inches (98 cm). Based on this finding, which of the following is a priority intervention?

Educate the client regarding her increased risk for hypertension and diabetes.

The nurse is developing a health-promotion program at a company in which many employees are women in their 20s and 30s. For this population, the nurse plans to include information about

Parenting issues

A student nurse asks the nursing instructor, "What will my role as a nurse encompass after I graduate?" What is the best response by the nursing instructor?

You will care for individuals and families and play a role in health education, illness prevention, and promotion.

A novice nurse is learning the difference between community-based nursing and community-oriented nursing. Which scenario does the nurse recognize as a role of the community-oriented nurse?

Nurse working a booth at a health fair performing blood pressure and glucose screenings

A client recovering from gastric bypass surgery accidentally removes the nasogastric tube. What is the best action by the nurse?

Notify the surgeon about the tube's removal

Which phase of the nursing process encompasses the establishment of expected outcomes?

Planning

Which question would help the nurse gather information about a client's lifestyle that may be a factor in the client's present illness?

"How many cups of coffee do you drink each day?"

A nurse is caring for a patient with a Salem sump gastric tube attached to low intermittent suction for decompression. The patient asks, "What's this blue part of the tube for?" Which response by the nurse would be most appropriate?

"It is a vent that prevents backflow of the secretions."

During the health history, the nurse asks the client about the health status of siblings and grandparents. The client asks why the nurse is asking about her family members. Which response from the nurse is most appropriate?

"Often the health status of family members helps to identify genetic diseases."

A nurse educator for a local home care company is teaching staff nurses on the use of the Outcome and Assessment Information Set (OASIS). What statement will the nurse include when teaching about the OASIS?

"Results are used to improve overall quality improvement efforts."

What is the purpose of early discharge planning as explained to a client?

"To ensure you have the resources you need when you leave"

A nurse is preparing to administer a 500 mL bolus tube feeding to a patient. The nurse anticipates administering this feeding over which time frame?

10 to 15 minutes Typically a bolus tube feeding of 300 to 500 mL requires about 10 to 15 minutes to complete.

A waist circumference greater than which value is indicative of excess abdominal fat in men?

101.60 cm (40 in)

A patient has a gastric sump tube inserted and attached to low intermittent suction. The physician has ordered the tube to be irrigated with 30 mL of normal saline every 6 hours. When reviewing the patient's intake and output record for the past 24 hours, the nurse would expect to note that the patient received how much fluid with the irrigation?

120

A nurse measures the residual gastric volume of a patient receiving intermittent tube feedings. The patient's last residual volume was 250 mL. Which finding would lead the nurse to notify the physician?

225 mL Explanation: If a residual volume greater than 200 mL is obtained twice, the nurse would need to notify the physician. A single residual volume of 200 mL or more does not indicate a need to withhold a feeding. Feedings may be continued in patients as long as there is close monitoring of gastric residual volume trends, x-ray study results, and the patient's physical status.

The client has the intake and output shown in the accompanying chart for an 8-hour shift. What is the positive fluid balance?

260 Explanation: Intake includes all the components listed in the intake column, which amounts to 710 mL. The output, which is the urine of 450 mL, is subtracted from the total intake. This leaves 260 mL as a positive fluid balance.

As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach?

4

The nurse inserts a nasogastric tube into the right nares of a patient. When testing the tube aspirate for pH to confirm placement, what does the nurse anticipate the pH will be if placement is in the lungs?

6

A client is receiving a parenteral nutrition admixture that contains carbohydrates, electrolytes, vitamins, trace minerals, and sterile water and is now scheduled to receive an intravenous fat emulsion (Intralipid). What is the best action by the nurse?

Attaches the fat emulsion tubing to a Y connector close to the infusion site

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

Auscultate lung sounds every 4 hours.

A nurse is preparing to assist a health care provider with a peripherally inserted central catheter. The nurse demonstrates understanding of this procedure by preparing which insertion site?

Basilic vein

A nurse determines that a patient has poor nutrition based on which assessment finding?

Beefy-red tongue

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first?

Clamp the catheter.

A nurse is caring for a client with a long-term central venous catheter. Which care principle is correct?

Clean the port with an alcohol pad before administering I.V. fluid through the catheter.

A home care nurse is assessing a client's need for home visits. Which of the following would the nurse use as the primary determinant for future visits?

Client's current health status

Which management function involves a team effort to achieve patient care outcomes?

Collaboration

A nurse providing care to a patient who is receiving nasogastric tube feedings finds that the tube is clogged. Which of the following would be least appropriate to use to unclog the tube?

Cranberry juice

A community health nurse is preparing learning materials for an upcoming public seminar for adults. What factors will the nurse consider, based on applying concepts of adult learning readiness? Select all that apply.

Culture Personal values Physical status Emotional status

A nurse is caring for a client who wants to quit smoking. The client tells the nurse he has thrown out all of his cigarettes. Which stage is the client in, according to the transtheoretical model of change?

Decision-making

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome?

Diarrhea

Which step of the nursing process determines whether the client understands the health teaching that is provided?

Evaluation

A patient is receiving nasogastric tube feedings. The intake and output record for the past 24 hours reveals an intake of 3100 mL and an output of 2400 mL. The nurse identifies which nursing diagnosis as most likely?

Excess fluid volume

What is the first step in becoming culturally competent?

Exploring one's own cultural beliefs

A client has been receiving intermittent tube feedings for several days at home. The nurse notes the findings as shown in the accompanying documentation. The nurse reports the following as an adverse reaction to the tube feeding:

Fasting blood glucose level

The nurse assesses a patient who recently had a nasoenteric intubation. Symptoms of oliguria, lethargy, and tachycardia in the patient would indicate to the nurse what common complication?

Fluid volume deficit

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

Flush with 10 mL of water.

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the:

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration

A client has a gastrointestinal tube that enters the stomach through a surgically created opening in the abdominal wall. The nurse documents this as which of the following?

Gastrostomy tube

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was:

Greater than 200 mL.

Which health promotion model does the nurse identify is the reason some people choose actions to foster health and others refuse to participate?

Health Belief Model

Which is an important role for a nurse in the health care delivery system?

Identifying patient needs and working with patients to address them

A current trend in health education that significantly influences nursing practice is:

Increased emphasis on patient involvement in their own care.

Which of the following is a diagnosis related to health education?

Ineffective health maintenance

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

The nurse is assessing a client's abdomen and percusses a large area of dullness on the right side of the abdomen, not the expected tympany. What has the nurse percussed?

Liver

A nurse is preparing to perform a dressing change to the site of a client's central venous catheter used for parenteral nutrition. Which equipment and supplies would the nurse need to gather? Select all that apply.

Masks Skin antiseptic Alcohol wipes Sterile gauze pads

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct?

Monitoring the feeding closely.

A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this as a reflection of which need?

Physiologic needs

According to the American Nurses Association (1995), the advanced practice registered nurse is distinguished from other registered nurses according to scope of practice. Select the activity that would distinguish the advanced practice nurse from other RNs.

Prescribes medications

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing.

A nurse knows that the use of a learning contract increases motivation and increases the likelihood of patient compliance with the treatment regimen. Which client goal best exemplifies a well-designed learning contract?

The client who wishes to stop smoking agrees to cut back on one cigarette a day for the first week of treatment and then decrease smoking by two cigarettes the following week of treatment.

After making the initial home visit, a nurse develops a plan of care for a client with diabetes. As part of the plan of care, the nurse identifies the nursing diagnosis "deficient knowledge related to daily insulin administration for diabetic self-care." Which outcome would be most appropriate?

The client will demonstrate independence in daily insulin self-administration.

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process

The nurse is making an initial home visit to assess a patient for home health services. Which patients most frequently require home health services?

The frail and elderly who need skilled care

Based on the nurse's knowledge of nonadherence to therapeutic regimens, which nurse needs to place extra emphasis on adherence to the treatment plan?

The nurse planning to teach adults aged 65 about congestive heart failure management

A client receiving home care observes the visiting nurse place a bag on a paper barrier at the beginning of the visit. To avoid misunderstanding, what does the nurse teach the client about the practice of placing the supplies on the barrier?

The placement of the barrier is to follow universal precautions.

Results from the 2013 OASIS data study revealed that data from the study can be used to identify individuals at greatest risk for readmission to the hospital. Using this data, what can the nurse determine will decrease the readmission rate of hospitalizations?

The shift of resources to the community

A graduate nurse is cleaning a central venous access device (CVAD) and is being evaluated by the preceptor nurse. The preceptor nurse makes a recommendation for relearning the skill when she notes the graduate nurse does the following action:

Wipes catheter ports from distal end to insertion site

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is

acidic

A client is being treated for injuries resulting from a skateboarding accident and is very agitated as the nurse cleans several gashes on the client's head. Which of the nursing responsibilities outlined by the American Nurses Association is the nurse fulfilling?

administering medications, wound care, and numerous other personal interventions

A client is experiencing social isolation. Using Maslow's hierarchy of needs, identify the level that would correspond to this need?

belonging & affection

The primary source of microorganisms for catheter-related infections are the skin and the

catheter hub.

The nurse on an evidence-based practice council makes recommendations to ensure patency of nontunneled central venous lines. The nurse recommends that daily saline and diluted heparin flushes be used in which situation?

daily when not in use

To ensure patency of central venous line ports, diluted heparin flushes are used

daily when not in use.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?

diaphoresis, vomiting, and diarrhea.

The nurse attempts to unclog a client's feeding tube. Attempts with warm water agitation and milking the tube are unsuccessful. The nurse uses evidence-based practice principles when subsequently using which technique to unclog the tube?

digestive enzymes and sodium bicarbonate

The nurse prepares to administer all of a client's medications via feeding tube. The nurse consults the pharmacist and/or physician when the nurse notes which type of oral medication on the client's medication administration record?

enteric-coated tablets

Rebound hypoglycemia is a complication of parenteral nutrition caused by

feedings stopped too abruptly.

The nurse conducts discharge education for a client who is to go home with parenteral nutrition (PN). The nurse determines the client understands the education when the client indicates a sign and/or symptom of metabolic complications is

loose, watery stools.

At which body mass index (BMI) value are patients considered to have increased risk for problems associated with poor nutritional status?

lower than 18.5

Which condition is caused by improper catheter placement and inadvertent puncture of the pleura?

pneumothorax

The nurse teaches an unlicensed caregiver about bathing clients who are receiving tube feedings. The most significant complication related to continuous tube feedings is the

potential risk for aspiration.

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

The nurse monitors a client with nasoenteric intubation. When should the nurse contact the physician?

urinary output 20 mL/hr

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion?

Allow the patient to sip water as the tube is being inserted.