Fundamentals of Nursing Exam 2

A patient needs to have a foley catheter inserted. Place the following steps into the correct order for this procedure. 1. Apply sterile gloves 2. Open the catheterization kit 3. Wash the perineal area with soap and water 4. Position the patient 5. Drape the perineum 6. Clean the urethra

4, 3, 2. 5, 1, 6

Place the steps of administering an intradermal injection in the correct order. 1. Inject medication slowly 2. Note the presence of a bleb 3. Advance needle through epidermis to 3mm 4. Using nondominant hand, stretch skin over site with forefinger 5. Insert needle at a 5 to 15 degree angle into the skin until resistance is felt 6. Cleanse site with antiseptic swab

6, 4, 5, 3, 1, 2 Rationale: This is the correct sequence of steps to administer an intradermal injection.

Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. True False

True Rationale: This is the correct definition of healing by primary intention

To maintain normal elimination patterns in a hospitalized patient, why should the nurse encourage the patient to take time to defecate 1 hour after meals? a. The presence of food stimulates peristalsis b. Mass colonic peristalsis occurs at this time c. Irregularity helps to develop a habitual pattern d. Neglecting the urge to defecate can cause diarrhea

b

21) Which meal best promotes healing for a patient recovering from a burn injury? a. Pork chop, fried potatoes, coffee b. Pasta marinara, garlic bread, ginger ale c. Chicken breast, strawberries, milk d. Peanut butter and jelly sandwich, banana, tea

c Rationale: The meal with the best nutrition for wound-healing includes protein and vitamin-C. Foods that have low nutritional value, such as sugar or those with low or no calories, are not beneficial.

When teaching a patient about wound healing, the nurse should tell the patient which of the following? a. Inadequate nutrition delays wound healing and increases the risk of infection b. Chronic wounds heal more effectively in a dry, open environment, so leave them open to air whenever possible c. Long-term steroid therapy diminishes the inflammatory response and speeds wound healing d. Fat tissue heals more readily because there is less vascularization

a Rationale: Inadequate nutrition—including proteins, carbohydrates, lipids, vitamins, and minerals—delays tissue repair and increases risk for infection. Both full-thickness wounds and partial-thickness wounds heal more efficiently in a moist, protected environment. Long-term steroid therapy may diminish the inflammatory response and reduce the healing potential. Steroids slow collagen synthesis. Fat tissue has less blood supply, which decreases transport of nutrients and cellular elements required for healing.

The nurse would determine which factors as contributing to stress incontinence in a female client? Select all that apply. 1. Obesity 2. Sneezing 3. Nulliparity 4. Decreased estrogen 5. Performing Kegel exercises 6. Voiding at frequent intervals

1, 2, 4 Rationale: Obesity contributes to stress incontinence by causing intra-abdominal pressure. Sneezing or laughing often causes leakage of urine. A decrease in estrogen levels after menopause is also a factor. Nulliparity is not a factor, but a history of having three or more vaginal births may be a factor. Performing Kegel exercises is a means of strengthening muscle tone. Voiding at regular intervals, such as every 2 hours, decreases urine storage in the bladder, lessening the chance of incontinence.

It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to the automated dispensing system (ADS) or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside.

2 Rationale: It is the second step/check in accuracy

The nurse prepares the client for the removal of a nasogastric tube that was inserted to treat a bowel obstruction. During the tube removal, the nurse instructs the client to take which action? 1. Inhale deeply 2. Exhale slowly 3. Hold in a deep breath 4. Pause between breaths

3 Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal. The maneuver partially occludes the airway during tube removal; afterward, the client exhales as soon as the tube is out and thus avoids drawing the gastric contents into the trachea. The nurse pulls the tube out steadily and smoothly while the client holds the breath. The remaining options are incorrect because options 1 and 2 increase the risk of aspiration, and option 4 is ineffective.

The nurse is planning on administering eardrops to an infant. The nurse would plan to proceed by taking which step to assure the appropriate instillation of the medication? 1. Pull down and back on the auricle, and direct the solution onto the eardrum 2. Pull up and back on the earlobe, and direct the solution toward the wall of the ear canal 3. Pull up and back on the auricle, and direct the solution toward the wall of the ear canal 4. Pull down and back on the auricle, and direct the solution toward the wall of the ear canal.

4 Rationale: The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the nurse pulls down and back on the auricle. The wrist of the dominant hand is rested on the infant's head. The medication is administered by aiming it at the wall of the ear canal rather than directly onto the eardrum. The infant should be held or positioned with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult, the auricle is pulled up and back the straighten the auditory canal.

While preparing to administer an intravenous (IV) medication, the nurse notes that the medication, the nurse notes that the medication is incompatible with the IV solution. Which intervention would the nurse take to assure the client's safety? 1. Ask the provider to prescribe a compatible IV solution 2. Start a new IV catheter for the incompatible medication 3. Collaborate with the provider for a new administration route 4. Flush tubing before and after administering the medication with normal saline

4 Rationale: When giving a medication intravenously, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline to prevent in-line precipitation of the incompatible agents. Starting a new IV, changing the solution, or changing the administration route is unnecessary because a simpler, less risky, viable option exists.

A nurse suspects that a patient may be experiencing urinary retention. What should the nurse expect to find on assessment? a. Spasms and difficulty urinating b. Pain in the umbilical region c. Large amounts of voided cloudy urine d. Small amounts of urine voided 2 to 3 times her hour

d

A patient with a Foley catheter needs a urine sample for culture and sensitivity. What is the most appropriate action for the nurse to take? a. Insert a sterile blunt cannula in the catheter port to withdraw urine b. Open the drainage bag and withdraw urine c. Disconnect the drainage tube from the catheter d. Withdraw urine from the close system drainage bag

a

16) A nurse is reviewing factors that increase the risk of a urinary tract infection (UTIs). Which of the following factors should the nurse include? (Select all that apply) a. Frequent sexual intercourse b. Lowering of testosterone levels c. Wiping from front to back to clean the perineum d. Location of the urethra close to the anus e. Frequent catheterization

a, d, e Rationale: Having frequent sexual intercourse increases the risk of UTIs in all clients. The close proximity of the urethra to the anus is a factor that increases the risk of an infection. Frequent catheterization and the use of indwelling catheters are risk factors for UTIs.

Elevating the head of the bed to the maximum allowed amount of 30 degrees for a patient in balanced suspension traction helps to promote normal elimination by which of the following? a. Decreasing peristaltic movement b. Promoting contraction of the thigh muscles c. Strengthening the resistance of the internal and external sphincters d. Exerting increased pressure on the rectum

d

Which of the following may indicate an increased risk for wound dehiscence? a. It is within the first 24 to 48 hours after surgery b. The patient holds a pillow over the abdomen whenever coughing c. There is a small amount serous drainage noted o the dressing d. There is an increase in serosanguineous drainage from the wound

d Rationale: When there is an increase in serosanguineous drainage from a wound, the nurse should be alert for the potential for dehiscence. Dehiscence most commonly occurs before collagen formation (i.e., 3 to 11 days after injury or surgery). Risk for hemorrhage is greatest during the first 24 to 48 hours following surgery. Placing a pillow or folded thin blanket over the abdomen provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure. This is done to prevent wound dehiscence.

The client has a close catheter irrigation system. Which information would the nurse include in this client's documentation? Select all that apply. 1. Character of drainage 2. Presence of blood clots 3. Client complaint of pain/spams 4. Type and amount or irrigation used 5. Amount of solution returned as drainage 6. How often the drainage system was changed each shift

1, 2, 3, 4, 5 Rationale: The character of drainage would describe details such as color and sediment and is a means of evaluating the effectiveness of the irrigation. Presence and size description of blood clots, complaints of spasms, type and quantity of solution infused, and amount of solution returned as drainage all provide information as to the effectiveness of the procedure and client status. The drainage system is not changed every shift.

The nurse observe a continual oozing from the rectum of a patient who has been immobilized following surgery. The nurse recognizes that this condition is most likely a result of which of the following? a. Diarrhea b. Flatulence c. Fecal impaction d. The Valsalva maneuver

c

What signs manifest in infants and young children who are dehydrated? Select all that apply. a. Dizziness b. Light-headedness c. Dry eyes when crying d. High fever e. Sunken eyes f. Irritability

c, d, e, f Rationale: In infants and young children, dehydration manifests in high fever, sunken eyes, or cheeks, an absence of tears when crying, and irritability. In contrast, dizziness and lightheaded-ness are characteristics of dehydration in adults.

Patients with urinary incontinence are unable to completely empty their bladder. The nurse can assist a patient to void by using which of the following methods? Select all that apply. 1. Completely manual bladder compression 2. Having the patient assume the normal position for voiding 3. Telling the patient to void only when he or she has the urge 4. Pressing down on the right and left flanks of the patient 5. Running water in the sink

1, 2, 5

After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply) 1. Assess the injection site 2. Administer an oral medication for pain 3. Notify the patient's health care provider of assessment findings 4. Document assessment findings and related interventions in the patient's medical record 5. This is a normal finding, so nothing needs to be done 6. Apply ice to the site for relief of burning pain

1, 3, 4 Rationale: Assessing the injection site may reveal a sire reaction or induration from the injection. The health care provider needs to be notified in case there is an adverse effect from the injection. The nurse must always document adverse effects so that the site and patient can be monitored.

Which information is most appropriate for the nurse to include in client teaching regarding ostomy care? Select all that apply 1. Change the appliance daily 2. Empty the pouch when 1/3 to 1/2 full 3. The stoma should be dry and pale pink 4. The stoma should be moist and pink to red 5. The skin barrier should be within 1/16 to 1/8 inch of the stoma 6. Change the appliance every 3 day or longer, or if it is leaking effluent

2, 4, 5, 6 Rationale: The pouch should be emptied when 1/3 to 1/2 full to prevent the weight of contents from loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to within 1/16 the 1/8 inch of the base of the stoma prevents effluent from irritating the skin. With an adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2 weeks. Changing the appliance daily would damage the skin around the stoma. A stoma that is dry and pale pink is indicative of an unhealthy stoma.

The home-care nurse visits an older client diagnosed with Parkinson's disease who requires instillation of multiple eye drops. Which instruction for the administration of eye drops would the nurse plan to provide to this client who demonstrates signs/symptoms of this diagnosis? 1. Administer the eye drops rapidly 2. Have a family member instill the eye drops 3. Lie down on a bed or sofa to instill the eye drops 4. Keep the eye drops in the refrigerator so that they will thicken

3 Rationale: Older adults diagnosed with Parkinson's disease will experience tremors, making it more difficult to instill eye drops. The older client is instructed to lie down on a bed or sofa to instill eye drops to provide control and allow the drops to be administered more easily. If multiple eye drops are needed, there should be a wait time of 3 to 4 minutes between drops. It's reasonable to expect a family member to be available consistently to instill eye drops. Additionally, this discourages client independence. Placing eye drops in the refrigerator should not be done unless specifically prescribed.

The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate? 1. Reassuring the client that those sensations will subside 2. Raising the enema bag so that the solution can be introduced quickly 3. Discontinuing the enema and notifying the primary health care provider 4. Clamping the tubing for 30 seconds and restarting the flow at a slower rate

4 Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.

The nurse receives a patient from the emergency department with the diagnosis of ileus. The nurse expects the health care provider to order NPO for dietary status, and insert a nasogastric tube. The nurse knows that the purpose of the nasogastric tube is to do which of the following? a. Decompress the stomach until peristalsis returns b. Provide tube feeding until peristalsis resumes c. Allow for the release of flatulence d. To keep the stomach expanded until peristalsis resumes

a

14) A client with an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is patent b. Reassure the client that it is not possible for them to urinate c. Recatheterize the bladder with a larger-gauge catheter d. Collect a urine specimen for analysis

a Rationale: A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.

The HCP orders a patient to have a fecal occult blood test. To obtain an accurate result, the nurse instructs the patient to do which of the following? a. Submit one sample for analysis b. Take extra amounts of vitamin C supplements c. Stop taking aspirin 14 days prior to the beginning of the test d. Refrain from ingesting red meats for 3 days before testing

d

The nurse is caring of a client receiving intravenous (IV) therapy monitors for which signs of infiltration of an IV infusion? (Select all that apply) 1. Slowing of the IV rate 2. Tenderness at the insertion site 3. Edema around the insertion site 4. Skin tightness at the insertion site 5. Warmth of the skin at the insertion site 6. Fluid leaking from the insertion site

1, 2, 3, 4, 6 Rationale: Infiltration is the leakage of an IV solution into the extracellular tissue. Manifestations include slowing of the IV rate, burning, tenderness, or general discomfort at the insertion site; increasing edema in or around the catheter insertion site; complaints of skin tightness; blanching or coolness of the skin; and fluid leaking from the insertions site.

A 56 year-old patient, who has recently become postmenopausal, made an appointment with her health care provider for symptoms of a UTI. The patient has had three previously diagnosed UTIs in the past 4 months. She asks the nurse if this is a normal occurrence with postmenopausal women. What is the best response from the nurse? a. "Yes, and this is why I'm not looking forward to going through menopause." b. Yes, because as women go through menopause, the lining of the urethra becomes more susceptible to infections." c. "No, but why don't you ask your health care provider for some antibiotics to keep on hand?" d. "Yes, and this must be frustrating because as we become older our body starts to cause us more problems."

b

A male patient has been admitted with a fever and malaise. The HCP had ordered a clean catch midstream specimen for urinalysis on this patient. To collect the urine specimen, the nurse should instruct the patient to do which of the following? a. Ask the patient to void into a cup or urine collection container b. Cleanse his penis, begin his stream, and then void into a sterile cup c. Return to bed to obtain the specimen using a straight catheter insertion d. Use sterile gloves to cleanse his penis and collect the specimen in a sterile cup.

b

A patient is undergoing abdominal surgeries, which will most likely result in an ostomy. The patient asks the nurse, "what will the stool from my ostomy look like?" What is the best answer? a. "The consistency of your stools will be very soft" b. "The consistency of your stools will depend on the location of the stoma (ostomy)" c. "Your stools won't change from what they currently are" d. "The consistency of your stools will be liquid"

b

3) The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? a. Left Sims' position b. Right Sims' position c. On the left side of the body, with the head of the bed elevated 45 degrees d. On the right side of the body, with the head of the bed elevated 45 degrees.

a Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

9) The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? a. Dark red drainage b. Dark brown drainage c. Green-tinged drainage d. Light yellowish-brown drainage

a Rationale: For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green-tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

Identify contributing factors to pressure ulcer formation. (Select all that apply) a. Malnutrition b. Middle age c. Decreased sensory perception/mobility d. Stress e. Anemia f. Excessive sweating g. Ethnic background

a, c, d, e, f Rationale: Three pressure-related forces contribute to the development of a pressure ulcer: intensity of pressure (how much pressure is applied), duration of pressure (how long the pressure is applied), and tissue tolerance (the ability of the tissue to redistribute the weight). Having decreased mobility or decreased ability to perceive the need to shift one's weight or change position places an individual at risk for pressure ulcer development. Three extrinsic factors, shear, friction, and moisture, make the tissues less tolerant of pressure. Other factors important in pressure ulcer development include poor nutrition, advanced age, medical conditions that support poor tissue perfusion (low blood pressure, smoking, elevated temperature, anemia), and psychosocial status (in particular stress-induced cortisol secretion).

A nurse has delegated the administration of a tap water enema to a nursing assistive personnel (NAP). The NAP demonstrates understanding of the procedure when she states which of the following? (Select all that apply) a. "I will lower the enema when the patient complains of cramping" b. :I will speed up the enema administration when the patient complains of cramping" c. "I will withdraw the tube when the patient complains of cramping" d. "I will clamp the tubing when the patient complains of cramping" e. "I will fill the bag with hot water because it will cool while I am administering the enema" f. "I will have the patient sit on the toilet while I am administering the enema"

a, d

The labor/delivery nurse is caring for a 33 year-old who is in labor with her first child. The patient complained to the nurse about the hemorrhoids that she has experienced during the last month of her pregnancy. She asks, "what can I do to prevent future problems with hemorrhoids?" That is the nurse's best response? a. "Hemorrhoids are caused by defecation of stools that are loose and watery" b. "You need to soften your stools by drinking plenty of fluids" c. "You should eat less carbohydrates" d. "There is nothing that you can do to prevent hemorrhoids"

b

28) The nurse is providing wound care for a client with a Stage III pressure ulcer. Which of the following signs indicates that the wound is healing? a. Skin is red and does not blanch when pressed b. The wound bed is getting smaller c. Appearance of the serum-filled blister d. Eschar covers the wound area

b Rationale: The ulcer presents clinically as a deep crater with or without undetermined of adjacent tissue. Signs of healing include: the sore gets smaller; pinkish tissue starts forming along the edges, moving to the center; some bleeding may be present, indicating good circulation to the area. Eschar is dead tissue; when it covers a pressure ulcer, the wound can't be staged, Skin that is red and doesn't blanch when pressed indicates a Stage I ulcer. Appearance of a serum-filled blister occurs in Stage II.

35) The bed of a patient who has an indwelling urinary catheter (Foley) is found wet with urine. After determining that the catheter is patent, the nurse should: a. Tell the patient to use the bedpan when there is an urge to void b. Insert a larger-size catheter c. Provide perineal care whenever necessary d. Position a waterproof pad under the patient's buttocks

b Rationale: Urine is leaking around the urinary retention catheter and a larger-size catheter is required; once ordered, it is within the role of the nurse to select the appropriate size catheter and perform the insertion.

10) A nurse is assessing a patient who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply) a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema

b, c, d Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an elevated temperature, a decrease in blood pressure, poor skin turgor, tachycardia, and weakened peripheral pulses. Peripheral edema results from a fluid overload.

The nurse is caring for a patient with abdominal pain. While obtaining a stool specimen for occult blood, the nurse notices that the specimen is black. The nurse recognizes that the color change may be a result of which of the following? a. Absence of bile b. Malabsorption of fat c. Diarrhea d. Iron supplements or GI bleeding

d

30) While providing preoperative education to a client, the nurse explains that the client will return from surgery with a sequential compression device (SCD). Which of the following statements by the nurse would be most correct? a. "You won't have to do any other exercises." b. "The SCD means you can stay on bed rest." c. "You will wear the SCD when ambulating." d. "The SCD imitates the action of walking."

d Rationale: A Sequential Compression Device (SCD) is a method of DVT prevention that improves blood flow in the legs. SCDs are shaped like "sleeves" that wrap around the legs and inflate with air one at a time. This imitates walking and helps prevent blood clots. The SCD is worn while sitting or in bed; the device is removed for ambulating. Clients should still do foot exercises, including circles and flexing. Clients should be up and walking as soon as possible post-surgery, and continue to ambulate frequently.

As the nurse begins to administer scheduled doses of furosemide and nifedipine, the client asks for an as needed (PRN) dose of aluminum hydroxide. Which action by the nurse would best ensure the effectiveness of all the medications? 1. Assess the client's immediate need for the antacid 2. Administer all three medications at the same time 3. Administer the nifedipine and aluminum hydroxide, then the furosemide 1 hour later 4. Administer the furosemide and aluminum hydroxide, then the nifedipine 1 hour later

1 Rationale: Antacids such as aluminum hydroxide often interfere with the absorption of other medications. For this reason, antacids should be separated from other medications by at least 1 hour. Because of the diuretic action of the furosemide and the antihypertensive action of the nifedipine, it is important to administer them on time if the client can tolerate waiting for the aluminum hydroxide. The nurse should assess the client to determine the need for the antacid. Therefore, options 2, 3, and 4 are incorrect.

When administering medication intramuscularly, the nurse would document the intervention by including which information? (Select all that apply) 1. Site of injection 2. The amount of medication injected 3. The name of the medication injected 4. The time the medication was prepared for injection 5. Confirmation that the medication was injected intramuscularly

1, 2, 3, 5 Rationale: Safe administration of medication requires appropriate documentation, which includes the name, route, and amount of the medication; in the case of an injection, the site is also included. The time the medication is given (not the time is was prepared) is included in the documentation.

The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? (Select all that apply) 1. Surgery 2. Bladder training 3. Scheduled toileting 4. Dietary modifications 5. Pelvic muscle exercises 6. Intermittent Catheterization

2, 3, 4, 5 Rationale: Urge continence is the involuntary passage of urine after a strong sense of the urgency to void. It's characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contractions; and voiding in either small amounts (<100 mL)or large amounts (>500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment or urge incontinence.

31) One of the nurse's patients has a nasogastric (NG) tube for tube feedings and medications. Which nursing action is appropriate when caring for this patient? a. Check the area where the tape is applied qd b. Change the tubing from the feeding q 48 hr c. Place the bed in the low Fowler's position for feedings d. Flush the NG tube q 4 hr with hot water

a Rationale: The nurse should change the tape at the patient's nose every day and assess the skin for breakdown. Tubing and feeding items are replaced every 24 hours. The NG tube is flushed with warm water to avoid burning the patient or causing discomfort. The bed is placed in the high Fowler's position for tube feedings.

12) A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply) a. Warm the enema solution prior to instillation b. Position the client on the left side with the right leg flexed forward c. Lubricate the rectal tube or nozzle d. Slowly insert the rectal tube about 5 cm (2 in) e. Hang the enema container 61 cm (24 in) above the client's anus

a, b, c Rationale: Warm enema solution because cold fluid can cause abdominal cramping, and hot fluid can damage the intestinal mucosa. Place the client on the left side with the right leg flexed forward to promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon. Lubricate the tubing to prevent trauma or irritation to the rectal mucosa. The correct length of insertion of an adult patient is 7.6 to 10.2 cm (3 to 4 in). The maximum recommended height to hang enema container is 46 cm (18 in).

5) The nurse is preparing to administer medication using a client's nasogastric tube. What actions should the nurse take before administering the medication? Select all that apply. a. Check the residual volume b. Aspirate the stomach contents c. Turn off the suction to the nasogastric tube d. Remove the tube and place it in the other nostril e. Test the stomach contents for a pH indicating acidity

a, b, c, e Rationale: By aspirating stomach contents, the residual volume can be determined, and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary.

Which of the following conditions could affect the function of the digestive process? (Select all the apply) a. Increase in mobility b. Diagnostic testing c. Increase in nutrition d. Medications e. Increase in fluid intake f. Surgery

a, b, d, f

Which of the following are functions of dressings? )Select all that apply) a. To promote hemostasis b. To keep the wound bed dry c. Wound debridement d. To prevent contamination e. To increase circulation

a, c, d Rationale: Dressings provide several functions, which include debridement, maintaining a moist wound environment, protecting from outside contamination and further injury, preventing the spread of microorganisms, increasing patient comfort, and promoting hemostasis.

The nurse on a rehabilitation unit is caring for a 77 year-old patient who had undergone total knee replacement surgery. Since surgery, the patient has had several instances of urinary incontinence. The HCP is contemplating the order of a foley catheter. What is the nurse's best response to this suggestion? a. "perhaps you could order intermittent straight catheter insertions instead?" b. "I think it would be better to put a disposable undergarment on her." c. Could we try a toileting schedule before you order the foley?" d. "I think that is a good idea; it will prevent skin breakdown"

c

The nurse is assessing a 55 year-old patient who is in the clinic for a routine physical. When would the nurse instruct the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT)? a. If there is a family history of polyps b. As part of a routine examination for colon cancer c. If patient reports rectal bleeding d. If a palpable mass is detected on digital examination

b Rationale: Guaiac fecal occult blood testing (gFOBT) is used as a diagnostic screening tool for colon cancer as recommended by the American Cancer Society. More advanced screenings, such as a colonoscopy, would be indicated for rectal bleeding, a palpable mass detected upon digital examination, and/or a family history of polyps.

24) A client refers to the unit after abdominal surgery. While monitoring the client, the nurse observes a moderate amount of red blood on the dressing. The nurse will document this type of wound drainage as... a. Serosanguineous b. Sanguineous c. Purulent d. Serous

b Rationale: Wound drainage is described by type, color, amount, and odor. Types of drainage are: 1. Serous: clear and thin; may be present in a healthy, healing wound. 2. Serosanguineous: containing blood; may also be present in a healthy, healing wound. 3. Sanguineous: primarily blood. 4. Purulent: thick, white, and pus-like; may be indicative of infection and should be cultured.

36) The registered nurse who works on a medical/surgical unit cares for a patient with a feeding tube. What would cause the nurse to suspect that the feeding tube's placement is incorrect? a. The patient coughs frequently b. The patient develops a fever c. The pH of the aspirate is 3 d. The pH of the aspirate is 7

d Rationale: A pH of 7 indicates that the aspirate we have drawn comes from the lungs rather than the stomach. Normal stomach pH is 1-4.

17) A nurse is preparing to initiate a bladder training program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply) a. Restrict the client's intake of fluids during the daytime b. Have the client record urination times c. Gradually increase the urination intervals d. Remind the client to hold urine until next scheduled urination time e. Provide a sterile container for urine

b, c, d Rationale: Asking the client to keep track of urination times, gradually increasing the intervals between urinations, and reminding the client to hold urine until the next scheduled time helps their progress toward the goal of 4-hr intervals between urination.

Which patients benefits the most from an enema prepared with a hypertonic solution? a. A patient who is a young infant b. A patient who is dehydrated c. A patient who is suffering from acute inflammation in the lower colon d. A patient who is unable to tolerate large volumes of fluid

d Rationale: An enema prepared with a hypertonic solution is designed to be low volume. Patients unable to tolerate large volumes of fluid benefit most from this enema type. This type of enema is contraindicated for infants and dehydrated patients. A patient with acute inflammation in the lower colon will receive an enema containing steroid medication.

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse is noticing? a. These are expected findings for this postoperative time period b. The patient may become dependent upon pain medication c. The nurse should observe the patient more closely for wound dehiscence d. The patient is demonstrating signs of postoperative wound infection

d Rationale: The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection include fever, tenderness and pain at the wound site, an elevated white blood cell count, and may appear inflamed at the edges of the wound. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending upon the causative organism.

Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? (Select all the apply) 1. Use strict aseptic technique 2. Place the drainage bag lower than the bladder level 3. Inflate the balloon with 4 to 5 mL beyond its capacity 4. Swab the urinary catheter with sterile water before inserting 5. Advance the catheter 1 to 2 inches after urine appears in the tubing

1, 2, 5 Rationale: The nurse would use strict aseptic technique to insert the catheter. The drainage bag is placed lower than bladder level to ensure drainage, prevent retrograde flow of urine, and reduce the risk of infection. Advancing the catheter 1 to 2 inches beyond the point where the flow of urine is first noted is also good practice because this ensures that the catheter balloon is completely in the bladder before it's inflated. The nurse risks rupturing the catheter's balloon by overinflating it; therefore, the nurse inflates the balloon with the specified volume for the catheter because inflating the balloon with 4 to 5 mL beyond it's capacity is unsafe. The urinary catheter is sterile, so it is inappropriate and unnecessary to swab it with sterile water before inserting.

A client who had surgery this morning has a distended bladder and is unable to void. Which nursing interventions are most appropriate initially? Select all that apply. 1. Run warm water over the perineum 2. Have the client listen to the sound of running water 3. Obtain a prescription for an indwelling urinary catheter 4. Position the client on a bedpan with the head the bed elevated 5. Perform a bladder ultrasonography to evaluate the amount of urine left in the bladder

1, 2, 4, 5 Rationale: Before performing any interventions, the nurse should use a bladder ultrasonography to obtain data about the amount of urine in the client's bladder. The nurse should first use conservative methods such as maintaining a functional position with the head of the bed elevated, running warm water over the perineum, and having the client listen to the sound of running water. If these interventions are unsuccessful, the nurse should obtain a prescription for a straight catheterization. The use of an indwelling catheter places the client at risk for infection.

An older client has been diagnosed with functional incontinence. Which strategies are most appropriate to implement for this type of incontinence? Select all that apply. 1. Modify clothing for easy removal 2. Assess environment for obstacles 3. Decrease fluid intake to 1500 mL/day 4. Schedule a toileting routine every 2 hours 5. Obtain a prescription for catheterization to eliminate embarrassment 6. Set up schedule of cues such as mealtimes, awakening, and bedtime

1, 2, 4, 6 Rationale: Modifying clothing to use Velcro or easy fasteners can save time in reacting to urge. Environmental obstacles such as poor lighting or lack of assistive devices can make it difficult to reach the toilet in a timely manner. Decreasing fluid intake to below 2000 mL will irritate the bladder and may contribute to incontinence. Toileting every 2 hours will prevent overfilling of the bladder. A schedule will provide reminders to use the toilet. Catheterization will contribute to risk of infection.

2) The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Assess the patency of the airway b. Check tubes or drains for patency c. Check the dressing to assess for bleeding d. Assess the vital signs to compare with preoperative measurements

a Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

32) A client with a nasogastric (NG) tube complains that his nasal passage is irritated. Which action by the nurse is most appropriate? a. Apply a water-soluble lubricant to the nares b. Place the client in a lateral recumbent position c. Give the client an ice pack to hold on his nose d. Reposition the NG tube every 8 hours

a Rationale: The nurse should apply a water-soluble lubricant to the irritated nare. Repositioning the NG tube will not eliminate the irritation. Placing the client in a different position or using an ice pack will not affect the client's discomfort within the nasal passage.

37) A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) a. Stage 3 pressure injury b. Sutured surgical incision c. Casted bone fracture d. Laceration sealed with adhesive e. Open burn area

a, e Rationale: Open burn areas and pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. Sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin.

38) A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) a. Cover the area with saline-soaked sterile dressings b. Apply an abdominal binder snugly around the abdomen c. Use sterile gauze to apply gentle pressure to the exposed tissues d. Position the client supine with the hips and knees bent e. Offer the client a warm beverage (herbal tea)

a, d Rationale: Cover the wound with the sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. The supine position minimizes pressure on the abdominal area.

Which if the following patients would be expected to benefit from a moist-to-dry dressing? (Select all that apply) a. A 24 year-old patient with an open, infected wound from a spider bite b. A 7 year-old with abrasions on the knees c. A 50 year-old with a postoperative knee-replacement incision d. A 30 year-old who had a large cyst removed and now has some necrotic tissue present in the crater-type wound

a, d Rationale: Moist-to-dry dressings are best used with necrotic, infected wounds requiring debridement. Moist dressings are often used for helping to heal full-thickness wounds that look like craters. Dry, woven- gauze dressings are most often used for abrasions and postoperative incisions when minimal drainage is anticipated.

An 80 year-old woman with a history of diabetes and arthritis has made an appointment with her health care provider for complaints of urinary incontinence (UI). The patient states that she has recently become incontinent of urine and thinks it is because of her age. What is the best response from the nurse? a. "That is not normal. You must have a UTI." b. "Are you having issues with walking to the bathroom or toileting?" c. "You need to decrease your fluid intake so you don't have to go to the bathroom as often." d. "As you get older the sensations that your bladder is full become hypersensitive and cause a person to go to the bathroom more frequently."

b

26) An unconscious trauma patient is admitted to the ICU. The HCP prescribes enteral feedings via the nasogastric (NG) tube. Before the nurse administers a formula feeding, which finding by the nurse requires IMMEDIATE action? a. The volume of residual formula is 90 mL b. Breath sounds are decreased in the right lower lobe. c. Urine output for the last 8 hours was 40 mL/hr d. Bowel sounds are hyperactive in all quadrants

b Rationale: A major risk associated with enteral feedings is aspiration, resulting in atelectasis and pneumonia. The right lower lobe (RLL) is the most common site. Clients should be positioned at a minimum of 30 degrees of head elevation during feedings and up to two hours afterward. The nurse should verify tube placement before each feeding, or every four to eight hours if the client is receiving a continuous feeding. Residual volumes of up to 100 mL are acceptable. Urine output of less than 30 mL/hr should be reported to the HCP. Decreased bowel sounds should be monitored but are not an immediate concern.

23) When a patient's nasogastric (NG) tube stops draining, what is the nurse's first action? a. Clamp for 1 hour b. Check tube placement c. Instill 50mL of water d. Retract 2 inches

b Rationale: ALWAYS verify tube placement before taking other measures. NEVER put anything in a NG tube unless you know that its tip is in the stomach. Clamping has no effect on NG tube placement. Retracting without knowing where the tip is would be unsafe for the patient.

While assessing a patient before administering an enema, the nurse inspects the patient's abdomen for distention. What is the purpose of the nursing intervention? a. It helps determine the number and type of enemas to be given b. It provides a baseline for determining the effectiveness of the enema c. It helps determine conditions that contraindicate the use of enemas d. It allows the nurse to plan for appropriate teaching measures

b Rationale: Before administering an enema, the nurse should inspect the abdomen for distention. This provides a baseline for determining the effectiveness of the enema. The nurse should determine the patient's level of understanding of the purpose of the enema before planning for appropriate teaching measures. The nurse should verify the HCP's order for type of enema and amount to be given. Before administration of the enema, the nurse should check the patient's medical record for any conditions that may contraindicate the use of the enema.

22) A nurse is caring for a client whose heel has a pressure ulcer covered with intact hard, dry, black tissue. Which is the appropriate dressing for this client? a. Apply a hydrocolloid dressing b. Cover with sterile gauze c. Do a wet-to-dry dressing change d. No dressing is necessary

d Rationale: Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema) eschar on the heels should not be removed. Eschar works as a natural barrier or biological dressing by protecting the wound bed from bacteria. Unless it is wet, draining, or loss, it should remain in place. Unless the nurse is a certified wound specialist, removal or debridement of eschar should be performed by a HCP. The other dressings are not indicated.

13) A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply) a. Limit total daily fluid intake b. Decrease or avoid caffeine c. Take calcium supplements d. Avoid drinking alcohol e. Use the Crede maneuver

b, d Rationale: Alcohol and caffeine is a bladder irritant and can worsen stress incontinence. Stress incontinence results from weak pelvic muscles and other structures, limiting fluids will not resolve the problem.

20) A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the HCP that the stoma has retracted? a. Pinkish red and moist b. Narrowed and flattened c. Concave and bowl shaped d. Dry and reddish purple

c Rationale: A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal contents will pass. A healthy stoma will protrude about 2.5cm with an open lumen at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma has retracted. A retracted stoma can be difficult to care for. Complications include problems maintaining appliance placement, leading to leakage and sore skin.

1) The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? a. Insert the tube quickly. b. Notify the health care provider immediately. c. Remove the tube and reinsert it when the respiratory distress subsides. d. Pull back on the tube and wait until the respiratory distress subsides.

d Rationale: During the insertion of the nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the HCP immediately or remove the tube completely. Quick inserting the tube is not an appropriate action because, in this situation, it is likely that the tube has entered the bronchus.

29) When caring for a client who has an order for strict I & O, which is the best way to obtain accurate measurements? a. Ask the client to write down how many cups of fluid he or she drinks b. Give the client a marked cup to measure urine output c. Clear and rest all IV pumps to zero on each shift d. Remind the client not to drink anything that's not on the meal tray

c Rationale: The nurse or nursing delegate has sole responsibility for maintaining accurate I&O. Clearing and resetting IV pumps will provide this information. Not all clients are on restricted intake when I&O is being monitored, so they may ask for fluids other than those provided at meal times. Asking a client to record his or her own intake and output is not appropriate.

33) Before administering a soap suds enema, which position is appropriate for the client? a. Prone b. Supine c. Sims d. Lithotomy

c Rationale: To receive an enema, the client should be in the Sims position. The client lies on his or her left side, with the right leg flexed forward. This position facilitates the flow of the enema solution into the rectum and colon. Supine position is lying horizontally with the face and torso facing up. Prone position is lying horizontally with the torso down and the head turned to the side. Lithotomy position is lying on the back with hips and legs flexed 90 degrees.

When should wound drainage be cultured? a. When there is a change in color, amount, or odor of drainage b. If the patient complains of pain c. When the drain is removed d. If the nurse empties the drainage evacuator without applying sterile gloves

a Rationale: Wound drainage should be cultured when infection is suspected, as indicated by the drainage appearing to be purulent, a change in the amount or color of the wound drainage, or when a foul odor of the drainage is noted. It is appropriate for the nurse to wear clean gloves to empty the drainage evacuator.

6) The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? a. Position the client supine to assist in medication absorption b. Aspirate the nasogastric tube after medication administration to maintain patency. c. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication d. Change the suction setting to low intermittent suction for 30 minutes after medication administration

c Rationale: If the client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

25) When cleaning the perineal area around the site of an indwelling catheter, the nurse should... a. Vigorously wash the periurethral area b. Wipe the catheter away from the urinary meatus c. Scrub the tubing toward the urinary meatus d. Apply powder after giving perineal care

b Rationale: The catheter should be wiped away from the meatus, to decrease the risk of introducing pathogens into the urinary tract. The perineum should be washed gently with soap and water. Powder can retain moisture, leading to an infection.

4) The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? a. Right side b. Low Fowler's c. High fowler's d. Supine with the head flat

c Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler's position to facilitate insertions of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

The health care provider has written the following orders. Which orders does the nurse need to clarify before administering the medication? Timoptic .25% solution 1 drop OD BID Metoprolol 12.50 mg QD Insulin Glargine 6 u SC twice a day Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100

The nurse needs to clarify all of the orders. Rationale: Timoptic .25% solution 1 drop OD BID has a "naked" decimal point, and OD (right eye) could be mistaken for AD (right ear). Metoprolol 12.50 mg QD has a trailing zero, and the dosage could be mistaken for 1250 mg if the decimal point is not seen; it also has no route identified. Insulin Glargine 6 u SC twice a day includes the letter u, which means units but could be mistaken as the number 0 or 4, and SC could be mistaken as SL. Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100 has a period after mg, which could be mistaken as the number 1, and the < sign could be mistaken as greater than. The correctly written orders are "Timoptic 0.25% solution 1 drop right eye BID. Metoprolol 12.5 mg QD PO Insulin glargine 6 units subcutaneous twice a day Enalapril 2.5 mg PO three times a day, hold for systolic blood pressure less than 100."

The home health nurse is visiting is 67 year-old widow who lives at home by herself. The patient voices a concern about constipation. What is the best way for the nurse to approach the patient's concerns? a. "Tell me why you think you are constipated?" b. "Have you noticed that your stools are hard?" c. "How frequently are you having a bowel movement?" d. "What color is your stool?"

a

15) A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take? a. Discard the first voiding b. Keep the urine in a single container at room temperature c. Dispose the last voiding d. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

a Rationale: Discard the first voiding of the 24-hour specimen and note the time. Voiding should be saved until the end of the collection period.

27) The tool that predicts the risk of developing a hospital- or facility- acquired pressure ulcer or injury is called the a. Braden Scale b. Likert Scale c. Misophonia Scale d. Apgar Scale

a Rationale: The Braden Scale uses a score from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer or injury. The Braden Scale should be used on admission, transfer, and receiving, and with any change in the client's condition. The Likert Scale is used on questionnaires. The Misophonia Scale is used for a disorder in which certain sounds trigger emotional or physiological responses. The Apgar Scale measures the health of a newborn.

39) A nurse is caring for a client who is at risk for developing pressure injury, Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) a. Keep the head of the bed elevated 30 degrees b. Massage the client's bony prominences frequently c. Apply cornstarch liberally to the skin after bathing d. Have the client sit on the gel cushion when in a chair e. Reposition the client at least every 3 hr while in bed

a, d Rationale: Slightly elevate the head of the client's bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. Have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. Repositioning the client at least every 2 hours. Frequent position changes are important for preventing skin breakdown, but every 3 hours is not frequent enough.

11) While a nurse is performing a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Have the client hold their breath briefly and bear down b. Clamp the enema tubing c. Remind the client that cramping is common at this time d. Raise the level of the enema fluid container

b Rationale: Clamp the enema tubing for 30 seconds to reduce intestinal spasms. Telling the client that cramping is common is non therapeutic and implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it.

A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? a. "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." b. "Make sure that you have a margin of 1 to 1.5 inches around the wound, and that the skin is thoroughly dry before applying the dressing." c. "This type of dressing requires frequent changing because they do not stay in place." d. "You probably are applying it incorrectly , or perhaps you are just too anxious about having to perform the dressing change." e. "There are many options on the market. Why don't you use a nonadhesive-backed transparent dressing instead?"

b Rationale: If the transparent dressing does not stay in place, the size of the dressing should be evaluated for adequate (1 to 1.5 inches) margin, and the skin should be dried thoroughly before reapplication. The patient requires further instruction, not necessarily a referral, regarding interventions to aid in dressing adherence. The dressing coming off is an unexpected outcome. Blaming the patient is non- therapeutic.

34) Which type of ostomy puts a client at the MOST risk for skin breakdown? a. Sigmoid colostomy b. Ileal conduit c. Ileostomy d. Transverse colostomy

c Rationale: An ostomy is an artificial excretory opening of the body. The ostomy type and leakage are major risk factors for skin complications. Ileostomy patients have been found to be at significantly greater risk of developing skin complications than colostomy patients. Ileostomy output, which is from the small intestine, is of a continuous, liquid nature. This output contains gastric and enzymatic agents that when present on the skin can denude the skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy, the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy, the output is formed with an intermittent output. An ileal conduit is a urinary diversion, with the ureters being brought out to the abdominal wall.

18) A female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be a sign of a. Diarrhea b. Bowel incompetence c. Fecal impaction

c Rationale: Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; or not wanting to eat. The impaction may need to be manually removed. Patient education should include increasing liquids and fiber, as well as regular physical activity.

19) A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer? a. Stage I b. Stage III c. Stage II d. Stage IV

c Rationale: Stage I pressure ulcers have intact skin with a reddened area that may be firm and painful. Stage II pressure ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed. Stage III pressure ulcers have full-thickness skin loss and may contain slough, visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have full-thickness skin loss and exposed muscle, bone, or tendons.

7) The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35, Based on this information, which action should the nurse take at this time? a. Retest the pH using another strip b. Document that the nasogastric tube is in the correct place c. Check for placement by auscultating for air injected into the tube d. Call the health care provider to request a prescription for a chest radiograph (xray)

d Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the stomach. Based on this information, the nurse should call the HCP to request a chest xray to determine if placement is accurate. Retesting the pH using another test strip is unnecessary and checking for placement by auscultating for air injected into the tube is not a definitive method of checking for tube placement. The nurse should not document that the tube is in the correct place because the data indicates this may not be the case.

Which is the most appropriate indwelling catheter for an adult client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? a. Intermittent; Plastic; Size 10 Fr; 5 mL balloon with sterile water b. Short-term; Latex; Size 16 Fr; 5 mL balloon with sterile water c. Long-term; Silicon; Size 16 Fr; 5 mL balloon with sterile water d. Condom-Catheter; Latex; Size 18 Fr; 5 mL balloon with sterile water

c Rationale: Long-term indwelling catheters are used for severe urinary retention, recurrent urinary tract infections, and when wounds are irritated by contact with urine. Silicon is preferred because it can stay in place for 2 to 3 months. Size 16 is a standard size, and only sterile water should be used to inflate the balloon. Intermittent and short-term catheterization would not solve the issue of sever urinary retention and would require repeated catheterization, increasing the risk of infection. A condom catheter will not remedy urinary retention and does not have a balloon.

8) The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? a. Mark the tube at 10 inches (25.5 cm) b. Mark the tube a 32 inches (81 cm) c. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process d. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum

c Rationale: Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches (56 to 66 cm). The remaining options identify incorrect procedures for measuring the length of the tube.