NUR 215 EXAM 3

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

footboard

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus developmental? (select all that apply)

Apply elastic stockings. Assist the client to change positions often.

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (select all that apply)

auscultate bowel sounds. assist the client to an upright position. test the pH of gastric aspirate.

A nurse is reviewing dietary recommendations with a group of clients at a health fair. Which of the following information should the nurse include?

"Make protein 10% to 35% of total calories each day"

A nurse educator is teaching a class on culture and food to a group of newly hired nurses. Which of the following statements by a nurse indicates an understanding of the teaching?

"Most clients who practice orthodox Judaism do not eat meat with dairy products"

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?

"Have a table beside your bed so you can sit on the beside and rest your arms on the table"

a nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I have a set of my brother's crutches in my basement I can also use"

A nurse is discussing the use of a low-profile gastrostomy device with the guardian of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse?

"The device is usually comfortable for children"

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (select all that apply)

"The wonder my center of gravity, the more stability I have" "To broaden my base of support, I should spread my feet apart" "When I left an object, I should hold it as close to my body as possible"

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They improve your circulation to keep the blood from pooling in your legs"

A nurse is evaluating a client's understanding of the use of sequential compression device. Which of the following client statements indicates client understanding?

"This device will keep the blood pumping through my leg"

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make?

"Water help clear the tube so it doesn't get clogged"

A nurse at an extended-care facility is instructing a class of AP's about the use of assistive devices during ambulation. Which of the following should the nurse give the AP's about the clients' use of a cane?

"When the client moves, he should move the cane forward first"

A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?

"move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches"

A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching?

"report diarrhea while taking this medication"

A nurse is instructing a client on how to administer cyclic enteral feedings at home. Which of the following information should the nurse include?

"set the feeding up before you go to bed" "weigh yourself daily"

A nurse is discussing foods that are high in vitamin D with a client who is unstable to be out in the sunlight. Which of the following should be included in the teaching?

2 large, poached eggs

A nurse in a nutrition clinic is calculating body mass index (BMI) for several clients. The nurse should identify which of the following client BMIs as overweight?

27

A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? (select all that apply)

A client who has a wired jaw due to a motor vehicle crash. A client who is 24 hr postoperative following temporomandibular joint repair. A client who has difficulty chewing due to oral surgery.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An older adult who has a hip fracture and is in Buck's traction

A nurse is reviewing the effect of culture on nutrition during a staff in-service. Which of the following groups prescribes eating specific foods to balance forces in the body during illness? (select all that apply)

Asian culture Hispanic/Latin culture

A nurse is caring for a client who weighs 80kg (176lb) and 1.6m (5ft 3in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

BMI-weight(kg)/height(m2) 1.6x1.6=2.56m2 80/2.56=31.25 greater than 30=pt is obese

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy?

Carbohydrates

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hgb is 12g/dL and BMI 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply)

Chronic illness Low hemoglobin Malnutrition

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?

Crohn's disease

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?

Determine the client's ability to help with the transfer

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?

Encourage the client to perform antiembolic exercises every 2hr.

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate?

Gait belt

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (select all that apply)

Hct 55% Blood sodium 150mEq/L Urine specific gravity 1.035

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Hold the cane on the right side to provide support for the weaker leg.

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (select all that apply)

Hold the cane on the right side. Keep two points of support on the floor. After advancing the cane, move the weaker leg forward.

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply)

Increase in incisional pain fever and chills reddened wound edges

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion

A nurse receives a laboratory report for a client indicating a potassium level of 5.2mEq/L. When notifying the provider, the nurse should expect which of the following actions?

Initiating continuous cardiac monitoring

A nurse is caring for client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax.

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?

Instruct the client to tuck their chin when swallowing.

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (select all that apply)

Older adults are more prone to dehydration than younger adults are. Older adults need the same amount of most vitamins and minerals as younger adults do. Many older men and women need calcium supplementation.

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?

Pressure injury

A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (select all that apply)

Review a signal the client can use if feeling any distress. Lay a towel across the client's chest.

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?

Semi-Fowler's

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?

Stop the feeding

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (select all that apply)

Tachycardia Syncope Decreased skin turgor

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?

Vanilla custard

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure?

Verify the placement of the NG tube

A nurse is caring for a client who has multiple sclerosis and requires liquids with honey-like thickness. Which of the following foods can the client consume without adding a thickening agent?

Yogurt

A nurse on a medical surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?

a client who has heart failure

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?

a client who has nasogastric suctioning

A nurse in a long-term care facility is caring for an older client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

a reddened area over the sacrum

A nurse is caring for a client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility?

active range-of-motion exercises of the left leg

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include?

check the client's weight each morning

A nurse is caring for a client following an appendectomy who has a postoperative prescription that reads "discontinue NPO status; advance diet as tolerated" Which of the following are appropriate for the nurse to offer the client initially? (select all that apply)

chicken broth cranberry juice

A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (select all that apply)

confusion bone pain nausea and vomiting

A client who had abdominal surgery 24hr 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)

cover the area with saline-soaked sterile dressings position the client supine with the hips and knees bent

A nurse is preparing to administer intermittent enteral feeding to a client. Which of the following are appropriate nursing interventions? (select all that apply)

discard feeding equipment after 24hr. place an unused formula in open cans in the refrigerator. Flush the feeding tube every 4hr.

A nurse is educating a client who has anemia about dietary intake of iron. Which of the following is a non-heme source of iron?

dried beans

A nurse is performing a nutrition assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (select all that apply)

dry hair weak hand grips impaired coordination

A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are appropriate selections by the client? (select all that apply)

grounded turkey mashed carrots cottage cheese

A nurse is teaching a group of female clients about risk factors for developing osteoporosis. Which of the following risk factors should the nurse indicate? (select all that apply)

inactivity family history cigarette smoking

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?

infuse hypotonic IV fluids

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)

keep the head of the bed elevated 30 degrees have the client sit on a gel cushion when in a chair

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

lower the client to the floor

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

measure from heel to the popliteal space

A nurse on an orthopedic unit is reviewing data for a client who has sustained trauma in a motor-vehicle crash. Which of the following values indicates the client is in a catabolic state (using protein faster than protein is being synthesized)?

negative nitrogen balance

A nurse is caring for a client who is to receive a level 2 dysphagia diet due to a recent stroke. Which of the following dietary selections is most appropriate?

poached eggs

A nurse is caring for a client who has hypertension. Which of the dietary patterns is sometimes followed by Asian clients and places at risk for this condition?

preparation of foods using sodium

A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentrism?

recommending one's own favorite food

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (select all that apply)

request assistance when repositioning a client. Avoid twisting your spine or bending at the waist. Use smooth movements when lifting and moving clients.

A nurse is discussing health problems associated with nutrient deficiencies with a group of clients. Which of the following conditions is associated with a deficiency of vitamin C? (select all that apply)

scurvy bleeding gums

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)

stage 3 pressure injury open burn area

A nurse is teaching a client who is starting continuous feedings about the various types of enteral nutrition (EN) formulas. Which of the following should the nurse include in the teaching?

standard formula contains whole protein

A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods is a major source of magnesium?

tuna

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

use a powered standing assist lift

A nurse is administering bolus enteral feedings to a client who has malnutrition. Which of the following are appropriate nursing interventions? (select all that apply)

verify the presence of bowel sounds. flush the feeding tube with warm water. administer the feeding at room temperature.