Exam 2 Clicker Questions

A Muslim female client has been stabilized after an assault in the parking lot of a local restaurant. The nurse manager is making assignments for the oncoming shift. Which action by the nurse manager is the most appropriate to ensure the client's comfort? 1.Assign the best male nurse to the client. 2.Assign the client a female nurse for every shift. 3.Allow the client to pick which nurses she would like to care for her. 4.Remove the client's clothing each shift to perform a skin assessment.

2.Assign the client a female nurse for every shift.

1.The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? A.3.5 B.6.5 C.7.35 D.8.0

A.3.5

Thinking back to the patient in the previous question, what type of stool would you expect the stoma to be excreting? A. Liquid stool B. Lose to partly formed stool C. Similar to normal stool D. Semi-solid stool

A. Liquid stool

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 86 mm Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which result? A. Normal results B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis

A. Normal results

Sitz baths are prescribed for a client with an inflamed painful hemorrhoid . How do the sitz baths aid the healing process? A. Promoting vasodilation B. Cleansing perineal tissue C. Softening the incision site D. Tightening the rectal sphincter

A. Promoting vasodilation

The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? A. Protruding Stoma B. Sunken and hidden stoma C. Narrowed and flattened stoma D. Dark and bluish-colored stoma

A. Protruding Stoma

Your patient is NPO and is receiving continuous tube feeding via PEG tube. All of the following are appropriate nursing actions EXCEPT A.Check blood sugar AC/HS B.Keep the bead of bed at or above a 30-degree angle C.Place feeding on hold when placing patient in a supine position D.Checking residual every 4 hours

A.Check blood sugar AC/HS

A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client's CO2 level rises, what will occur with the blood pH? A.Fall B.Rise C.Double D.Remain unchanged

A.Fall

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which action by the home health aide indicates understanding about the nursing team's responsibility in relation to pressure ulcers? A.Inspecting the skin daily B.Providing a foam seat on which to sit C.Massaging body lotion over reddened areas D.Applying a heating pad to bony prominences

A.Inspecting the skin daily

A client with diabetes mellitus has a blood glucose level on admission of 596 mg/dL. The nurse should anticipate that this client could be experiencing which type of acid-base imbalance? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis

A.Metabolic acidosis

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A.This is a normal, expected event. B.The client is experiencing early signs of ischemic bowel. C.The client should not have the nasogastric tube removed. D.This indicates inadequate preoperative bowel preparation.

A.This is a normal, expected event.

A patient has had colon surgery as a result of an intestinal obstruction. Which is a method of delivering nutrition that avoids the gut? A.Total parenteral nutrition (TPN) B.Puree diet with thickened liquids C.Tube feeding per gastrostomy tube D.Tube feeding per nasogastric (NG) tube

A.Total parenteral nutrition (TPN)

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings A.pH 7.25, Pco2 50 mm Hg B.pH 7.35, Pco2 40 mm Hg C.pH 7.50, Pco2 52 mm Hg D.pH 7.52, Pco2 28 mm Hg

A.pH 7.25, Pco2 50 mm Hg

•The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? A.transparent film B.gauze C.hydrocolloid dressing D.hydrogel sheet

A.transparent film

A.Stage 1 ulcer B.Stage 2 ulcer C.Stage 3 ulcer D.Stage 4 ulcer

B Very superficial - no subq fat, bones or tissue

The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, "I'm upset because I know I won't be able to have children now that I have an ileostomy." Which response by the nurse is best? A."Many women with ileostomies decide to adopt. Perhaps you could consider that option?" B."Having an ileostomy doesn't necessarily mean that you can't bear children. Let's talk about your concerns." C."I can understand your reasons for being upset. Having children must be important to you." D."I'm sure you will adjust to this situation with time. Try not to be too upset."

B."Having an ileostomy doesn't necessarily mean that you can't bear children. Let's talk about your concerns."

A client is one day post-op following a transverse loop colostomy. Which assessment finding would be indicative of a complication? A.Hypoactive bowel sounds B.A dusky color to the stoma C.Soft stool measuring 200 mL D.Scant bleeding at the stoma site

B.A dusky color to the stoma

Mrs. D returns from surgery with a new colostomy. The nurse assesses the stoma and notes that it is red and edematous. What is the best nursing action based on this finding? A.Place patient in a prone position B.Document the findings C.Apply ice immediately D.Call the health care provider

B.Document the findings

A nurse is assessing a wound while completing a dressing change. The nurse documents the pressure ulcer as stage III. Which is the best description of the stage III pressure ulcer? A.Partial-thickness skin loss involving the epidermis, dermis, or both B.Full-thickness skin loss involving damage to subcutaneous tissue C.Redness with intact skin that client reports as "itchy" D.Full-thickness

B.Full-thickness skin loss involving damage to subcutaneous tissue

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? A.Administer TPN through a nasogastric or gastrostomy tube. B.Handle TPN using strict aseptic technique. C.Auscultate for the presence of bowel sounds prior to administering TPN. D.Designate a peripheral IV site for TPN administration.

B.Handle TPN using strict aseptic technique.

2. How should the nurse determine the length of the nasogastric tube to be inserted? A.Insert the tube until resistance is felt. B.Measure from the nose to the earlobe to the xiphoid process. C.Insert the tube nasally until the patient feels discomfort. D.Have the patient to swallow some water, and insert the tube to the third premarked line.

B.Measure from the nose to the earlobe to the xiphoid process.

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis

B.Metabolic alkalosis

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to2 hours? A.Maintain comfort B.Prevent pressure ulcers C.Prevent flexion contractures of the extremities D.Improve venous circulation in the lower extremities

B.Prevent pressure ulcers

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions? A. A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. B. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. D. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.

C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. Dependent on what stage they are - essential amino acid but want to avoid urea buildup

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? A.Stage 2 Pressure injury B.Stage 1 Pressure injury C.Deep tissue injury D.Unstageable injury

C.Deep tissue injury

Before administering an intermittent enteral feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to accomplish which purpose? A.To relieve gastric pressure B.Assess fluid and electrolyte status. C.Evaluate absorption of the last feeding. D.Confirm proper nasogastric tube placement.

C.Evaluate absorption of the last feeding. Intermittent is usually bolus feeding

A nurse reviews a client's arterial blood gas values and notes a pH of 7.50, a Pco2 of 30 mm Hg, and an HCO3 of 25 mEq/L. The nurse should interpret these values as an indication of which condition? A.Metabolic acidosis, uncompensated B.Respiratory acidosis, uncompensated C.Respiratory alkalosis, uncompensated D.Metabolic acidosis, partially compensated

C.Respiratory alkalosis, uncompensated

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving? A.The patient's fasting blood sugar decreased from 100 to 90 mg/dL. B.The patient's prothrombin time (PT) increased from 20 to 25 seconds. C.The patient's ammonia level decreased from 160 to 120 mg/dL. D.The patient's AST (SGOT) increased from 24 to 30 units.

C.The patient's ammonia level decreased from 160 to 120 mg/dL.

While a client is receiving TPN, it is MOST important for the nurse to monitor A.vital signs and level of consciousness. B.arterial blood gases and liver enzymes. C.serum glucose and electrolytes. D.skin turgor and daily weights.

C.serum glucose and electrolytes.

On assessment of a patient with a colostomy, you note the stoma is located on the right lower quadrant. Due to its location, this is known as what type of colostomy? A. Descending Colostomy B. Transverse C. Ileostomy D. Ascending Colostomy

D. Ascending Colostomy

The nurse is reviewing the arterial blood gas (ABG) values of a client and notes that the pH is 7.31, Pco2is 50 mm Hg, and the bicarbonate (HCO3) level is 27 mEq/L. The nurse concludes that which acid-base disturbance is present in this client? A. Normal results B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory acidosis

D. Respiratory acidosis

Prior to being transported to the surgery suite, the nurse asks the client whether the client has any allergies. The client responds, "Does anyone communicate with anyone? I've been asked that question over and over!" What is the nurse's best response? A."I'm sorry! I just have to ask that question for the record." B."It's an important question, and we just have to check." C."You will hear it again and again as you go through surgery." D."This question is asked for verification and safety with each new phase of treatment."

D."This question is asked for verification and safety with each new phase of treatment." D - validates feelings

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? A.Continue the infusion until the remaining 300 mL is infused. B.Change the filter on the tubing, and continue with the infusion. C.Notify the health care provider (HCP), and obtain prescriptions to alter the flow rate of the solution. D.Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

D.Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A.Intact skin B.Full-thickness skin loss C.Exposed bone, tendon, or muscle D.Partial-thickness skin loss of the dermis

D.Partial-thickness skin loss of the dermis