Exam Two

CH 16 8. The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? 1. "Do you have any allergies?" 2. "Will you be able to wash your own hair?" 3. "Are there any areas you want us to spend more time bathing?" 4. "Do you have any preferences regarding how we help you bathe?"

1. "Do you have any allergies?"

CH 16 2. The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply. 1. "I should not use someone else's crutches." 2."I need to remove any scatter rugs at home." 3."I can use crutch tips even when they are wet." 4."I need to have spare crutches and tips available." 5."When I'm using the crutches, my arms need to be completely straight."

1. "I should not use someone else's crutches." 2."I need to remove any scatter rugs at home." 4."I need to have spare crutches and tips available."

CH 17 9. The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure? 1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma 2. Advising the client to hold the breath if cramping occurs during installation of the solution 3. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso 4. Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamping the tubing to allow the solution to follow into the stoma

1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma

CH 38 10. The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings would the nurse expect to observe? Select all that apply. 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids

1. Pallor 2. Edema 3. Anorexia 4. Proteinuria

CH 34 10. Which interventions would the nurse include when creating a care plan for a child with hepatitis? Select all that apply. 1. Providing a low-fat, well-balanced diet 2. Teaching the child effective handwashing techniques 3. Scheduling playtime in the playroom with other children 4. Notifying the primary health care provider (PHCP) if jaundice is present 5. Instructing the parents to avoid administering medications unless prescribed 6. Arranging for indefinite homeschooling because the child will not be able to return to school

1. Providing a low-fat, well-balanced diet 2. Teaching the child effective handwashing techniques 5. Instructing the parents to avoid administering medications unless prescribed

Ch 38 3. The nurse is planning care for a child with hemolytic uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse would plan to implement which measure? 1. Restrict fluids as prescribed. 2. Care for the arteriovenous fistula. 3. Encourage foods high in potassium. 4. Administer analgesics as prescribed.

1. Restrict fluids as prescribed.

CH 34 The nurse provides home care instructions to the parents of a child with celiac disease. The nurse would teach the parents to include which food item in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

1. Rice

CH 16 9. The nurse is teaching a client with right-sided weakness related to a stroke about how to properly ambulate with a cane. Which client action would indicate a need for further teaching? 1. The client holds the cane on the right side of the body. 2. The client moves the weaker leg toward the cane first. 3. The client holds the cane 6 inches laterally from the foot. 4. The client keeps two points of support on the floor at all times.

1. The client holds the cane on the right side of the body.

CH 17 3. A client with ulcerative colitis 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? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation.

1. This is a normal, expected event.

Ch 38 1. The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement that relates to this diagnosis would the nurse expect to hear from the child's parents? 1. "The pediatrician said the kidneys are working well." 2. "I noticed the urine was the color of cola lately." 3. "I'm so glad they didn't find any protein in the urine." 4. "The nurse who admitted my child said the blood pressure was low."

2. "I noticed the urine was the color of cola lately."

Ch 38 7. The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse would plan which intervention? 1. Cover the bladder with petroleum jelly gauze. 2. Cover the bladder with a non adhering plastic wrap. 3. Apply sterile distilled water dressings over the bladder mucosa. 4. Keep the bladder tissue dry by covering it with dry sterile gauze.

2. Cover the bladder with a non adhering plastic wrap.

Ch 38 2. The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? 1. Hypertension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

2. Generalized edema

CH 16 1.A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates

2. Injury to the brachial plexus nerves

CH 34 7. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

2. Projectile vomiting

CH 17 2. The nurse is providing care for a client with ulcerative colitis who underwent the creation of a transverse colostomy. Which observation requires immediate notification of the surgeon? 1. Stoma is beefy red and shiny. 2. Stoma has a purple discoloration. 3. Skin excoriation is noted around the stoma. 4. Semiformed stool is noted in the ostomy pouch.

2. Stoma has a purple discoloration.

CH 16 5. The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound? 1. Hydrogel dressing 2. Transparent dressing 3. Antimicrobial dressing 4. Calcium alginate dressing

2. Transparent dressing

CH 17 1. The nurse is assessing a client with bladder cancer who had a cystectomy and creation of a ureteros- tomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. "I change my pouch every week." 2. "I change the appliance in the morning." 3. "I empty the urinary collection bag when it is two-thirds full." 4. "When I'm in the shower, I direct the flow of water away from my stoma."

3. "I empty the urinary collection bag when it is two-thirds full."

CH 16 7. The nurse is reviewing dental care with a client who is edentulous and wears dentures. Which client statement indicates an understanding of proper dental care? 1. "Since I have no teeth, I do not need to brush my mouth." 2. "I need to use hot water when cleaning my dentures to kill bacteria." 3. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water." 4. "When I am not wearing my dentures during the day, I can keep them in the denture cup with no water, as they should only be in water at night."

3. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water."

CH 17 10. Thenurseisteachingaclientwithaurinarystomaabout how to change the collection bag and appliance at home. Which of the following client statements indicates an understanding of the procedure? 1. "The stoma needs to be cleaned with only water." 2. "The best time to change the appliance is at night." 3. "The pouch needs to be changed every 5 to 7 days." 4. "I'll cut the skin barrier 10 millimeters larger than the stoma."

3. "The pouch needs to be changed every 5 to 7 days."

CH 16 10. The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply. 1. A client with leukocytosis 2. A client with thrombocytosis 3. A client with thrombocytopenia 4. A client receiving an antiplatelet medication 5. A client receiving acetaminophen as needed for mild pain

3. A client with thrombocytopenia 4. A client receiving an antiplatelet medication

CH 17 7. The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain? 1. A straight catheter 2. A Coudé tip catheter 3. A triple-lumen catheter 4. A double-lumen catheter

3. A triple-lumen catheter

Ch 38 9. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which would the nurse most likely expect to note? 1. Hematuria 2. Proteinuria 3. Bacteriuria 4. Glucosuria

3. Bacteriuria

CH 34 3. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

3. Choking with feedings

CH 34 6. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? 1. Bile-stained fecal emesis 2. The passage of currant jelly-like stools 3. Failure to pass meconium stool in the first 24 hours after birth 4. Sausage-shaped mass palpated in the upper right abdominal quadrant

3. Failure to pass meconium stool in the first 24 hours after birth

CH 34 2. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse would place the infant in which best position at this time? 1. Prone position 2. On the stomach 3. Left lateral position 4. Right lateral position

3. Left lateral position

CH 17 8. A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? 1. Prone position 2. Lithotomy position 3. Left lateral side-lying position 4. Right lateral side-lying position

3. Left lateral side-lying position

CH 34 5. A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which problem? 1. Diarrhea 2. Metabolic acidosis 3. Metabolic alkalosis 4. Hyperactive bowel sounds

3. Metabolic alkalosis

CH 17 5. The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching? 1. Cleans the catheter proximally to distally with soap and water 2. Maintains the urinary collection bag below the level of the bladder 3. Removes a loose catheter anchor and places a new anchor on the lower leg 4. Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position

3. Removes a loose catheter anchor and places a new anchor on the lower leg

CH 16 4. The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse clas- sify this pressure injury? 1. Stage 1 pressure injury 2. Stage 2 pressure injury 3. Stage 3 pressure injury 4. Stage 4 pressure injury

3. Stage 3 pressure injury

Ch 38 6. The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "I need to be cautious when straddling my infant on a hip." 2. "Vital signs need to be taken daily to check for bladder infection." 3. "Catheterization will be necessary when my infant does not void." 4. "Circumcision has been delayed to save tissue for surgical repair."

4. "Circumcision has been delayed to save tissue for surgical repair."

Ch 38 8. Which question would the nurse ask the parents of a child suspected of having glomerulonephritis? 1. "Did your child fall off a bike onto the handle bars?" 2. "Has the child had persistent nausea and vomiting?" 3. "Has the child been itching or had a rash anytime in the last week?" 4. "Has the child had a sore throat or a throat infection in the last few weeks?"

4. "Has the child had a sore throat or a throat infection in the last few weeks?"

Ch 38 5. The nurse has provided discharge instructions to the parents of a 2-year-old child who underwent an orchiopexy to correct cryptorchidism. Which statement by the parents indicates a need for further instruction? 1. "I'll check my child's temperature." 2. "I'll give medication so that my child will be comfortable." 3. "I'll check my child's voiding to be sure there's no problem." 4. "I'll let my child decide when to return to play activities."

4. "I'll let my child decide when to return to play activities."

CH 34 The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stools

4. Bright red blood and mucus in the stools

CH 17 4. A client with Crohn's disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance

4. Fluid and electrolyte imbalance

CH 34 1. The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the parent to seek health care for the infant? 1. Diarrhea 2. Projectile vomiting 3. Regurgitation of feedings 4. Foul-smelling ribbon-like stools

4. Foul-smelling ribbon-like stools

Ch 38 4. A 7-year-old child is seen in a clinic, and the pedia- trician documents a diagnosis of nighttime (noc- turnal) enuresis. The nurse would plan to provide which information to the parents? 1. Nighttime (nocturnal) enuresis does not respond to treatment. 2. Nighttime (nocturnal) enuresis is caused by a psychiatric problem. 3. Nighttime (nocturnal) enuresis requires surgical intervention to improve the problem. 4. Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.

4. Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.

CH 16 3. The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss with exposed dermis

4. Partial-thickness skin loss with exposed dermis

CH 17 6. The nurse is inserting an indwelling urinary catheter in a client. As the nurse begins to indicate the balloon, the client starts to complain of pain. Which action would the nurse take? 1. Continue to indicate the balloon. 2. Deflate the balloon, slightly withdraw the catheter, and attempt to re-inflate the balloon. 3. Deflate the balloon, completely withdraw the catheter, and end the procedure to notify the primary health care provider. 4. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before re-inflating the balloon.

4. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before re-inflating the balloon.

CH 16 6. The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching? 1. The nursing student tells the client to avoid soaking the feet. 2. The nursing student dries the feet thoroughly, including in between the toes. 3. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. 4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.

4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.

CH 34 4. The nurse provides feeding instructions to the parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction would the nurse give to the parent to assist in reducing the episodes of emesis? 1. Provide less frequent, larger feedings. 2. Burp the infant less frequently during feedings. 3. Thin the feedings by adding water to the formula. 4. Thicken the feedings by adding rice cereal to the formula.

4. Thicken the feedings by adding rice cereal to the formula.