foundations exam 2

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? "Auscultated abdomen for bowel sounds. Bowel not functioning." "All four abdominal quadrants auscultated. Inaudible bowel sounds." "Bowel sounds auscultated. Client has no bowel sounds." "Client may have bowel sounds, but they can't be heard."

"All four abdominal quadrants auscultated. Inaudible bowel sounds."

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? "Begin the collection when you first urinate in the morning." "Discard your first urine and begin the collection after that." "Start collecting the urine with the next time you urinate." "You will need to have a catheter inserted for this collection."

"Discard your first urine and begin the collection after that."

The nurse has been educating a client about health promotion and exercise. What statement made by the client demonstrates that the education has been successful? "I will start a walking program, walking as fast as I can." "Ideally, I should exercise for an hour 2 times a week." "I will do the same kind of activity or exercise every day." "I will invite a friend to exercise with me."

"I will invite a friend to exercise with me."

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? "I will place a bath blanket over the client to provide privacy." "The client will be placed in a reclining position with knees bent." "I will use clean gloves to handle the catheter and other equipment." "Washing hands before and after the procedure is important."

"I will use clean gloves to handle the catheter and other equipment." Must be sterile

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? "I will place a bath blanket over the client to provide privacy." "The client will be placed in a reclining position with knees bent." "I will use clean gloves to handle the catheter and other equipment." "Washing hands before and after the procedure is important."

"I will use clean gloves to handle the catheter and other equipment." Requires sterile gloves not clean gloves.

The nurse is caring for a client who had surgery 24 hours ago and is experiencing severe pain. The client states, "My pain medication is effective, but will this pain ever get better and go away?" Which response is correct? "Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe." "It is unusual for you to still have severe pain. I will contact your surgeon." "If the prescribed analgesics are controlling the pain, we do not worry about the severity of the pain." "If the pain does not subside by this time tomorrow, you will need to be screened for the development of chronic pain."

"Incisional pain is usually most severe for the first 2 to 3 days, and then it progressively becomes less severe."

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? "It would be best just to get some adult diapers." "Let me refer you to a urologist who can help you." "Don't worry, this is a normal condition for older adults." "Let's explore structuring activities and toileting breaks."

"Let's explore structuring activities and toileting breaks."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response? "I agree; please make an appointment with your healthcare provider." "This only happened one time, so it is nothing to worry about." "Let's review your medication history and whether you consume bladder irritants." "I suggest that you invest in incontinence undergarments."

"Let's review your medication history and whether you consume bladder irritants."

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response? "This is good to help bowels move." "Perhaps you should do this twice daily." "Mineral oil enemas can interfere with absorption of fat-soluble vitamins." "It is important that you discontinue this type of treatment immediately."

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse? "Stool cannot be collect from a child's diaper." "Stool can be collected only from a cloth diaper." "It depends on which testing developer is used." "Only if the stool has not been contaminated by urine."

"Only if the stool has not been contaminated by urine."

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary? "The hand rolls help keep my thumb positioned away from my hand." "The hand rolls help me to develop strength in my grip." "I can use a rolled up wash cloth if I don't have a hand roll." "I need to remove the hand roll often to exercise my hand muscles."

"The hand rolls help me to develop strength in my grip."

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client? "It is important to us that you remain free from injury." "You will mostly stay in bed while you are hospitalized." "Use the call bell for any needs and wear nonslip footwear." "Do not get up without assistance for any reason."

"Use the call bell for any needs and wear nonslip footwear."

A nurse failed to document the administration of a client's warfarin and the nurse on the next shift administered the drug again, believing that it had been overlooked. When performing root cause analysis in order to identify the essential cause of this error, what question should first be asked? "Has this, or something very similar, ever happened on the unit before?" "Why did the second nurse administer this drug to the client?" "What could the two nurses have done to ensure this didn't happen?" "What were the possible adverse outcomes that could have resulted from this error?"

"What could the two nurses have done to ensure this didn't happen?"

The nurse is assessing a female client who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply? "You are experiencing stress incontinence. Do you know how to do Kegel exercises?" "You are experiencing reflex incontinence. Have you had a spinal cord injury in the past?" "You are experiencing total incontinence. Have you had any surgeries or trauma that may be causing this?" "You are experiencing transient incontinence. Have you been administered diuretics or IV fluids lately?"

"You are experiencing stress incontinence. Do you know how to do Kegel exercises?"

Owen is a 15-year-old client who is waking up postoperatively. He became combative and tried to strangle one of the nurses. A support team was called and 4-point restraints were applied in this emergent situation. How soon does a licensed provider need to assess the client and place the restraint order? 15 minutes 4 hours 1 hour 30 minutes

1 hour

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad? 90°F to 99°F (32.2°C to 37.2°C) 100°F to 104°F (37.7°C to 40°C) 105°F to 109°F (40.5°C to 43°C) 110°F to 115°F (43.3°C to 46.1°C)

105°F to 109°F (40.5°C to 43°C)

In the nursing care plan for constipation, the nurse should have an intervention that addresses the number of grams of cellulose that are needed for normal bowel function. How many grams should be in the daily diet? 20-30 g 40-50 g 60-70 g >80g

20-30 g

For which client would digital removal of stool be contraindicated? A client recovering from prostate surgery A diabetic client with renal complications An older adult client who is incontinent of stool A client with a urinary tract infection

A client recovering from prostate surgery

The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action? A risk that the peristomal skin will become excoriated The appliance will need to be changed daily. The appliance will fit securely to the client's skin. A heightened risk that the stoma will prolapse

A risk that the peristomal skin will become excoriated

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult? High fever Dysuria Acute confusion Nausea

Acute confusion

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? Adduction Abduction Circumduction Extension

Adduction

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? Warm the solution for 40 seconds in a microwave to prevent chilling the client. Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. Administer analgesia 30 minutes before the procedure. Administer the solution gradually over 5 to 10 minutes.

Administer the solution gradually over 5 to 10 minutes.

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide? Collect the first urine expelled. After the initial stream is initiated, collect the sample. Wait until the void is almost over to collect a specimen. Collect the entire urinary output.

After the initial stream is initiated, collect the sample.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a skin protectant to the skin around the incision. Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a transparent dressing over the incision site.

Apply a skin protectant to the skin around the incision.

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? Asking the client when he or she had last urinated Determining any pain when palpating the lower abdomen Palpating the bladder above the symphysis pubis Obtaining the bladder scanner to check the urine volume

Asking the client when he or she had last urinated

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial intervention is appropriate? Assess for the need to urinate. Administer a prescribed dose of lorazepam. Raise the side rails. Contact the health care provider for a prescription to apply a waist restraint.

Assess for the need to urinate.

The nurse is applying graduated compression stockings to the legs of a postsurgical client. The client suddenly complains of sharp pain to his left leg as the nurse is unrolling the stockings. What is the nurse's most appropriate action? Roll back the stocking partially and apply padding over the tender region. Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider. Stop applying the stocking and reattempt in 30 minutes. Apply the stocking, administer analgesia to the client, and then inform the primary care provider.

Assess the client's leg for signs and symptoms of deep vein thrombosis and inform the primary care provider.

An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client? Assess the color of the stoma. Apply device for stool collection. Perform stoma irrigation. Have the client perform self stoma care

Assess the color of the stoma.

A nurse is following a health care provider's order to irrigate a client's NG tube. Which guideline is recommended in this procedure? Assist the client to a 30- to 45-degree position, unless this is contraindicated. Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe. If Salem Sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent. If unable to irrigate the tube, remove it and obtain an order for replacement.

Assist the client to a 30- to 45-degree position, unless this is contraindicated.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included? Encourage the client to wait to at least 30 minutes before voiding when the urge is felt. Place the client on a schedule to void every 4 hours during the daytime hours. Assist the client to a normal voiding position when possible. Explain to the client that privacy is not important with urination.

Assist the client to a normal voiding position when possible.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Administer an IV on the arm high above the access site. Perform venipuncture below the access site to obtain a blood sample for laboratory testing. Measure the client's blood pressure on the arm above the access site.

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.

The nurse would like the client to perform some exercises that use muscle shortening and active movement. The nurse tells the client it will help build bone and improve cardiac and respiratory functioning. Which exercises should the nurse encourage the client to do? Select all that apply. Yoga exercises Lifting weights Walking Swimming Bicycling

Biking Swimming Walking

Which is true regarding the normal urination? Catheterized clients should drain a minimum of 30 mL of urine per hour. In adults, the average amount of urine per void is 500 mL. Urinary output does not vary all that much between adults and children. In adults, the amount of urine voided typically does not depend on fluid intake and losses.

Catheterized clients should drain a minimum of 30 mL of urine per hour.

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action? Gather equipment and supplies. Assess urine characteristics. Explain the procedure to the client. Check electronic health record for medical order.

Check electronic health record for medical order.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care? Cleanse the wound from the outer area towards the inner area. Cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing. Cleanse the wound using parallel stroke from the top to the bottom of the wound. Cleanse with a new gauze for each stroke.

Cleanse with a new gauze for each stroke.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? Collect 15 to 30 mL of the client's liquid stool. If portions of the stool include visible blood, mucus, or pus, discard the stool. If the specimen contains barium or enema solution, document this on the container. Refrigerate the specimen until it is cooled before sending it to the laboratory.

Collect 15 to 30 mL of the client's liquid stool.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? Infection of the wound Herniation of the wound Dehiscence of the wound Evisceration of the viscera

Dehiscence of the wound

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication? Fistula Dehiscence Hemorrhage Evisceration

Evisceration

A 57-year-old man is suffering from polyuria. What can cause polyuria? Diabetes insipidus Renal disease Urinary tract infection Renal calculi

Diabetes insipidus

The nurse considers applying restraints to an agitated client. Which action should the nurse take first? Assess the client for existing injuries to the wrists and hands. Ensure the client cannot reach any objects in the room. Call a family member to come and sit with the client. Dim the lights and speak softly about something the client enjoys.

Dim the lights and speak softly about something the client enjoys.

A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? Discard the swab and inform the health care provider that the wound is too infected to culture Obtain the swab as prescribed and send it to the lab for culture Obtain the swab and then clean the wound Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab

Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? Discontinue the therapy and assess the client. Notify the health care provider of the findings. Document the findings in the client's medical record. Gently rub and massage the area to warm it up.

Discontinue the therapy and assess the client.

When performing a dressing change, the home care nurse notes that the base of the client's leg wound is red and bleeds easily. What is the appropriate action by the nurse? Notify the physician. Consult a wound care nurse. Document the findings. Send the client to the emergency room.

Document the findings.

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? gauze Montgomery straps Tegaderm DuoDerm

DuoDerm

A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? Emptying a client's ileostomy appliance Assessing a client's GI system Inserting a client's NG tube Irrigating a client's NG tube

Emptying a client's ileostomy appliance

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? Use clean technique when inserting the catheter. Ensure that the catheter is removed as soon as possible. Irrigate the catheter with sterile water once per shift. Administer prophylactic antibiotics, as ordered.

Ensure that the catheter is removed as soon as possible.

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure? Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time. Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. Provide a light meal before the test and administer two Fleet enemas. Ensure that the client fasts 6 to 12 hours before the test as per policy.

Ensure that the client fasts 6 to 12 hours before the test as per policy.

A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take? Facilitate a more private setting, such as assisting the client to a bathroom. Administer a normal saline enema after obtaining the relevant order. Obtain a diet change order to increase the amount of fiber in the client's meals. Position the client on his side and administer a glycerin suppository.

Facilitate a more private setting, such as assisting the client to a bathroom.

A hypertonic enema solution lubricates the stool and intestinal mucosa, making stool passage more comfortable. True False

False

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? Remove the catheter every 8 hours, or more often in humid weather. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application. Fasten the condom securely enough to prevent leakage without constricting blood flow. Ensure the tip of the tubing is touching the tip of the client's penis.

Fasten the condom securely enough to prevent leakage without constricting blood flow.

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms? Flexion Abduction Adduction Dorsiflexion

Flexion

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? supine prone Sims' Fowler's

Fowler's

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence? Stress Urge Functional Total

Functional

A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours? Functional incontinence Transient incontinence Stress incontinence Reflex incontinence

Functional incontinence

A nurse is ordered to perform digital removal of stool for a client with stool impaction. Which action is an appropriate step in this procedure? Position the client supine, as dictated by client comfort and condition. Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client not to bear down while extracting feces in order to prevent vagal response.

Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address? Outlets and switches have cover plates. Machines used infrequently are unplugged. Hair dryer is placed next to the sink. No extension cards are being used.

Hair dryer is placed next to the sink.

A nurse needs to administer a hypertonic enema solution to the client. Which actions must the nurse perform? Select all that apply. Help the client into a Sims' position. Cool the container holding the solution. Compress the container as the solution instills. Wipe the lubricated tip of the container before insertion. Encourage the client to retain the solution.

Help the client into a Sims' position. Compress the container as the solution instills. Encourage the client to retain the solution.

A nurse is assessing a client who has recently had bowel surgery and will be receiving a nasogastric tube. Which finding would most likely contraindicate placement of a nasogastric (NG) tube by the nurse in this client? History of facial fractures One nare being less patent than the other Abdominal distention Bleeding in the gastrointestinal tract

History of facial fractures

A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction? Lean into the cane as it supports you. Hold your cane on the right side. Hold the cane 6 in (15 cm) in front of you. You may switch hands with your cane if you become tired.

Hold your cane on the right side.

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? Visible waves of abdominal peristalsis Hyperactive bowel sounds Increased anal area pigmentation Dry, hard stool

Hyperactive bowel sounds

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer? To ensure safety, do not allow the client to assist with the transfer. Use assistive devices if either of the nurses will need to lift more than 60 lb (27.2 kg). If the client is in pain, administer analgesics in advance of the transfer. Avoid using handling aids unless absolutely necessary.

If the client is in pain, administer analgesics in advance of the transfer.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client? Impaired Skin Integrity related to functional incontinence Urinary Incontinence related to urinary tract infection Impaired Skin Integrity related to urinary bladder infection and dehydration Risk for Urinary Tract Infection related to dehydration

Impaired Skin Integrity related to urinary bladder infection and dehydration

The student nurse is preparing a presentation on how to perform a physical assessment on the abdomen. Place the assessment steps in the correct order. 4 Palpation 1 Inspection 2 Auscultation 3 Percussion

Inspection, Auscultation, Percussion, and Palpation

A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? Investigate the possibility of discontinuing his or her catheter. Limit the resident's fluid intake in order to reduce his or her urge to void. Collaborate with the resident's health care provider to have his or her diuretics discontinued. Increase the resident's physical activity to reduce evening restlessness.

Investigate the possibility of discontinuing his or her catheter.

As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise? Isotonic Aerobic Isometric Anaerobic

Isometric

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? Make sure the bed brakes are unlocked. Put the chair at the foot of the bed. Place the bed in the highest position. Raise the head of the bed to a sitting position.

Raise the head of the bed to a sitting position.

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in? Right lateral Left lateral Prone Semi-Fowler's

Left lateral

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? Left side-lying Prone Right side-lying Supine

Left side-lying

A nurse is caring for a female cardiac client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action? Many clients find it embarrassing or degrading to use a bedpan. Incorrect placement of a bedpan has been linked to development of UTIs. Bedpans should not be used if the client needs to defecate. The nurse should assess the client's integument before placing the bedpan.

Many clients find it embarrassing or degrading to use a bedpan.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? Autolytic debridement Biosurgical debridement Enzymatic debridement Mechanical debridement

Mechanical debridement

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? Calculating the flow rate of urinary output Monitoring the characteristics of the urinary output Assessing PVR using a bladder scanner Palpating the client's bladder region

Monitoring the characteristics of the urinary output

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? Moist perineal skin Reddened perineal skin Presence of smegma Absence of discharge

Reddened perineal skin

The nurse is caring for an older client who is ordered restraints. What is the priority nursing action? Keep arm restraints loose to prevent injury Offer the client bathroom privileges and assistance Remove the restraints every six hours to prevent skin breakdown Secure restraints with paper tape to allow quick removal

Offer the client bathroom privileges and assistance

The nurse is turning a client in bed. Where would the nurse stand when using the friction-reducing sheet to turn the client to the opposite side of the bed? At the client's feet. At the client's head. At the client's center. Opposite the client's center.

Opposite the client's center.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? Peptic Ulcer Chronic Constipation Cirrhosis of the Liver Gastroesophageal Reflux Disease (GERD)

Peptic Ulcer

An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls? Provide a bedside commode and ensure adequate lighting. Obtain an order for insertion of an indwelling urinary catheter. Limit the client's fluid intake during the evening. Accompany the client to the bathroom every 4 hours around the clock.

Provide a bedside commode and ensure adequate lighting.

A client who was receiving care on a psychiatric unit committed suicide at a time when nurses are known to be handing off to nurses on the next shift. What is a responsibility of the organization when responding to this sentinel event? Inform local health care institutions about the event in order to promote safety. Change the institution's policies regarding supervision of clients. Appropriately discipline the nurses who were participating in the shift change. Report the event to the Joint Commission.

Report the event to the Joint Commission.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

Rotate the swab several times over the wound surface to obtain an adequate specimen.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing describes this? Primary intention Maturation Secondary intention Tertiary intention

Secondary intention

What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? Secure the drain to the client's gown with a safety pin below the level of the wound. Tape the drain to the dressing material securely below the level of the wound. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. Apply an abdominal binder over the entire wound and drain to support the site.

Secure the drain to the client's gown with a safety pin below the level of the wound.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document? Serosanguineous Purulent Serous Sanguineous

Serosanguineous

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document? Serous Sanguineous Serosanguineous Purulent

Serosanguineous

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces? Sigmoid colostomy Ileostomy Transverse colostomy Ascending colostomy

Sigmoid colostomy Furthest portion of the colon will produce the most well formed stool.

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration? Sims prone supine semi-Fowlers

Sims

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure? Position the client on his back and drape properly. Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. Introduce solution quickly over a period of 3 to 5 minutes. Encourage the client to hold the solution for at least 20 minutes.

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury? Stage I Stage II Stage III Stage IV

Stage IV

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple is removed. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision.

Stop removing staples and inform the surgeon

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. Stop the administration of the enema and notify the physician. Stop the administration of the enema momentarily. Increase the flow of the enema until all of the solution has been administered.

Stop the adminstration of the enema momentarily.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? Stop the procedure and reposition the client. Slow the infusion rate, have the client take deep breaths, then resume the enema. Slow the infusion rate, withdraw the tubing slightly, then resume the enema. Stop the procedure, monitor heart rate and blood pressure.

Stop the procedure, monitor heart rate and blood pressure.

Which type of incontinence is caused by pelvic floor muscle weakness? Urge Overflow Functional Stress

Stress

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? Reflex incontinence Stress incontinence Urge incontinence Functional incontinence

Stress incontinence

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure injury? Support the client from sliding in bed. Lubricate the area with skin oil. Improve the client's hydration. Pull client up under the arms.

Support the client from sliding in bed.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? Supports the area around the wound Maintains a moist environment Keeps the wound clean Reduces swelling and inflammation

Supports the area around the wound

A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? Tell the client he can remove them for 20 or 30 minutes during this shift. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. Permit the client to remove the stockings indefinitely and speak to the physician about the necessity of having the client wear them.

Tell the client he can remove them for 20 or 30 minutes during this shift.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred? The NG tube is in the client's airway. The NG tube is curled in the back of the client's throat. The client is experiencing a vasovagal reaction. The client is forcefully resisting the procedure.

The NG tube is in the client's airway.

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? The client has an enlarged prostate. The diameter of the catheter is too large. The nurse failed to deflate the retention balloon after pretesting it for integrity. The client has an occult abscess in the urethra.

The client has an enlarged prostate.

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? The client returned from a foreign country 2 days ago. The client has a daily fluid intake of 2,000 to 3,000 mL. The client consumes large qualities of fresh vegetables. The client repeatedly ignores the urge to defecate.

The client returned from a foreign country 2 days ago.

What is the most appropriate outcome for the client who has a nursing diagnosis of "Risk for Injury related to the use of assistive mobility devices in an unfamiliar environment?" The client will demonstrate safety measures to prevent falls. The client will establish safety priorities with family members. The client will identify resources for safety information. The client will identify unsafe situations in his or her environment.

The client will demonstrate safety measures to prevent falls.

The acute care nurse is caring for a client who is at risk for falling. Which desired outcome is most appropriate for this client? The client will not experience a fall and remains free of injury. The client will stay in bed. The client will wear nonskid footwear The client will not ambulate without assistance.

The client will not experience a fall and remains free of injury.

A health care provider has ordered restraints for an older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints? Chemical restraints should be tried before using physical restraints. The restraints can be ordered by the nursing supervisor in emergency situations. The client's vital signs must be assessed every hour. The client's order for restraints must be renewed by the health care provider every 4 hours.

The client's vital signs must be assessed every hour.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true? The largest part of a regular bedpan should be placed under the client's buttocks. A regular bedpan is generally more comfortable for clients than a fracture bedpan. A fracture bedpan is preferred for urination and a regular bedpan is preferred for defecation. A fracture bedpan should be used only for clients who have fractures of the femur or lower spine.

The largest part of a regular bedpan should be placed under the client's buttocks.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted? The novice nurse asks the client to take a deep breath when resistance was met during insertion of the catheter. The novice nurse selects an 18 French Foley catheter to insert. The novice nurse places a trash receptacle within easy reach. The novice nurse assists the client to a dorsal recumbent position with knees flexed, feet about 2 ft (0.6 m) apart.

The novice nurse selects an 18 French Foley catheter to insert. Appropriate size is 14F - 16F

A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process? The nurse adds the information in the safety event report to the client health record. The nurse calls the primary health care provider to fill out and sign the safety event report. The nurse provides an opinion of the physical and mental condition of the client that may have precipitated the incident. The nurse details the client's response and the examination and treatment of the client after the incident.

The nurse details the client's response and the examination and treatment of the client after the incident.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? The nurse works outward from the wound in lines parallel to it. The nurse uses friction when cleaning the wound to loosen dead cells. The nurse swabs the wound with povidone-iodine to fight infection in the wound. The nurse swabs the wound from the bottom to the top.

The nurse works outward from the wound in lines parallel to it.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? The stoma is pink. The stoma has a small amount of bleeding. The stoma is prolapsed. The stoma is on the abdominal surface.

The stoma is prolapsed.

The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid: adduction of the affected leg. hip abduction. flexion of the knee on the affected leg. extension of the knee on the affected leg.

adduction of the affected leg.

Which factor is related to the highest proportion of falls in long-term care settings? Toileting Agitation Polypharmacy Impaired sleep patterns

Toileting

The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence? Stress incontinence Functional incontinence Total incontinence Overflow incontinence

Total incontinence

A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client? Powered stand-assist Transfer chair Repositioning lift Gait belt

Transfer chair Chairs that can convert into stretchers are available. These are useful with clients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the client

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice? Specimen hat Large urine collection bag Bedpan Urinal

Urinal

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? Elevate the head of the bed 90 degrees. Use pillows to maintain a side-lying position as needed. Provide incontinent care every 4 hours as needed. Place a foot board on the bed.

Use pillows to maintain a side-lying position as needed.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma? Use water only. Use alcohol-based sanitizer. Use water and mild soap. Use mineral oil.

Use water and mild soap.

A nurse is teaching a client who has unilateral weakness how to walk with a cane. Which guideline promotes safe use of this device? The client should hold the cane in the hand on the same side as the leg with the most severe deficit. The client should stand with as much weight as possible placed on the feet, using the cane for balance. When taking a step, the client should advance the stronger leg forward ahead of the cane and follow with the weaker leg. When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

When taking a step forward, the heel of the client's foot should be slightly beyond the tip of the cane.

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle. Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic.

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

A program has been introduced at a hospital with the goal of improving client safety. The nurses participating in the program should recognize what event as posing the most significant threat to a client's safety? transferring the client from one location in the hospital to another electronically reporting the results of diagnostic testing to the client's primary care provider administering medications to the client admitting the client to the health care facility

administering medications to the client

The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of: ataxia. tremors. chorea. athetosis.

ataxia.

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? a. "Auscultated abdomen for bowel sounds. Bowel not functioning." b. "All four abdominal quadrants auscultated. Inaudible bowel sounds." c. "Bowel sounds auscultated. Client has no bowel sounds." d. "Client may have bowel sounds, but they can't be heard."

b. "All four abdominal quadrants auscultated. Inaudible bowel sounds."

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend? fracture pan bedside commode bedpan regular bathroom

bedside commode

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, dark amber strongly aromatic, amber

cloudy, foul odor

During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care? condom catheter indwelling catheter intermittent catheterization at bedtime toileting the client every 2 hours

condom catheter

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? reddish-brown, clear clear, light yellow dark brown, cloudy aromatic, green

dark brown, cloudy

The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? reports of pain in the lower back decrease in flexibility stumbling gait unequal pupil size

decrease in flexibility

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. dehiscence. evisceration.

dehiscence.

A client admitted with cellulitis of the leg has been prescribed amoxicillin-clavulanate potassium. After 3 days of antibiotic therapy, the client develops severe diarrhea, and the nurse notifies the health care provider. The nurse would anticipate which course of action in response to the client's diarrhea? discontinuation of the amoxicillin and the administration of a different antibiotic administration of an antidiarrheal drug and continuance of the amoxicillin increase in the client's dietary fiber and continued administration of amoxicillin discontinuation of the amoxicillin and administration of an antidiarrheal drug

discontinuation of the amoxicillin and the administration of a different antibiotic

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spiral-reverse turn spica turn figure-of-eight turn

figure-of-eight turn

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? before bedtime afternoon evening first thing in the morning

first thing in the morning

The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing? urge total reflex functional

functional

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? indwelling urethral catheter intermittent urethral catheter Foley catheter retention catheter

intermittent urethral catheter aka straight cath

A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs? large-volume cleansing enema with hypotonic solution small-volume cleansing enema with hypotonic solution small-volume cleansing enema with isotonic solution large-volume cleansing enema with oil

large-volume cleansing enema with hypotonic solution

When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed? back arm chest leg

leg

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be: bloody. mucus-filled. soft semi-formed. liquid consistency.

liquid consistency.

A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather? mineral oil tap water soap and water hypertonic saline

mineral oil

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a: cystocele. enuresis. overactive bladder. neurogenic bladder.

neurogenic bladder.

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion? inability to control either urinary or bowel elimination hygiene measures used to keep meatus and adjacent area of the catheter clean. use of a catheter to collect urine in a sterile environment one or both of the ureters are surgically implanted elsewhere

one or both of the ureters are surgically implanted elsewhere

The nurse is administering a rectal suppository. How far will the nurse insert the suppository? past the internal sphincter just past the opening of the anus far enough to still visualize the end of the suppository until the client reports feelings of discomfort

past the internal sphincter

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of: nature and amount of food eaten by the client. drinking and smoking habits of the client. physiologic or lifestyle changes in the client. social and emotional setting of the client.

physiologic or lifestyle changes in the client

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? contacting the primary care physician placing a small towel under the neck administering a muscle relaxer positioning the client on the stomach

placing a small towel under the neck

The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for related to the positioning? plantar flexion of the feet. flexion contracture of the neck. skin breakdown of the sacrum. hyperextension of the hips.

plantar flexion of the feet.

The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for related to the positioning? plantar flexion of the feet. flexion contracture of the neck. skin breakdown of the sacrum. hyperextension of the hips.

plantar flexion of the feet.

The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation? supine prone Sims' Fowlers'

prone

Which action by the unlicensed assistive personnel (UAP) requires intervention from the nurse when providing care to an older adult client who is at risk for falls? places bed at lowest setting provides slippers for ambulation clears a path from bed to bathroom has client sit in bed for a few moments before standing

provides slippers for ambulation

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of: protein. calculi. pus. casts.

pus.

The nurse directs the unlicensed assistive personnel (UAP) to assist an inactive client with positioning. Which action by the UAP would cause the nurse to intervene? raising the height of the bed to the waist level prior to moving the client turning the client as a complete unit to avoid twisting the spine placing the client in good alignment with joints slightly flexed replacing pillows and positioning devices

raising the height of the bed to the waist level prior to moving the client

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client? increases the volume of the stool, making defecation easier removes hardened fecal impactions from the rectum provides an outlet for diarrhea to be funneled into a collection unit softens and facilitates the removal of intestinal polyps

removes hardened fecal impactions from the rectum

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: first degree or superficial second degree or partial thickness third degree or full thickness fourth degree or fat layer

second degree or partial thickness

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: second degree or partial thickness first degree or superficial third degree or full thickness fourth degree or fat layer

second degree or partial thickness

An 85-year-old Caucasian woman walks 1 mile (1.6 km) every morning and every evening. She continues to smoke, but has cut back to half a pack per day. She had a total oophorectomy at age 45 secondary to stage I ovarian cancer. This client is currently not on any medications. Which is not a primary risk factor for osteoporosis for this client? oophorectomy at age 45 smoking Caucasian race sedentary lifestyle

sedentary lifestyle

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? blood pressure 130/80 mm Hg temperature 99.9 degrees F skin turgor response 5 seconds heart rate 90 beats per minute

skin turgor response 5 seconds

The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. How does the nurse document this finding? hypertrophy. atrophy. flaccidity. spasticity.

spasticity.

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, colorless strongly aromatic, dark amber

strongly aromatic, dark amber

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? under the client's head supporting the client's back in front of the client's abdomen under the client's feet

supporting the client's back

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? thrombus formation skeletal contractures pooling of secretions oliguria

thrombus formation