Fundamentals Exam 3

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

Absent bowel sounds with distention

An RN and a licensed practical nurse (LP) are caring for a client who has a small bowel obstruction and is NO with a nasogastric (NG) tube set to continuous suction. Which of the following tasks should the RN perform?

Asses for bowel sounds every 2hrs.

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.)

Coat the tip of the tube with a water soluble lubricant; ask the client to swallow water while the tube enters her throat; tell the client to tilt her head backwards as insertion begins

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the clients head of the bed 45 degrees before the feeding

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration?

Elevate the head of the bed to 30° or 45°

A nurse is demonstrating colostomy care to a client who has a new colostomy. Which of the following actions should the nurse teach the client to perform?

Empty the bag when it is one-third to one-half full Cut the skin barrier opening a little larger than the ostomy Wash the peristomal skin with mild soap and water

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1 in)

A nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea which of the following actions should the nurse take?

Irrigate the tube with normal saline solution.

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COP). Which of the following oxygen-delivery methods should the nurse plan to use for this client?

Nasal cannula.

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the tube (to decrease the risk of aspiration of any gastric contents)

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side.

A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes?

Prevents excessive pressure on suture lines The NG tube remains in place after surgery to prevent pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In doing so, it also prevents vomiting and GI distention.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly.

A nurse is assessing a client who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings indicates that a possible bowel perforation has occurred?

Rigid abdomen

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement?

Verify the initial X-ray examination Measure the length of the exposed tube Determine the pH of aspirated fluid

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

Wear cotton clothing to avoid static electricity.

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen?

auscultation

A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect?

hyperactive bowel sounds above the obstruction

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

second intercostal space to the right of the sternum