Fundamentals Test 7 Practice Questions

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the client's skin.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain

A nurse is caring for a client who has GI bleeding. Which of the following actions should the nurse take first?

Assess orthostatic blood pressure

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted?

Bear down

A nurse is caring for a client who has an indwelling catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Bladder infection

A nurse is caring for a client who came the to ER with abdominal distention and is now on the med-surg unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working

A nurse is caring for a client who has an active upper gastrointestinal bleed. After inserting a NG tube into the client, which of the following findings should the nurse anticipate?

Coffee-ground drainage

A nurse is teaching a client who has a prescription for a NG tube to treat a pyloric obstruction. Which of the following rationales for the use of the NG tube should the nurse include in the teaching?

Decompress the stomach

A nurse is teaching a client who has a new prescription for pancrelipase to aid in digestion. The nurse should inform the client to expect which of the following GI changes?

Decreased fat in stools

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

Self-report of pain

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of GI perforation?

Sudden abdominal pain

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hours

A nurse removes an indwelling catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain?

The client's self-report of pain severity

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

Elderly and prenatal patients are difficult to assess for pain.

True

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times?

When the client has the urge to defecate

A nurse is caring for a client who has an indwelling catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

Withdraw 3 to 5 mL of urine from the port

A nurse is performing gastric lavage on a client using a large-bore NG tube. Which of the following actions should the nurse take?

Withdraw fluid until it is clear

Of the following would you choose for a patient that needs a low residue diet? A. celery B. baked broccoli C. roasted barley D. vanilla pudding E. sesame seeds

celery

Before flushing the enteral feeding tube - what should you use your 60mL syringe for? * A. check placement of tube B. check for residual from previous feeding C. add hydration to the GI tract D. listen for gurgling sounds in the lungs

check for residual from previous feeding

What is the #1 vitamin nurses should encourage women who are trying to get pregnant to take daily to prevent spina bifida? * A. Echinacea B. Folic acid (Folate) C. B12 D. Zinc

folic acid

What is the GOLD standard to check correct placement of an enteral feeding tube? * A. auscultate the lungs for bubbling B. auscultate the esophagus C. perform a single view chest x-ray D. auscultate the stomach

perform a single view chest x-ray

A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? A. place the patient in reverse trendelenberg B. place the patient in a sitting position C. avoid giving narcotic pain meds no matter how much pain they are in D. prepare a barium enema for the patient

place the patient in reverse trendelenberg

What position should you place your patient in prior to administering an enema? A. lithotomy B. reverse trendelenberg C. supine D. sims

sims

The World Health Organization (WHO) recommends a three-step approach, the "analgesic ladder" to the management of cancer pain. What type of medication would you expect a person to be prescribed with a cancer pain level of 9/10? * A. adjuvant B. NSAID C. straight opioid D. Nonopioid plus an adjuvant E. Opioid plus an adjuvant

straight opioid

How do you measure for correct length to mark your NG tube before you insert it in your patient?

xyphoid process, tip of the earlobe, tip of the nose

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicated an understanding of pain control?

"I will call for pain medication before the previous dose wears off."

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs to further teaching?

"It's unfortunate that I have to be in the hospital for this treatment."

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? (Select all that apply.)

-Apply to intact skin -Apply the medication an hour before the procedure begins -Cleanse the skin prior to the procedure -Use a visual pain rating scale to evaluate effectiveness of the treatment

A nurse is planning care for a client who is postoperative. Which of the following statements about pain management should the nurse consider when implementing client care? (Select all that apply.)

-Each client's expression of pain may be different and individualized. -Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range. -Pain level and pain tolerance can be assessed using a scale from 0 to 10. -The client will express the feeling of pain both verbally and nonverbally.

The nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.)

-Offer the client a back rub -Remind the patient to use incisional splinting -Identify the client's pain level -Change the client's position

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

-Report of feeling pressure -Tenderness over the symphysis pubis -Distended bladder -Voiding 30 mL frequently

A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply.)

-Restlessness -Grimacing -Clenching

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.

1. Hand hygiene 2. Place package on work surface 3. Open outermost flap away from self 4. Open side flap, pulling to the side 5. Open innermost flap toward self 6. Use inner surface of package as sterile field

A nurse is preparing to administer an enteral feeding via NG tube. Identify the correct sequence the nurse should follow to initiate the feeding.

1. Verify tube placement 2. Check the residual feeding contents 3. Administer feeding 4. Evaluate tolerance of feeding

The nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose?

3 capsules

How many mL's of tap water do you flush the enteral feeding tube with before beginning feeding? * A. 5 mL B. 30 mL C. 100 mL D. 500 mL

30 ml

How many Kcal/gram do proteins provide? * A. 4 B. 9 C. 30 D. 500

4

How many extra cal/day do pregnant and lactating women need? * A. 100 B. 250 C. 500 D. 1000

500

When a person is receiving elemental nutrition - when their parenteral nutrition reaches what percentage can elemental nutrition be discontinued? * A. 25% B. 50% C. 75% D. 100%

75%

How many Kcal/gram do fats provide? * A. 4 B. 9 C. 30 D. 500

9

A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention?

A client who reports urinary frequency

A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's GI tract is digesting and absorbing blood?

Elevated blood urea nitrogen (BUN)

A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?

Euphoria

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?

Hirschsprung's disease

A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

A nurse is caring for a client who has a gastric ulcer. Which of the following herbal supplements should the nurse recommend?

Licorice

A charge nurse is observing a newly licensed nurse insert an indwelling catheter for a male client. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

Lubricates the first 2.5 to 5 cm (2 in) of the catheter.

Your patient with heart failure needs an enema. For the QSEN concept of safety and providing individualized care - what additional nursing interventions would you do for this patient as opposed to a patient without heart failure? WHY?

Monitor pulse because enemas stimulate the vagus nerve and cause a person to vasovagal down

A nurse is caring for a preterm newborn who has a NG tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?

Necrotizing enterocolitis

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Obtain vital signs for both clients

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Palpates the abdomen prior to performing auscultation.

A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling catheter. Which of the following actions should the nurse take first?

Perform a bladder scan

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

Position the client supine

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esphagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take?

Provide frequent oral and nares care

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply.)

Relief of urinary retention