Funds Exam 3

A nurse is providing information about pain control for a client who has acute pain following an abdominal injury. Which of the following client statements indicates an understanding of pain control?

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

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching?

"I will have him sit in his chair during the feeding."

A nurse is teaching a client who is preoperative for a colostomy. The client asks the nurse why he needs a large-bore NG tube. Which of the following statements should the nurse make?

"The tube will remove gas a fluid from your stomach."

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching

"You may experience a small amount of bleeding around the stoma."

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? a. "I'll urinate a little then stop." "b. "I'll use 3 cleansing wipes from front to back. One on each side and then in the middle." c. "I'll clean the inside of the container with a wipe." d. "I'll use each cleansing wipe twice."

"b. "I'll use 3 cleansing wipes from front to back. One on each side and then in the middle."

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? -Bear down hard when defecating. -Drink four to five glasses of water daily. -Increase dietary intake of raw vegetables and fruit -Limit activity.

-Increase dietary intake of raw vegetables and fruit

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? -Urinary tract infection -Urinary incontinence -Urinary frequency -Urinary retention

-Urinary tract infection

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply) 1-Excessive laxative use 2-Ignoring the urge to defecate 3-Inadequate fluid intake 4-Increased fiber in the diet 5-Increased activity

1-Excessive laxative use 2-Ignoring the urge to defecate 3-Inadequate fluid intake

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching? 1. "I will empty my pouch when it becomes 1/3 full." 2. "I will be certain to take enteric-coated medications." 3. "I will change my entire pouch-system at least weekly." 4." I will use caution when eating high fiber foods."

2. "I will be certain to take enteric-coated medications."

A nurse is assisting a group of clients in an outpatient clinic. For which of the following clients should the nurse anticipate scheduling a colonoscopy? 1- 56 yo who had a colonoscopy 6 years ago 2- 34 yo who reports a new onset of constipation 3- 32 yo who has a sister who died of colon cancer 4- 51 yo who is being seen for an annual physical exam

4- 51 yo who is being seen for an annual physical exam

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 with small amounts.

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? A. Atelectasis B. Pneumonia C. Pulmonary embolism D. Arterial thrombus

A. Atelectasis

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.) A. Report of feeling pressure B. Dysuria C. Distended bladder D. Voiding 30 ml frequently

A. Report of feeling pressure C. Distended bladder D. Voiding 30 ml frequently

When collecting a 24 hour urine sample the first voided urine in the morning the sample is to begin is discarded. A. True B. False

A. True

Which of the following are direct visualization studies? (select all that apply) A. colonoscopy B. Barium Enema C. cystoscopy D. ultrasound

A. colonoscopy C. cystoscopy D. ultrasound

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 patient has began a 24 hour urine sample at 10 am on Tuesday. On Wednesday morning the patient first voided urine is at 6am. Would the urine voided on Wednesday morning need need to be discarded from the 24 hour urine sample? A. True B. False

B. False

Which is the safest enema solution which lessens the danger of excess fluid shifting (movement into or out of cells)? A. Hypertonic B. Normal Saline C. Tap Water D. Carminative

B. Normal Saline

Which type of incontinence is associated with chronic retention of urine and an overdistended bladder? A. Functional B. Overflow C. Stress D. Reflex

B. Overflow

A patient may need an NG tube for decompression for which of the following? A. Increased peristalsis B. Paralytic Ileus C. Fecal Impaction D. Diarrhea

B. Paralytic Ileus

Which of the following urinary diversions is needed for a patient who has had the bladder surgically removed? A. Foley Catheter B. Urostomy C. Colostomy D. Nephrostomy

B. Urostomy

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Blood

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision and assessment reveals an evisceration. Which of the following actions should the nurse take first? A. Have the client lie flat in bed. B. Use sterile gauze to place gentle pressure on the exposed organs. C. Cover the area with saline-soaked sterile dressings. D. Apply an abdominal binder

C. Cover the area with saline-soaked sterile dressings.

A 70 year old client is admitted to the PACU with an intravenous (IV) solution of 0.9% NaCl which is running at 125cc/hour. The nurse detects new onset of crackles in the lung bases and distended neck veins. What is nurses the priority action? A. Notify a health care provider B. Immediately document findings in the medical record C. Decrease the IV flow rate. D. Discontinue the IV.

C. Decrease the IV flow rate.

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue B. Passage of the ET tube into the esophagus C. Movement of the ET tube into the right main bronchus D. Infection of the vocal cords

C. Movement of the ET tube into the right main bronchus

Pain that is not protective and promotes poor quality of life is?

Chronic

A nurse assesses an opioid-naive client one hour after giving an opioid analgesic. Which signs or symptoms would be of greatest concern requiring immediate intervention? A. O2 saturation of 96% B. pain intensity of 8 on a 10 point scale C. respirations of 14 /minute D. Difficulty arousing the client

D. Difficulty arousing the client

The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse notes that the client's respiratory rate is 6 breaths per minute. The client has minimal response to physical stimulation. The nurse should prepare to administer which of the following medications? A. Intravenous flumazenil (Romazicon) B. Oral modafinil (Provigil) C. Nebulized albuterol (Proventil) D. Intravenous naloxone (Narcan)

D. Intravenous Naloxone (Narcan)

A nurse is reviewing the provider's prescription for a client experiencing a paralytic ileus following an appendectomy. Which of the following actions should the nurse expect to take?

Insert nasogastric tube

A nurse is caring for a client who is prescribed bedrest. The plan of care indicate that the client to perform isometric exercises every two hours. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax

A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." What action should the nurse take?

Notify the surgeon that the client wishes to withdraw informed consent for the procedure.

A nurse is assessing a client who is 3 days postoperative following abdominal surgery and notes the absence of bowel sounds, abdominal distention, and the client passing no flatus. Which of the following conditions should the nurse suspect? A. Ulcerative colitis B. Cholecystitis C. Paralytic ileus D. Wound dehiscence

Paralytic Ileus

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?

Removing the abdominal dressing

A nurse is caring for a client who needs a stool specimen collected. Which action should the nurse take when obtaining the specimen?

Send specimen container immediately to the lab.

A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following is an appropriate nursing action?

Slow the flow of enema solution briefly.

A nurse is caring for a client who has a hip fracture that requires surgical repair. The nurse should identify which of the following health care professionals as responsible for obtaining informed consent from the client for the procedure?

Surgeon

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse identify as being at risk for hypokalemia?

The client who has a NG tube to suction.

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

For which of the following findings should the nurse notify the provider?

Urine output of 600 ml/hr

A nurse is implementing a bowel training program for a client. For the program to be effective the client should be taken to the bathroom 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 urinary 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 removes an indwelling urinary 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? a. Temporary urinary retention b. Urinary frequency for several days c. Blood-tinged urine d. Highly concentrated urine

a. Temporary urinary retention

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I will walk briskly for 30 minutes before bedtime." b. "I will no longer have a glass of wine before bedtime." c. "I will have a cup of hot cocoa immediately before bedtime." d. "I will do my muscle relaxation techniques each afternoon."

b. "I will no longer have a glass of wine before bedtime."

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? a. Increase fluids. b. Perform a bladder scan. c. Insert a straight catheter. d. Provide assistance to bathroom

b. Perform a bladder scan.

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? a. remind the client to tell the nurse when he has to urinate b. use adult diapers to prevent frequent clothing changes c. take the client to the bathroom every 2 hr d. request a prescription for an indwelling urinary catheter

c. take the client to the bathroom every 2 hr

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? a. clamps the NG tube during auscultation b. performs auscultation between meals c. auscultates bowel sounds for 3 to 5 min d. palpates the abdomen prior to performing auscultation

d. palpates the abdomen prior to performing auscultation