NUR 215 FInal
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1.A client with an ileostomy 2.A client with heart failure 3.A client on long-term corticosteroid therapy 4.A client receiving frequent wound irrigations
1.A client with an ileostomy
A client with liver cancer receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse should try to limit which food that is most likely to cause this taste for the client? 1.Beef 2.Custard 3.Potatoes 4.Cantaloupe
1.Beef
The nurse is caring for a pregnant client who is iron deficient. What groups are vulnerable to this condition? Select all that apply 1.Diabetics 2.Alcoholics 3.Vegetarians 4.People with hemochromatosis 5.Women of childbearing years 6.Older people who consume poor diets
2.Alcoholics 3.Vegetarians 5.Women of childbearing years 6.Older people who consume poor diets
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6. strawberries
2.Raisins 3.Potatoes 4.Cantaloupe 6. strawberries
A client with heart disease is provided instructions regarding a low-fat diet. The nurse should determine that the client understands the diet if the client states that which food item should be avoided? 1.Apples 2.Oranges 3.Cherries 4.Avocados
4.Avocados
The nurse consults with a nutritionist regarding the dietary preferences of an Asian American client. Which food should be included in the dietary plan? 1.Rice 2.Chili 3.Red meat 4.Fried foods
rice
The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1.Peas 2.Nuts 3.Cheese 4.Cauliflower 5.Processed oat cereals
1. Peas 2. NUTs 4. Cauliflower
The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. 1.Bounding pulse 2.Difficulty breathing 3.Increased urine output 4.Presence of dependent edema 5.Neck vein distention in the upright position
1.Bounding pulse 2.Difficulty breathing 4.Presence of dependent edema 5.Neck vein distention in the upright position
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? 1.Dehydration 2.Hypokalemia 3.Fluid overload 4.Hypernatremia
1.Dehydration
A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? 1.High-fiber diet 2.Full liquid diet 3.Low-fiber diet 4.Low-sodium diet
1.High-fiber diet
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1.Twitching 2.Hypoactive bowel sounds 3.Negative Trousseau's sign 4.Hypoactive deep tendon reflexes
1.Twitching
The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1.Weight loss and poor skin turgor 2.Lung congestion and increased heart rate 3.Decreased hematocrit and increased urine output 4.Increased respirations and increased blood pressure
1.Weight loss and poor skin turgor
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1.Document the findings. 2.Attempt to arouse the client. 3.Contact the primary health care provider (PHCP) immediately. 4.Check the medication administration history on the PCA pump.
2.Attempt to arouse the client.
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1.Milk 2.Oranges 3.Bananas 4.Chicken
2.Oranges
A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." 2."I know that I should follow up after giving medication to make sure it is effective." 3."I will be sure to cue in to any indicators that the client may be exaggerating their pain." 4."I know that pain in the older client might manifest as sleep disturbances or depression."
3."I will be sure to cue in to any indicators that the client may be exaggerating their pain."
The nurse is creating a plan of care for a client receiving enteral feedings. Which client problem is the highest priority? 1. Diarrhea 2.Nutrition 3.Aspiration 4.Deficient fluid volume
3.Aspiration
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1.Right side 2.Low-Fowler's 3.High-Fowler's 4.Supine with the head flat
3.High-Fowler's
The nurse is consulting with a dietitian to plan a menu for a client who is on a regular diet and is a vegan. Which food item would the nurse and the dietitian select for the client's meal? 1.Scrambled eggs 2.Buttered wheat toast 3.Stir-fried vegetables 4.Chocolate milkshake
3.Stir-fried vegetables
In planning a low-sodium diet for a client who has recently been diagnosed with heart failure, the nurse should offer the client which food item? 1.Beef bouillon 2.Grilled cheese 3.Cottage cheese 4.Chicken breast
4.Chicken breast
The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1."The enema will be given while I am sitting on the toilet." 2."I should try and hold the fluid as long as possible after it is run in." 3."I know that there will be some cramping after the enema solution is run in." 4."I should tell the nurse if cramping occurs when the fluid is running in."
1."The enema will be given while I am sitting on the toilet."
A child with leukemia is complaining of nausea. The nurse suspects that the nausea is related to the chemotherapy regimen. The nurse, concerned about the child's nutritional status, should offer which item during this episode of nausea? 1.Cool, clear liquids 2.Low-protein foods 3.Low-calorie foods 4.The child's favorite foods
1.Cool, clear liquids
The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? 1.Daily weight 2.Urinary output 3.IV fluid intake 4.NG tube intake
1.Daily weight
The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? 1.Iron deficiency 2.Protein deficiency 3.Fatty acid deficiency 4.Vitamin K deficiency
1.Iron deficiency
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids
1.The client who is taking diuretics
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? 1.Do not exceed 1 L/min. 2.Do not exceed 2 L/min. 3.Adjust the oxygen depending on SpO2. 4.Adjust the oxygen depending on respiratory rate.
3.Adjust the oxygen depending on SpO2.
The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? 1.Bradycardia 2.Elevated blood pressure 3.Changes in mental status 4.Bilateral crackles in the lungs
3.Changes in mental status
The nurse is planning the menu for an Asian American client in collaboration with the hospital dietitian. The meal plan is designed to incorporate which food as a usual component of an Asian diet? 1.Milk 2.Vegetables 3.Large portions of meat 4.Desserts high in sugar content
.Vegetables
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1.Red, hard skin 2.Serous drainage 3.Purulent drainage 4.Warm, tender skin
2.Serous drainage
A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? 1.Tea 2.Gelatin 3.Custard 4.Ice pop
3.Custard
The nurse instructs a client about a low-fat diet. Which menu selection indicates that the client understands the nurse's instructions? 1.Shrimp and bacon salad 2.Liver, potato salad, sherbet 3.Turkey breast, boiled rice, and fruit 4.Lean hamburger steak and macaroni and cheese
3.Turkey breast, boiled rice, and fruit
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss and dry skin 2.Flat neck and hand veins and decreased urinary output 3.An increase in blood pressure and increased respirations 4.Weakness and decreased central venous pressure (CVP)
An increase in blood pressure and increased respirations
The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client? 1."Take a deep breath when I tell you, and hold it while I remove the tube." 2."Take a deep breath when I tell you, and bear down while I remove the tube." 3."Take a deep breath when I tell you, and slowly exhale while I remove the tube." 4."Take a deep breath when I tell you, and breathe normally while I remove the tube."
1."Take a deep breath when I tell you, and hold it while I remove the tube."
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1.Broth 2.Coffee 3.Gelatin 4.Pudding 5.Vegetable juice 6.Pureed vegetables
1.Broth 2.Coffee 3.Gelatin
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1.Face tent 2.Venturi mask 3.Aerosol mask 4.Tracheostomy collar
2.Venturi mask
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? 1.Vitamin A 2.Vitamin B12 3.Vitamin C 4.Vitamin E
2.Vitamin B12
A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose? 1.Prevents the client from getting a nosebleed 2.Gives the client added fluid via the respiratory tree 3.Humidifies the oxygen that is bypassing the client's nose 4.Prevents fluid loss from the lungs during mouth breathing
3.Humidifies the oxygen that is bypassing the client's nose
The nurse is developing a plan of care for a hospitalized Asian American client. The nurse should include which measures in the client's plan of care? Select all that apply. 1.Limit eye contact. 2.Clarify responses to questions. 3.Use hand gestures to communicate. 4.Maintain physical space with the client. 5.Hold the client's hand to provide comfort.
1.Limit eye contact. 2.Clarify responses to questions. 4.Maintain physical space with the client
The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply. 1.Timing 2.Volume 3.Voice tone 4.Eye contact 5.Hand gestures 6.Ability to share thoughts and feelings
1.Timing 2.Volume 3.Voice tone 4.Eye contact 6.Ability to share thoughts and feelings
The nurse is caring for a Hispanic American client admitted with a diagnosis of diabetic ketoacidosis. Several family members are present. What examples of nonverbal communication would the nurse expect? Select all that apply. 1.Maintaining eye contact 2.Dramatic body language 3.Smiling and shaking hands 4.Avoiding any confrontations with staff 5.Consistently expressing negative feelings 6.Using gestures or facial expressions to express emotion or pain
2.Dramatic body language 3.Smiling and shaking hands 4.Avoiding any confrontations with staff 6.Using gestures or facial expressions to express emotion or pain
The nurse caring for an Orthodox Jewish client plans a diet that adheres to the practices of the client's faith. When planning care, the nurse recognizes that which principles are consistent with dietary kosher laws? Select all that apply. 1.Meat and milk can be eaten together. 2.Eating fish with scales and fins is allowed. 3.Unleavened bread is eaten during Passover week. 4.Meat from animals that are vegetable eaters is allowed. 5.Meat is allowed if the food animal is ritually slaughtere
2.Eating fish with scales and fins is allowed. 3.Unleavened bread is eaten during Passover week. 4.Meat from animals that are vegetable eaters is allowed. 5.Meat is allowed if the food animal is ritually slaughtere
The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? 1.Increase to 3 L/min and titrate until the SpO2 is 95%. 2.Increase to 3 L/min and titrate until the SpO2 is 88%. 3.Place the client on a non-rebreather mask on 100% FiO2. 4.Maintain at 2 L/min and call respiratory therapy for a breathing treatment.
2.Increase to 3 L/min and titrate until the SpO2 is 88%.
The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1.Taking a rectal temperature for a client who has undergone nasal surgery 2.Taking an oral temperature for a client with a cough and nasal congestion 3.Taking an axillary temperature for a client who has just consumed hot coffee 4.Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic
2.Taking an oral temperature for a client with a cough and nasal congestion
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine
3.Hyperactive bowel sounds
The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? 1.Dilate the major bronchi. 2.Increase surfactant production. 3.Maintain inflation of the alveoli. 4.Enhance ciliary action in the tracheobronchial tree.
3.Maintain inflation of the alveoli.
The primary health care provider has prescribed a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the tray to be sure that which has occurred? 1.Sodium foods are restricted. 2.At least 1 serving of low-fat milk is served. 3.All food items are lukewarm in temperature. 4.All food items are liquid at body temperature.
4.All food items are liquid at body temperature.
The nurse calls the dietary department to obtain a dinner meal for a White American client who was admitted to the hospital at 4:00 p.m. The primary health care provider prescribed a diet "as tolerated." Considering the practices and preferences of the White American culture, which food should the nurse request for the meal? 1.Rice 2.Kosher foods 3.Blue cornmeal 4.Sirloin steak and potatoes
4.Sirloin steak and potatoes