Pre OP Care, Integumentary Elimination, Nutrion Infection Control

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

"Fresh foods such as fruits and vegetables are high in sodium."

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions?

"I cannot drink or eat anything after midnight on the night before surgery."

The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response?

"I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme."

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student?

"Lactated Ringer's solution is isotonic to plasma."

The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?

"These sensations dissipate over several months and usually resolve after 1 year."

A caregiver states that the client eats only about 25% of the food that is offered and is losing weight. The caregiver asks the nurse about feeding the client by a tube into the stomach. Which initial response by the nurse would be appropriate?

"Tube feedings can provide adequate amounts of required nutrients.

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery. When asking the client whether the client takes over-the-counter medications, which statement should concern the nurse? "Yes, I take a full-strength aspirin every day." "Yesterday I took a daily multiple vitamin medication." "I have stopped the medications my doctor told me to stop taking." "I have taken my medication for my blood pressure this morning." "I took the bowel preparation medications as prescribed starting 2 days ago."

"Yes, I take a full-strength aspirin every day." "I have taken my medication for my blood pressure this morning."

The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?

1000 calories

the nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. the healthcare provider has prescribed an amount of 100 mL/hr. how much formula should the nurse plan to add to fill the feeding bag?

800 mL of formula

The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for what data first?

A patent airway

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

A urinary output of 20 mL/hour

The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?

Apply Montgomery ties.

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?

Baked Turkey

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? Baked turkey Tomato soup Boiled shrimp Chicken gumbo

Baked Turkey Rationale: Regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium.

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply.

Bread and butter Carrots and peas Peppers and onions

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

Checking the wound site for drainage from the drain

Which types of nourishment should the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia? Select all that apply. Coffee Ice chips Beef broth Plain yogurt Tea with milk Lemon flavored gelatin

Coffee Ice chips Beef broth Lemon flavored gelatin

A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?

Compare these values to those recorded previously.

The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?

Coughing and deep breathing exercises

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? A dependent position Elevation of the knees Flat, without elevation Elevation above the level of the heart

Elevation above the level of the heart Rationale: Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation. Options 1, 2, and 3 are incorrect.

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time? Ensure that the client has voided. Administer all the daily medications. Practice postoperative breathing exercises. Verify the time that the client last ate or drank. Assist the client by contacting family members the client wants notified.

Ensure that the client has voided. Verify the time that the client last ate or drank. Assist the client by contacting family members the client wants to be notified.

The nurse is providing dietary instructions to a client with a diagnosis of ulcerative colitis. The client is prescribed to follow a low residue diet during episodes of diarrhea. Which food should the nurse instruct the client to avoid?

Fresh corn on the cob

A client with hypertension has been prescribed a low-sodium diet. The nurse reinforcing instructions about foods that are allowed should include which foods in a list provided to the client? Select all that apply.

Fresh tomato Summer squash

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat? Legumes Citrus fruits Vegetable oils Green, leafy vegetables

Green, leafy vegetables Rationale: Green, leafy vegetables are high in vitamin K, which acts as a catalyst for facilitating blood-clotting factors. Legumes are high in folic acid and thiamine. Citrus fruits are high in vitamin C, which helps with wound healing. Vegetable oil is high in vitamin E, which acts as an antioxidant.

A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period? Pain Anger Grief Anxiety Altered body image

Grief Anxiety Altered body image

A 17-year-old pregnant client is being seen at the obstetric clinic. The nurse is reviewing the following laboratory results, which were obtained 2 hours after breakfast: hemoglobin 10 g/dL (100 mmol/L), sodium 140 mEq (140 mmol/L), glucose 110 mg/dL (6 mmol/L), potassium 4.1 mEq (4.1 mmol/L). Which dietary instruction should the nurse reinforce for this client?

Increase the amount of red meats.

The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?

Increasing restlessness

The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication? Absent bowel signs Increasing restlessness A pulse rate of 108 beats per minute A blood pressure (BP) of 88/58 mm Hg Increasing pain unrelieved by analgesics

Increasing restlessness A pulse rate of 108 beats per minute A blood pressure (BP) of 88/58 mm Hg Increasing pain unrelieved by analgesics

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

Informing the surgeon of the situation

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply. Is allergic to penicillin Quit smoking 3 months earlier History of tonsillectomy at the age of 7 years Wonders if the surgery could cause incontinence Takes daily multivitamin and calcium supplements. History of deep venous thrombosis in right leg 10 years earlier

Is allergic to penicillin Quit smoking 3 months earlier Wonders if the surgery could cause incontinence Takes daily multivitamin and calcium supplement. History of deep venous thrombosis in right leg 10 years earlier

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position?

Lithotomy

the nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?

Milk

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?

Patency of the airway

The nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which before administering the clear liquids? Incision appearance Pain rating of 3 or less Presence of bowel sounds Urinary output of 30 mL per hour Whether the client has passed flatus

Presence of bowel sounds Urinary output of 30 mL per hour Whether the client has passed flatus

The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?

Pneumonia

The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply. Eggs Bread Lettuce Potatoes Avocados Salt substitute

Potatoes Avocados Salt substitute

The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply.

Potatoes Avacadoes Salt Substitute

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat foods from which nutrient categories to promote wound healing? Select all that apply.

Protien T Vitamin C

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse reinforces dietary teaching about the types of foods to avoid. The nurse determines that there is a need for further teaching if the client states that which food choices are good? Select all that apply

Sauerkraut American cheese

a client has a diagnosis of hyperphosphatemia. the nurse reinforces teaching the client to eliminate which from the diet?

fish

The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?

Suction equipment

The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication? Dehiscence Paralytic ileus Wound infection Skin irritation surrounding the wound

Skin irritation surrounding the wound

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?

Scallops

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? Scallops Chocolate Cornbread Macaroni products

Scallops Rationale: Scallops should be omitted from the diet of a client who has gout because of the high purine content. The food items identified in the remaining options have negligible purine content and may be consumed by the client with gout

The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?

Semi-Fowler's

A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?

TPN contains concentrated carbohydrates and raises blood glucose.

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client?

The best results are achieved when sitting at least halfway or fully upright.

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings?

The incision line is slightly edematous but shows no active signs of infection.

The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan?

The presence of food allergies

A client is receiving total parenteral nutrition and has been NPO. The primary health care provider (PHCP) prescribed small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth?

The presence of the swallow reflex

The nurse is preparing a client for surgery. Which would be a component of the plan of care? Verify the preoperative laboratory studies were drawn. Report any increases in blood pressure (BP) on the day of surgery. Verify that the client has received nothing by mouth (NPO) for 24 hours before surgery. Instruct the client not to swallow water with oral hygiene on the morning of surgery. A document that any medications the client was instructed to take before surgery are given.

Verify the preoperative laboratory studies were drawn. Instruct the client not to swallow water with oral hygiene on the morning of surgery. Document that any medications the client was instructed to take before surgery are given.

The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply.

Yogurt Cottage cheese

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply. Wound care Personal hygiene Activity restrictions Frequent assessment of vital signs Coughing and deep breathing exercises Pain monitoring and medications to relieve pain

Wound care Frequent assessment of vital signs Coughing and deep breathing exercises Pain monitoring and medications to relieve pain

the nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. the nurse tells the client that which food provides the least amount of potassium?

apple

when reinforcing instructions to a client with acute diverticulitis, which should the nurse include?

avoid whole-grain products

a client with a burn injury is transferred to the nursing unit and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?

chicken breast, broccoli, strawberries and milk

a client receiving total parenteral nutrition complains of nausea, excessive thirst, and increased frequency of voiding. the nurse should initially review which client data?

capillary blood glucose level

a child with leukemia is experiencing nausea realted to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea?

cool, clear liquids

a client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. the health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 ml/hr the nurse plans care, knowing that which is true regarding enteral feedings

enteral feedings require the normal digestive capabilities of the GI tract

the nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. the nurse is instructed to monitor the client for signs of fat overload. the nurse monitors for which signs and symptoms of this complication?

ever and pruritic urticaria

the nurse provides dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. the nurse tells the client that the fruit highest in potassium is which selection?

kiwifruit

a client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. the nurse notes that the client has abdominal distention as well. the nurse reviews the nutritional content on the label of the can to see if it contains which ingredient

lactose

a client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. in review of the nursing history for this client, which of these notations indicates the need to notify the health care provider?

lactose intolerance since childhood

the nurse is caring for a client following a total hip replacement. the client has been diagnosed with iron deficiency anemia. the nurse instructs the client to increase intake of which foods?

lean beef and chicken liver

the nurse is instructing a client on how to decrease the intake of magnesium in the diet. the nurse tells the client which food item contains the least amount of magnesium?

processed drinking water

the nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. the nurse is concerned about the client's swallowing ability. the nurse avoids including which food item in this client's diet?

spinach

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. Notify the registered nurse immediately. Document the client's complaint with the exact times. Place a sterile saline dressing and ice packs over the wound. Prepare the client for wound closure by notifying the surgery department. Place the client in a supine position without a pillow under the head. Instruct the client to remain quiet and reassure the situation is being taken care of.

1. Notify the registered nurse. 2. Document the client's complaint. 3. Instruct the client to remain quiet. 4. Prepare the client for wound closure. 6. Instruct the client to remain quiet and reassure the situation is being taken care of.

A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor vital signs. 2. Change dressing as needed. 3. Change infusion tubing every 24 hours. 4. Use strict aseptic technique when caring for the catheter. 5. Contact the primary health care provider for a prescription for antibiotics.

2. Change dressing as needed. 3. Change infusion tubing every 24 hours. 4. Use strict aseptic technique when caring for the catheter.

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? *Fill in the blank.* ____ mL

250mL Rationale: 200 mL × 8 hr = 1600 mL, which is the amount of normal saline infused. 850 − 1600 = 250 (total in receptacle minus irrigation)

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? 1 2 3 4

3 Rationale: Long-term indwelling catheters are used with severe urinary retention, recurrent urinary tract infections, and when wounds are irritated by contact with urine. Silicon is preferred because it can stay in place for 2 to 3 months. Size 14 to 16 are standard sizes, and only sterile water should be used to inflate the balloon. Saline will crystallize in the balloon. Intermittent and short-term catheterization would not solve the issue of severe urinary retention and would require repeated catheterization, increasing risk of infection. A condom catheter will not remedy urinary retention and does not have a balloon.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon? 1.Immediately inflate the balloon. 2.Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3.Advance the catheter to the bifurcation and inflate the balloon. 4.Insert the catheter until resistance is met and inflate the balloon.

3.Advance the catheter to the bifurcation and inflate the balloon. Rationale: Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine and then continues to advance the catheter to the point of bifurcation and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The balloon should not be inflated when urine is first observed, after advancing several more centimeters or when resistance is felt.

a client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?

green, leafy vegetables

the nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse should tell the client that which food contains the least amount of potassium?

lettuce

A client states that he has removed all dairy foods from his diet because he is lactose intolerant. The nurse plans care for the client knowing which information?

Calcium and protein are valuable nutrients and need to be supplemented in some form.

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse should provide the client with which instruction regarding positioning in the postoperative period?

Do not sleep on the left side.

The nurse is explaining the concept of time-out in the perioperative area to a group of nursing students. What is the purpose of a time-out?

To allow the surgical team a chance to verbally verify their agreement on the client's name, surgical procedure, and site

The nurse is taking care of a client preoperatively. The client is NPO and tells the nurse that he takes detemir insulin (Levemir) and aspart insulin (NovoLog) at 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?

Call the health care provider for clarification.

The nurse is reinforcing dietary instructions to a client with tuberculosis who has lost weight. The nurse reinforces instructions for the client to increase intake of protein and vitamin C. The nurse determines that teaching has been effective when the client selects which food items in the daily diet

Hamburger and oranges

The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items should be included in the client's diet? Select all that apply.

Milk Wild caught salmon

A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention?

Rolling the client to one side to view bedding

The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. Which is the rationale for prescribing this medication?

To decrease the bacteria in the bowel

The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply.

Central line dressing changes per protocol Blood glucose monitoring around the clock Using an electronic infusion pump with the infusion Reviewing prescribed blood laboratory values including electrolytes

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further teaching?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home with family caregivers. Which nursing response would be appropriate at this time?

"Tell me more about your concerns with your feedings after going home."

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? "I can give my child acetaminophen for fever." "I will watch for any hearing loss that may occur." "I know that I will need to watch for any rash that my child may develop." "I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

"I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months." Rationale: Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis, streptococcal pneumococci can cause many bacterial infections, including meningitis. Options 1, 2, and 3 are correct.

A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis?

"It felt like something just slit me wide open."

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? "If it's any help, everyone is nervous before surgery." "I will be happy to explain the entire surgical procedure to you." "Can you share with me what you've been told about your surgery?" "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

"Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem? "How often do you usually move your bowels?" "How often do you usually take a laxative?" "Have you been eating meat on a daily basis?" "What have you been eating and drinking since the surgery?" "Have you been experiencing any urge to move your bowels?" "What kind and how often have you been taking medications for pain?"

"What have you been eating and drinking since the surgery?" "Have you been experiencing any urge to move your bowels?" "What kind and how often have you been taking medications for pain?"

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?

"You are concerned that you don't feel any better after surgery?"

Which factors contribute to the problem of stress incontinence? *Select all that apply.* 1. Obesity 2. Sneezing 3. Nulliparity 4. Performing Kegel exercises 5. Voiding at frequent intervals

(1 & 2) Rationale: Obesity contributes to stress incontinence by causing increased intra-abdominal pressure. Sneezing or laughing also often cause leakage of urine due to sudden increased intra-abdominal pressure. Nulliparity refers to never having given birth and is not a factor of stress incontinence; rather, a history of having three or more vaginal births is associated with stress incontinence due to the weakening of the pelvic floor muscles. Performing Kegel exercises is actually a means of strengthening muscle tone. Voiding at frequent intervals, such as every 2 hours decreases the volume of urine in the bladder, thus decreasing the stretch and pressure in the bladder, and lessening the chance of incontinence.

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? *Select all that apply.* 1. Placing the scan head on the symphysis pubis and aiming toward the bladder 2. Pressing and holding the done button to display the volume measurement and print results 3. Applying a generous amount of transmission/conductivity gel across the client's abdomen 4. Pressing the gender button to select the male setting and wiping the scan head with an alcohol pad 5. Turning on the scanner by pressing the on/off button and then the scan button to turn on the scanning screen 6. Assisting the client to a supine position with head elevated on a pillow and exposing the client's lower abdomen

(1 & 3) Rationale: A bladder scan is a portable ultrasound used to estimate the amount of urine in the bladder. The student nurse should apply the conductivity gel 2.5 to 4 cm above the symphysis pubis, not across the abdomen. The scan head is placed in this area and aimed toward the client's head and slightly downward toward the coccyx, not downward on the symphysis pubis. The supine position is correct. The scanner is turned on and the male setting is used with a female client without a uterus (status post hysterectomy). The scan head is cleansed with alcohol before the scan. Once the scanner head is positioned the button is pushed to display the urine in the bladder. The nurse observes the picture on the scanner to make sure the picture on the screen correctly depicts the urine. The volume measurement is printed or noted and documented in the client's medical record. The client needs to be placed in the proper position before the scanner is turned on and gender is selected. After applying gel, the bladder can be scanned. Once the bladder is scanned, the volume measurement should be displayed and the results printed.

The client is to receive a soapsuds enema. Which is the *best* position for administering an enema? a left sidelining b prone c lithotomy d knee chest

(1) Rationale: The Sims, or left lateral position, is the position of choice for enema administration facilitating fluid to pass farther in the intestine. Many clients cannot tolerate the prone position. The lithotomy position is impractical for the procedure, and knee chest is too uncomfortable.

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply. 1. Maintain adequate fluid intake of 2 quarts. 2. Urinate regularly every 8 hours during the day. 3. Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. 4. Take all discharge medication as prescribed including antibiotics, and notify your primary health care provider if symptoms or signs of a UTI reappear. 5. Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating.

(1, 3, 4 & 5) Rationale: Besides taking all discharge medications as prescribed, including antibiotics, and notifying the primary health care provider if symptoms/signs of a UTI reappear, it is also important for the client to take adequate fluid amounts and use appropriate hygiene to prevent microorganisms from entering the bladder. Vaginal douches need to be avoided along with other products that can potentially irritate the perineal area. The client must be told to urinate at least every 4 to 6 hours.

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. *Select all that apply.* 1.Check the bladder for distention. 2.Review intake and output record. 3.Check to ensure drainage tubing is not kinked. 4.Ask the client about bladder spasms and discomfort. 5.Raise the drainage bag to the height of the bladder. 6.Deflate the balloon of the catheter, advance the catheter 2 cm, and reinflate the balloon.

(1,2,3 & 4) Rationale: A continuous bladder irrigation is often prescribed after a TURP to prevent blood clot formation that will obstruct the catheter. A drainage tube that is kinked will not allow the bladder irrigation solution to exit the body and can be done quickly while observing the system setup. Assessing the bladder for distention would follow because a clot may be preventing drainage. Asking the client if there is any discomfort or spasms may indicate improper drainage. Reviewing the intake and output record is done because the nurse can see that fluid is entering the system but not leaving. Raising the drainage bag will cause the urine to backflow into the bladder or stop flow. Deflating the balloon and advancing the catheter should not be done because this will introduce bacteria into the system.

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? *Select all that apply.* 1. Increase your fluid intake. 2. Include more fiber in your diet. 3. Ferrous sulfate changes the color of stool to black. 4. Iron slows colonic acid and often leads to constipation. 5. Use an enema every other day if you don't have a bowel movement. 6. Signs of constipation include not having a bowel movement every day.

(1,2,3 & 4) Rationale: As motility slows, feces are exposed to the intestinal walls and water is absorbed. Increasing fluid intake will help by adding more fluid to the intestinal contents. Fiber increases motility. Iron and several other medications slow motility. Lack of exercise or bed rest contributes to constipation. An enema should not be used every other day, usually no more frequently than on the third day. Many people do not have bowel movements every day. Constipation is not having a bowel movement in 3 days.

A client has been diagnosed with functional incontinence. Which interventions are *most appropriate* to care for this type of incontinence? *Select all that apply.* 1. Schedule toileting every 2 hours. 2. Modify clothing for easy removal. 3. Assess the environment for obstacles. 4. Decrease fluid intake to 1500 mL/day. 5. Obtain a prescription for catheterization to eliminate embarrassment. 6. Set up a schedule of cues such as mealtimes, awakening, and bedtime.

(1,2,3 & 6) Rationale: Functional incontinence is loss of urine by factors outside the urinary tract that interfere with the ability to respond in a socially appropriate way to the urge to void. It may be an inability or unwillingness of a person with normal bladder function to get to the bathroom in time, environmental barriers (e.g., raised side rails), physical limitations (e.g., can't walk self to bathroom), or mental factors (e.g., disorientation). Interventions include such things as clothing modifications, environmental alterations, scheduled toileting, and absorbent products. Therefore, option 2 is correct because modifying clothing to use Velcro or easy fasteners can save time in reacting to urge. Option 1 is correct because toileting every 2 hours will prevent overfilling of the bladder. Option 3 is correct because environmental obstacles such as poor lighting or lack of assistive devices can make it difficult to reach the toilet in a timely manner. Option 6 is correct because establishing a schedule will provide reminders to use the toilet. Option 4 is incorrect because decreasing fluid intake to below 2000 mL will irritate the bladder and may contribute to incontinence and may increase risk of infection. Option 5, catheterization, is incorrect because it contributes to risk of infection.

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? *Select all that apply.* 1. Character of drainage 2. Presence of blood clots 3. Amount of drainage emptied 4. Client complaint of pain/spasms 5. Type and amount of irrigation fluid used 6. Frequency of emptying the drainage bag

(1,2,3,4 & 5) Rationale: Options 1, 2, 3, 4, and 5 are all correct because they all are indications of the effectiveness of the bladder irrigation. Character of drainage describes details such as color and sediment and is a means of evaluating effectiveness of irrigation. Presence and size description of blood clots, complaints of spasms, type and quantity of solution infused, and amount of solution returned all provide information as to effectiveness of procedure and client status. Option 6 is incorrect because it is not necessary to document how frequently the drainage bag was emptied, but the amount of irrigation fluid that went in and the total amount of drainage emptied should be documented so that the actual urine output can be calculated by subtracting the input from the output.

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? *Select all that apply.* 1. Apply disposable gloves. 2. Place the client in the right Sims' position. 3. Lubricate the enema tube and insert it approximately 4 inches. 4. Clamp the tubing if the client expresses discomfort during the procedure. 5. Hang the enema solution container 24 inches above the client's anus. 6. Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

(1,3,4 & 6) Rationale: The administration of an enema is a clean procedure, and standard precautions must be used. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort subsides. The container containing the enema solution is hung about 12 to 18 inches above the client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between 100° F (37.8° C) and 105° F (40.5° C). Solution that is too hot will burn the client, and solution that is too cool will cause cramping.

A client is diagnosed with Haemophilus influenzaepneumonia. In addition to standard precautions, which other precautions should be institutedimmediately by the nurse? 1. Droplet precautions 2. Contact precautions 3. Airborne precautions 4. Neutropenic precautions

Correct Answer: 1

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? *Select all that apply.* 1. Obtain the bladder scan before the client voids. 2. Have the client void and then perform the bladder scan. 3. If residual urine is less than 100 mL, continue to monitor. 4. Reduce oral fluid intake to decrease amount of residual urine. 5. Straight catheterize the client if 100 mL of urine is viewed on the scan. 6. Notify the primary health care provider immediately if 30 mL of urine is viewed on the scan.

(2 & 3) Rationale: To obtain a residual urine, it is necessary for the client to void, then obtain a bladder scan. If less than 100 mL of urine (or the specific amount prescribed) is viewed on the scan, continuing to monitor as prescribed is appropriate. Obtaining the scan before voiding would tell the nurse how much fluid the bladder can hold. Decreasing fluids may lead to dehydration and will not affect residual urine. Notifying the primary health care provider of normal findings is inappropriate, as is catheterizing for 100 mL of residual urine.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement? 1."I walk 1 to 2 miles per day." 2."I need to decrease fiber in my diet." 3."I drink 6 to 8 glasses of water per day." 4."I have a bowel movement every other day."

(2) Rationale: Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse should recognize that which type of enema has the highest risk of water intoxication? 1. Soapsuds 2. Tap water 3. Normal saline 4. Hypertonic solution

(2) Rationale: Tap water is hypotonic, creating a lower osmotic pressure than the fluid in interstitial spaces. With repeated tap water enemas, fluid can escape from the bowel lumen into interstitial spaces and can cause circulatory overload or water intoxication if the body absorbs too much water. Normal saline enemas are the safest type of enema because of having the same osmotic pressure as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not cause any fluid shifts but may not be effective in evacuating the bowel. Castile soap is incorrect because it can be mixed with either water or saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is the only safe soap to use for a soapsuds enema because harsh soaps may cause inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull fluid from the interstitial spaces into the colon. Although this could have the potential for dehydration, it does not pose as high of a risk of complications as the tap water enema. A Fleets enema (commercially prepared sodium phosphate) is the most common type of hypertonic enema.

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply. 1. Change the appliance daily. 2. Empty pouch when ⅓ to ½ full. 3. The stoma should be a dry pale pink. 4. The stoma should be moist and pink to red. 5. The skin barrier should be within 1⁄16 to ⅛ inch of the stoma. 6. Change the appliance about every 3 days, or sooner, if it is leaking effluent.

(2,4,5 & 6) Rationale: The pouch should be emptied when ⅓ to ½ full to prevent the weight of contents from loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to within 1⁄16 to ⅛ inch of the base of the stoma prevents effluent from irritating the skin. With an adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2 weeks. Changing the appliance daily would damage the skin around the stoma. A dry pale pink is indicative of an unhealthy stoma and possibly dehydration.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason? 1. The nurse is right-handed. 2. The rectal sphincter will relax. 3. The enema will flow into the bowel easily. 4. The client is more likely to retain the enema solution.

(3) Rationale: When administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

An older client complains of chronic constipation. Which instructions should the nurse reinforce with the client? *Select all that apply.* 1. Include rice and bananas in the diet. 2. Increase the intake of sugar-free products. 3. Increase fluids to at least eight glasses a day. 4. Increase various potassium-rich foods in the diet. 5. Respond in a timely manner to the urge to defecate.

(3,5) Rationale: Increase of fluid intake and dietary fiber will help change the consistency of the stool and make it easier for the client to pass. Clients should respond to the feeling of peristalsis involved with urge to defecate. Some older clients with mobility issues may not respond to the urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client.

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the *need for further teaching? Select all that apply.* 1. Assess the stoma and skin. 2. Remove the used pouch and barrier. 3. Perform hand hygiene and don gloves. 4. Lightly scrub the stoma with soap and water. 5. Press the adhesive backing of the pouch against the skin. 6. Cut the opening on the appliance ½ inch larger than stoma.

(4 & 6) Rationale: The client washes the hands and dons gloves before removing the pouch and barrier. The peristomal area is cleansed with warm water to remove residue and improve visualization. The stoma is assessed for color, and the skin is checked for irritation. The appliance is measured and cut 1/16 inch larger than stoma to prevent strangulation of stoma, or too much room for skin irritation between the stoma and appliance. The adhesive backing of the appliance is pressed against the skin avoiding wrinkles to achieve seal.

A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. What is the maximal amount of calories the client should receive in an 8-hour period if the tube feeding is not interrupted? Fill in the blank.

360

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? A pink, edematous hand Fiery red skin with edema in the nail beds Black fingertips surrounded by an erythematous rash A white color of the skin which is insensitive to touch

A white color of the skin which is insensitive to touch Rationale: The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for further teachingis necessary when the client makes which statement? 1. "I need to breastfeed my baby." 2. "I can continue to hug and hold my other children." 3. "It may be 2 years before I know if my baby has HIV." 4."My husband and I can still sleep together in the same bed."

Correct Answer: 1

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? A staff member who has never had roseola A staff member who has never had mumps An unlicensed assistive personnel who has never had chickenpox Unlicensed assistive personnel who has never had German measles

An unlicensed assistive personnel who has never had chickenpox Rationale: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox. Options 1, 2, and 4 are not associated with the herpes zoster virus.

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? Anthrax is treated with antibiotic medications. The most lethal form of anthrax is contracted by inhalation of the spores. Anthrax can be transmitted by the consumption of meat from an infected animal. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis. Rationale: Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. Antibiotics are administered. Botulism is caused by a neurotoxin that causes severe paralysis and can be fatal.

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply.

Apples White bread Egg whites

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply. Fish Apples Almonds White bread Egg whites Whole-grain pasta

Apples White bread Egg whites

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse should tell the client that which foods are best to include in the diet for this disorder? Select all that apply. Beans Apples Cabbage Brussels sprouts Whole-grain bread

Apples Whole grain bread Rationale: A high-fiber, high-residue diet is used for constipation, irritable bowel syndrome when the primary symptom is alternating constipation and diarrhea, and asymptomatic diverticular disease. High-fiber foods include fruits and vegetables and whole-grain products. Gas-forming foods such as beans, cabbage, and Brussels sprouts should be limited.

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of the underlying tissue. Which should be the initial action by the nurse? Turn the client to the side with the knees bent. Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. Explain to the client that obesity is a risk factor and weight loss should be a future goal. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which action in the initial care of this wound?

Apply a sterile dressing soaked with normal saline.

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound.

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Apply the safety strap 2 inches above the knees.

The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care for the client? Select all that apply. Administering prescribed acyclovir Applying prescribed topical antibiotic Administering prescribed corticosteroid Administering prescribed oral amphotericin B Applying Domeboro solution to the affected skin

Applying prescribed topical antibiotic Administering prescribed corticosteroid Applying Domeboro solution to the affected skin Rationale: Pemphigus is a chronic autoimmune condition in which bullae (blisters) develop on the face, back, chest, groin, and umbilicus. The blisters rupture easily, releasing a foul-smelling drainage. Potassium permanganate baths, Domeboro solution, and oatmeal products with oil may be prescribed to soothe the affected areas, reduce odor, and decrease the risk of infection. Treatments may include corticosteroids, other immunosuppressants, and oral or topical antibiotics. Acyclovir is an antiviral medications used to treat chickenpox or shingles. Amphotericin B is an antifungal used to treat fungal infections.

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed? Ask if the client is thirsty and assist with drinking a glass of water. Ask how the client feels and inquire about any feelings of dizziness. Review the client record to determine time and type of analgesia last received. Review the client record to determine whether the client has voided postoperatively. Assist the client to perform leg exercises and then recheck the blood pressure and pulse rate. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

Ask how the client feels and inquire about any feelings of dizziness. Review the client record to determine the time and type of analgesia last received.gns. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery?

Ask the client to discuss information known about the planned surgery.

The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items should the nurse instruct the client to avoid? Select all that apply.

Bacon Salami Processed oat cereals

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, what should be the nurse's first action? Increase the rate of the IV fluid. Call the primary health care provider. Administer a 250-mL bolus of normal saline (0.9%). Check the client's overall intake and output record. Gather data about the urinary catheter and check for patency.

Check the client's overall intake and output record. Gather data about the urinary catheter and check for patency.

The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain? Check the drain for patency. Check that the drain is decompressed. Observe for bright red, bloody drainage. Maintain aseptic technique when emptying. Empty the drain when it is half full and every 8 to 12 hours. Secure the drain by curling or folding it and taping it firmly to the body.

Check the drain for patency. Check that the drain is decompressed. Observe for bright red, bloody drainage. Maintain aseptic technique when emptying. Empty the drain when it is half full and every 8 to 12 hours.

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?

Cheese

The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication?

Client complaints of a dry mouth

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention? 1. Determining what common food item was ingested by those affected 2. Reviewing the signs and symptoms related to the Salmonellabacteria 3. Notifying the U.S. Centers for Disease Control and Prevention (CDC) 4. Teaching the basic methods for preventing food contamination to those affected

Correct Answer: 1

In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies should the nurse bring to the child's room to prevent the transmission of the virus? 1. Mask and gloves 2. Gown and gloves 3. Goggles and gloves 4. Gown, gloves, and goggles

Correct Answer: 1

The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement? 1. "I should use disposable plates, forks, and knives." 2. "I should cough into tissues and throw them away carefully." 3. "It's important to cover my mouth if I laugh, sneeze, or cough." 4. "It's very important to wash my hands after I touch my mask, tissues, or body fluids."

Correct Answer: 1

The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure? 1. Discard used tissues in a plastic bag. 2. Wash hands at least four times a day. 3. Brush teeth and rinse the mouth once a day. 4.Turn the head to the side if coughing or sneezing.

Correct Answer: 1

The nurse is assigned to care for a client who has been diagnosed with human immunodeficiency virus (HIV). In planning care for the client, the nurse understands that educating staff concerning which instruction will have the greatest impact on minimizing the spread of the virus? 1. Using personal protective equipment appropriately 2.Understanding the implementation of airborne precautions 3. Knowing the HIV status of every client currently on the unit 4. Determining whether the client has been placed in protective isolation

Correct Answer: 1

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action? 1. Change the IV tubing. 2. Wipe the tubing with Betadine. 3. Scrub the tubing with an alcohol swab. 4. Scrub the tubing before attaching it to the IV bag.

Correct Answer: 1

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply. 1. Perform hand hygiene after removal of PPE. 2. Perform hand hygiene before donning any PPE. 3. When removing PPE, always remove gloves first. 4. Gloves should be applied under the sleeves of the gown. 5. Leaving the room wearing PPE for several minutes is permissible. 6. Protective eyewear and face shield are indicated if there is risk of splatter.

Correct Answer: 1, 2, 3, 6

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client? Select all that apply. 1. Check temperature at least every 4 hours. 2. Monitor white blood cell count daily as prescribed. 3. Eliminate fruits and vegetables from the client's diet. 4. Remove fresh flowers or plants from the client's room. 5. Administer oxygen to maintain the oxygen saturation level greater than 97%.

Correct Answer: 1, 2, 4

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply. 1. Put on a mask. 2. Don gown and gloves. 3. Apply shoe protectors. 4. Wear a pair of protective goggles. 5. Have the client wear a mask and goggles.

Correct Answer: 1, 2, 4

A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply. 1. Get plenty of sleep and rest. 2. Take all medications as prescribed. 3. Eat plenty of fresh fruits, salads, and vegetables. 4. Wash your hands frequently with antibacterial soap. 5. Having indoor plants is permissible, but no outdoor gardening. 6. Contact the primary health care provider (PHCP) if even a low-grade fever develops.

Correct Answer: 1, 2, 4, 6

Following a cleft lip repair, the nurse reinforces instructions to the parents of the infant. Which of the instructions should be given to the parents of the infant? Select all that apply. 1. Monitor frequency of diaper changes. 2. Cleanse the surgical site with normal saline 3. Offer the infant a pacifier in between feedings. 4. Do not use a car seat until the incision is healed. 5. Apply prescribed antibiotic ointment to the surgical site.

Correct Answer: 1, 2, 5

The nurse performs an audit in the hospital intensive care unit of clients who have indwelling urinary catheters. Which observations, found in the audit, pose a risk for a health care-associated infection? Select all that apply. 1. Drainage bag port touching the floor 2. Dependent loop in the catheter tubing 3. Cleansing around the catheter with soap and water twice daily 4. A stabilizing device in place to keep the catheter from moving 5. Use of one measuring container between two clients with the same pathogen in the urine 6 Using a sterile syringe through the tubing port cleansed with antiseptic to obtain a urine specimen

Correct Answer: 1, 2, 5

The nurse receives the culture test results for a client who developed a bloodstream infection from a central venous device. The culture report indicates that the infection is exogenous. The client asks the nurse how she could have contracted this infection. Which should the nurse include in the explanation of potential sources of infectious organisms? Select all that apply. 1. The health care facility 2. The nurse caring for the client 3. The client's use of homeopathy 4. The use of high doses of antibiotic therapy 5. The use of contaminated intravenous fluids 6. The reactivation of a previous dormant organism

Correct Answer: 1, 2, 5

The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review? Select all that apply. 1. Needle-stick injuries 2. Use of latex condoms 3. Transmission by breast milk 4. Mutually monogamous relationships 5. Inconsistent use of protective equipment

Correct Answer: 1, 3, 5

A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce? Select all that apply. 1. Wash soiled clothes in hot water. 2. Disinfect surfaces with 100% bleach. 3. Use gloves when handling body fluids. 4. Encourage a minimum of 12 hours sleep per day. 5. Other members of the household should not share a bathroom. 6. Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes.

Correct Answer: 1, 3, 6

A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse reinforces discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further teaching? 1. "I can use an ophthalmic analgesic ointment at night if I have eye discomfort." 2. "I do not need to be concerned about spreading this infection to others in my family." 3. "I should apply a warm compress before instilling antibiotic drops if purulent discharge is present in my eye." 4. "I should perform a saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present."

Correct Answer: 2

A client with tuberculosis, whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. What should the nurse tell the client? 1. "Five sputum cultures must be negative before returning to work." 2. "Three sputum cultures must be negative before returning to work." 3. "A sputum culture and a chest x-ray must be negative before returning to work." 4. "A sputum culture and a Mantoux test must be negative before returning to work."

Correct Answer: 2

A hospitalized child with leukemia has received chemotherapy by the intravenous (IV) route, and a discharge to home is being planned. Laboratory values indicate that the child is neutropenic. The child is being treated daily by cleansing and the application of a topical antibiotic on an open area from an old IV site. The nurse reinforces instructions to the mother regarding the signs of infection at this affected site. Which statement by the mother indicates that the mother understands the instructions? 1. "Pus at the site means that an infection is present." 2. "I will clean the site and apply the topical ointment every day." 3. "If I see redness at the site, I don't need to worry as long as there is no pus." 4. "If the temperature is elevated, I don't need to be concerned, because this is normal with affected white blood cells."

Correct Answer: 2

The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse should avoid which action? 1. Clamping the tubing of the drainage bag 2. Obtaining the specimen from the urinary drainage bag 3. Aspirating a sample from the port on the tubing attached to the drainage bag 4. Wiping the port on the tubing with an alcohol swab before inserting the syringe

Correct Answer: 2

The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which nursing action would be most appropriate in preparing the client for the test? 1. Plan to have the MRI performed at the bedside. 2. Place a surgical mask on the client for transport and for contact with other individuals. 3. Ask that the MRI department be called to tell technicians in the department to wear masks. 4. Ask that the MRI department be called to tell the technician that the test will have to be delayed until the airborne precautions are discontinued.

Correct Answer: 2

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which items when performing this care? 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3.Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear

Correct Answer: 2

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse use during the bathing of this client? 1. Gloves 2. Gown and gloves 3. Gown, gloves, and mask 4. Gown and gloves to change the bed linens and gloves only for the bath

Correct Answer: 2

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply. 1. Empty the urinary drainage bag every 12 hours. 2. Use indwelling urinary catheters judiciously. 3. Remove indwelling catheters when no longer needed. 4. Use strict aseptic techniques when inserting all urinary catheters. 5. Do not insert straight catheters into a client more than once a day. 6. Irrigate all indwelling catheters every day to prevent obstruction.

Correct Answer: 2, 3, 4

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply. 1. Use a dry table that is below waist level. 2. Open the distal flap of a sterile package first. 3. Prepare the sterile field just before the planned procedure. 4. Don clean gloves before touching items on the sterile field. 5. Place the sterile field 1 foot behind the working area and out of view of the client. 6. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

Correct Answer: 2, 3, 6

The nurse should plan to reinforce instructions to which clients about the risk for transmission of disease through blood and sexual contact? Select all that apply. 1. A client diagnosed with hepatitis A virus 2. A client diagnosed with hepatitis B virus 3. A client diagnosed with hepatitis C virus 4. A client diagnosed with Rocky Mountain spotted fever 5. A client with a wound infection with Staphylococcus aureus 6. A client diagnosed with human immunodeficiency virus (HIV)

Correct Answer: 2, 3, 6

The nurse reinforces instructions to a client diagnosed with impetigo. Which statements by the client indicate a need for further teaching? Select all that apply. 1. "I need to continue with the antibiotics as prescribed." 2. "I can wash my laundry with other household members' items." 3. "I need to wash my hands thoroughly and frequently throughout the day." 4. "I should not wash the lesions of the infection once the skin lesions have scabbed over". 5. "I need to separate my dishes and wash them separately from the dishes of other household members."

Correct Answer: 2, 4

The nurse is preparing to comb the hair of a child client who has been treated for pediculosis (lice) at a clinic. Which additional instructions should the nurse give the parents of the child? Select all that apply. 1. Having pediculosis once gives the child immunity. 2. All head wear and bed linens should be washed in hot water. 3. The presence of lice in a child are evidence of neglect and poor hygiene. 4. A parent should observe all persons in the household for presence of lice or nits 5. If others in the household are found to have pediculosis, they all must be treated and have the nits removed from their hair.

Correct Answer: 2, 4, 5

A 70-year-old client who has been treated for cellulitis of the leg asks the nurse how to improve resistance to infection. Which measures should the nurse reinforce in the teaching plan? Select all that apply. 1. Take a hot bath or shower twice daily. 2. Balance activity, rest, and avoid stress. 3. Eat mainly organic fruits and vegetables. 4. Keep skin on arms and legs well lubricated. 5. Wash any breaks in the skin with soap and water. 6 Receive recommended vaccines against influenza and pneumonia.

Correct Answer: 2, 4, 5, 6

The nurse is changing a dressing on the wound of a postsurgical client who is receiving contact precautions because of a history of methicillin-resistant Staphylococcus aureus (MRSA) from a previous surgery. Which interventions should the nurse follow? Select all that apply. 1. Wear a mask and apply a mask to the client. 2. Observe the incision line for redness and drainage. 3. Medicate the client for pain after the dressing change. 4. Press firmly on the incision to determine if drainage is present. 5. Change gloves between removal of the old dressing and applying the new.

Correct Answer: 2, 5

A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the primary health care provider's office because the leukemic child has never had chickenpox. The nurse should make which response to the mother? 1. "There is no need to be concerned." 2. "Keep the child out of school for a 2-week period." 3. "Bring the child to the office for an injection called immune globulin." 4. "Monitor the child for an elevated temperature and call the primary health care provider if a temperature occurs."

Correct Answer: 3

A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate? 1. "I have a vase in the utility room, and I will get it for you." 2. "I will get the vase and wash it well before you put the flowers in it." 3. "The flowers from your garden are beautiful, but they should not be placed in the child's room at this time." 4. "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."

Correct Answer: 3

A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions? 1. Places the client in a private room 2. Wears gloves, gown, and goggles when changing the client's colostomy bag 3. Wears a gown when caring for the client and removes the gown immediately after leaving the client's room 4. Places the client in a semiprivate room with another client who has active infection with the same microorganism but who has no other infection

Correct Answer: 3

A client with tuberculosis (TB) who is being prepared for discharge to home should be instructed to follow which practice to decrease the possibility of spreading the infection? 1. Wear a mask when at home with family members. 2. Have a weekly sputum culture to follow the course of the infection. 3. Wear a mask when in contact with people outside of the family until medications are effective. 4. Have a bacille Calmette-Guérin (BCG) vaccination to protect other people from exposure.

Correct Answer: 3

In developing a plan of care for a client hospitalized with tuberculosis (TB), the nurse should place emphasis on which intervention? 1. Instructions on deep-breathing techniques 2. An increase in fluid intake to at least 3000 mL a day 3. The strict adherence to following airborne precautions 4. Special assistance in order to perform activities of daily living (ADLs)

Correct Answer: 3

The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items? 1. Gloves and a gown 2 Gloves, mask, and goggles 3. Gloves, mask, gown, and goggles 4. Gloves, gown, and shoe protectors

Correct Answer: 3

The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first? 1. Location of supplies 2. The handling of equipment 3. Proper hand-washing technique 4. Method to report signs of infection

Correct Answer: 3

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client? 1. "You will be isolated from your newborn after delivery." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

Correct Answer: 4

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother? 1. Isolate the child from others because the virus is transmitted by breathing and coughing. 2. Wash sheets and towels used by the child separately in bleach to prevent the spread of the infection to the others. 3. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva. 4. Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection through the urine and feces.

Correct Answer: 3

The nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery? 1. Discussing the normal involution process with the client 2. Encouraging early ambulation and the return to daily activities 3. Reviewing hand-washing techniques and pericare with the client 4. Instructing the client in proper positioning of the infant to facilitate breastfeeding

Correct Answer: 3

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. Neutropenic precautions have been implemented. Which activity should the nurse question if observed while caring for this client? 1. The family brings a bouquet of plastic flowers to brighten the client's room. 2. The family member with a cold wears a mask while visiting for a short period of time. 3 The client orders lunch of soup, salad with tomatoes and cucumbers, and an apple. 4. The client wears a mask while being transported to the interventional radiology department.

Correct Answer: 3

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? 1. Wear gloves only. 2. Wear a mask and gloves. 3. Wear a gown and gloves. 4. Avoid touching the client's clothes.

Correct Answer: 3

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1. Contact 2. Enteric 3. Droplet 4. Neutropenic

Correct Answer: 3

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? 1. A staff member who has never had roseola 2. A staff member who has never had mumps 3. An unlicensed assistive personnel who has never had chickenpox 4. An unlicensed assistive personnel who has never had German measles

Correct Answer: 3

When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution should the nurse institute before making contact with the client? 1. Don a mask and gloves. 2. Put on a pair of gloves. 3. Put on a gown and gloves. 4. Don a mask and a gown.

Correct Answer: 3

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply. 1. Wear a mask if within 3 feet of the client. 2. Place a mask on the client when client is outside the room. 3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene. 5. Keep the door of the room shut except when entering or exiting the client's room.

Correct Answer: 3, 4

A health care worker who signed a waiver and never received the hepatitis B vaccine receives a needle stick from a client who has hepatitis B. Which treatments are indicated for the health care worker under this situation? Select all that apply. 1. Vitamin C orally 2. Ciprofloxacin orally 3. Hepatitis B immune globulin 4. Initiate hepatitis B vaccine series 5. Cleanse needlestick site with soap and water

Correct Answer: 3, 4, 5

The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV? Select all that apply. 1. Wear an N95 respirator when in the client's room. 2. Recap all needles to prevent accidental needle sticks. 3. Perform hand hygiene before and after contact with the client. 4. Use biohazard bags for items saturated with blood and bodily fluids. 5. Wear personal protective equipment when contact with blood and other bodily fluids are anticipated.

Correct Answer: 3, 4, 5

The nurse is working with an unlicensed assistive personnel (UAP) to care for clients. While observing the UAP's delivery of care, the nurse notes which actions by the UAP that indicates the need for further teaching regarding standard precautions? Select all that apply. 1. Does not wear gloves to comb a client's hair 2. Wears gloves and holds dirty linen away from own clothing 3. Removes gloves and immediately uses computer to document care 4. Uses alcohol-based hand sanitizer upon entering the room of a client 5. Uses soap and water to wash hands for 5 seconds and then dries hands 6. Empties collection bag of an indwelling urinary catheter without wearing gloves

Correct Answer: 3, 5, 6

A child is diagnosed with bacterial conjunctivitis and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse should make which response to the parent? 1. "The child can return to school immediately." 2. "The child cannot return to school until seen by the primary health care provider (PHCP) in 1 week." 3. "The child should be kept home until the antibiotic eye drops have been administered for 1 week." 4. "The child should be kept home until the antibiotic eye drops have been administered for 24 hours."

Correct Answer: 4

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications. 2. The most lethal form of anthrax is contacted by inhalation of the spores. 3. Anthrax can be transmitted by the consumption of meat from an infected animal. 4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

Correct Answer: 4

The nurse is giving a client a bed bath and drops the towel on the floor. The nurse should take which action? 1. Use a bath blanket as a towel. 2. Borrow a towel from the client's roommate. 3. Wash the hands, pick up the towel, and shake it off. 4. Wash the hands and go to the linen room to obtain another towel.

Correct Answer: 4

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which should be the appropriate form of isolation to use to prevent the spread of infection to others? 1. Droplet precautions isolation 2. Enteric precautions 3. Contact precautions 4. Standard precautions

Correct Answer: 4

The nurse prepares the client for irrigation of an abdominal wound. Refer to video. Click on the Question Video button to view a video showing preparation procedures. After preparation, the nurse should appropriately don which article(s) to perform the procedure? 1. Gloves 2. Gloves and a gown 3. Gloves and goggles 4. Gloves, gown, and goggles

Correct Answer: 4

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? 1. "I can give my child acetaminophen for fever." 2. "I will watch for any hearing loss that may occur." 3. "I know that I will need to watch for any rash that my child may develop." 4. "I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

Correct Answer: 4

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves? 1. Insert left hand into left glove. 2. Insert right hand into right glove. 3. Place gloved right hand under the cuff of left glove. 4. Pick up right glove at cuff with left thumb and forefinger.

Correct Answer: 4

Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive? 1. Instruct the mother to check the anterior fontanel for bulging and sutures for widening each day. 2. Instruct the mother to feed the newborn in an upright position with the head and chest tilted slightly back to avoid aspiration. 3. Instruct the mother to feed the newborn with a special nipple and burp the newborn frequently to decrease the tendency to swallow air. 4. Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.

Correct Answer: 4

A client is admitted to the surgical unit postoperatively with a wound drain in place. Which nursing action should the nurse avoid in the care of the drain?

Curl the drain tightly and tape it firmly to the body.

Which ostomy location would most likely need to be irrigated? Refer to figure. A) Asending B) Proximal Transverse C) Distal Transverse D) Descending

D Rationale: The ostomy located at the juncture of the descending and sigmoid colon would be most likely to need irrigating because the effluent would be the most solid. Effluent in the ascending colon would be mostly liquid, and would become more solid as fluid is absorbed during passage through the transverse colon.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?

Discontinue the aspirin 48 hours before the scheduled surgery.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply. Hold the feeding. Document the amount of residual. Place it into a container for laboratory analysis. Reinstill the residual and administer the feeding. Deduct the amount of the residual from the new feeding before administering

Document the amount of residual. Reinstill the residual and administer the feeding.

The nurse is caring for a client following an abdominal hysterectomy performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which action? Increase the amount of suction on the NG tube. Ask the client whether he has passed any flatus. Encourage the client to take frequent sips of water. Document the finding and continue to check for bowel sounds. Immediately notify the registered nurse or primary health care provider.

Document the finding and continue to check for bowel sounds. Ask the client whether he has passed any flatus. Immediately notify the registered nurse or primary health care provider.

A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray?

Eggs

The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply

Eggs White bread with butter

A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray? Eggs Milk Cheese Broccoli

Eggs Rationale: Lacto-vegetarians eat milk, cheese, and dairy foods but avoid meat, fish, poultry, and eggs

The nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which position? Elevate the right arm on one or two pillows. Do not check the radial pulse in the right arm. Use small-gauge needles if the IV is initiated in the left arm. Instruct the client to avoid bending the fingers of the right hand. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

Elevated on one or two pillows Do not check the radial pulse in the right arm. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?

Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.

A client has a diagnosis of hyperphosphatemia. The nurse reinforces instructions by telling the client to eliminate which items from the diet? Select all that apply.

Fish Chicken

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Have the client void before surgery. Avoid oral hygiene and rinsing with mouthwash. Verify that the client has not eaten for the last 24 hours. Determine that the client has signed the informed consent for the surgical procedure. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

Have the client void immediately before surgery. Verify that the client has not eaten for the last 24 hours. Determine that the client has signed the informed consent for the surgical procedure.

A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosus. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition? Hypoglycemia Increased risk for dehiscence Excessive bleeding at the surgical incision Increased likelihood of surgical site infection Very early wound healing, causing excessive scarring

Increased likelihood of surgical site infection Increased risk for dehiscence

The nurse is monitoring the status of the postoperative client. The nurse should become most concerned with which sign(s) that could indicate an evolving complication?

Increasing restlessness Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply. Increasing restlessness Capillary refill of 3 seconds in all extremities Hypoactive bowel sounds in all four quadrants White blood cell (WBC) count 9,500 mm3 (9.5 × 109/L) Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

Increasing restlessness Hypoactive bowel sounds in all four quadrants Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply. Metastasis is rare. It is encapsulated. It is highly metastatic. It is characterized by local invasion. Lesion is a nevus that has changed in color.

It is highly metastatic. Lesion is a nevus that has changed in color. Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis.

The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy? Select all that apply.

Kiwi Bananas Avocados

The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply.

Lean beef and chicken liver Clams and mussels

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. Lesion has a waxy border An irregularly shaped lesion Papule, with a red, central crater A small papule with a dry, rough scale A firm nodular lesion topped with a crust

Lesion has a waxy border An irregularly shaped lesion Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved.

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin? Milk Tomatoes Citrus fruits Green, leafy vegetables

Milk Rationale: Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid

During a surgical procedure, the nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause what?

Nerve and muscle damage

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse should provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply. New floaters Improvement in vision clarity Increasing redness in the eye Sensation of mild grittiness in the eye Pain relieved by acetaminophen 500 mg

New floaters Increasing redness in the eye

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?

Notify the registered nurse.

The nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. The client has had a swallowing study done that shows the client is at risk for aspiration and is able to feed self. The nurse should review which interventions with the unlicensed assistive personnel (UAP)? Select all that apply.

Observe client for episodes of coughing or choking. Add the prescribed thickener to liquids

The nurse employed in a well-baby clinic is reinforcing nutrition instructions to the mother of a 1-month-old infant. Which instruction should the nurse provide the mother?

Offer breast milk or formula as the main food.

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.

Oranges Broccoli Grapefruit

The nurse reinforces preoperative teaching to a client who will wear an abdominal binder postoperatively following abdominal surgery. Which instruction should the nurse reinforce in the preoperative teaching plan? Sit up for coughing while splinting the incision. Remove the binder before assisting the client to ambulate. Remove the binder only when the primary health care provider is present. Apply the binder over the abdominal dressing as tight as possible. Remove the binder to change the abdominal dressing as prescribed and reapply.

Sit up for coughing while splinting the incision. Remove the binder to change the abdominal dressing as prescribed and reapply.

The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?

Oxygen saturation 95% to 100%

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

Pain

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? Positive patch test Positive culture results Abnormal biopsy results Wood's light examination indicative of infection

Positive culture results Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply. Put on a mask. Don gown and gloves. Apply shoe protectors. Wear a pair of protective goggles. Have the client wear a mask and goggles.

Put on a mask. Don gown and gloves. Wear a pair of protective goggles. Rationale: Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. Shoe protectors are not necessary and are used in operating rooms in the surgical departments. If the client is under airborne or droplet precautions, a mask is worn by the client when going outside of the room. Goggles are not worn by clients.

The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?

Recheck the vital signs in 15 minutes.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply.

Reinstill the residual and administer the feeding. Document the amount of residual.

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply. Auscultate breath sounds. Review vital signs from previous hour. Observe the urinary catheter for patency and flow. Observe the IV site for patency and correct flow rate. Review when the client last received pain medication.

Review vital signs from previous hour. Observe the urinary catheter for patency and flow. Observe the IV site for patency and correct flow rate. Review when the client last received pain medication.

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?

Suction equipment

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply. Tea Crackers Ice cream Scrambled eggs Cream of tomato soup Cream of wheat cereal

Tea Crackers Ice cream Cream of tomato soup Cream of wheat cereal

The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection?

The presence of purulent drainage

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. Slight redness along the incision The presence of purulent drainage A temperature of 98.8° F (37.1° C) The client states that he feels cold. The client states that the incision itches. Tender firmness palpable around the incision

The presence of purulent drainage Tender firmness palpable around the incision

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? The surgeon marking the area of the operative procedure The circulating nurse marking the area of the operative procedure Marking the site of the operative procedure during the "time-out" period Marking the site of the operative procedure at the completion of the procedure to measure any increase in swelling

The surgeon marking the area of the operative procedure

The nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. Which action does site marking involve?

The surgeon marking the area of the operative procedure

The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?

To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site

The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply.

Tofu Broccoli Sardines Mustard greens

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates and is unable to obtain any residual tube feeding. Which action should the nurse take next?

Turn the client to the side and attempt to aspirate again

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to carefully monitor which parameter during the next hour?

Urinary output of 20 mL/hr

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? Select all that apply. Sunscreen should be applied every 8 hours. Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. Avoid sun exposure in the late afternoon and early evening hours. Examine your body monthly for any lesions that may be suspicious.

Use sunscreen when participating in outdoor activities. Wear a hat, opaque clothing, and sunglasses when in the sun. Examine your body monthly for any lesions that may be suspicious. Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 am to 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, Which is the initial nursing assessment?

Vital signs

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral?

Vitamin B12

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? Wear gloves only. Wear a mask and gloves. Wear a gown and gloves. Avoid touching the client's clothes.

Wear a gown and gloves. Rationale: The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves when in close contact with a person who has methicillin-resistant Staphylococcus aureus (MRSA). Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Methicillin-resistant Staphylococcus aureus (MRSA) is contagious and is spread to others by direct contact with infected skin or infected articles

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply. Wear a mask if within 3 feet of the client. Place a mask on the client when client is outside the room. Wear gloves and gown while in the room caring for the client. Use soap and water, not alcohol-based hand rub, for hand hygiene. Keep the door of the room shut except when entering or exiting the client's room.

Wear gloves and gown while in the room caring for the client. Use soap and water, not alcohol-based hand rub, for hand hygiene. Rationale: Contact precautions are necessary for colonization or infection with a multidrug-resistant organism. This includes enteric infection with Clostridium difficile. Measures used to prevent the spread of C. difficile are wearing gowns and gloves while in the room (not just during care) because the spores are on surfaces in the room. Washing with soap and water for hand hygiene is indicated because alcohol-based sanitizers are ineffective against the spores. The use of a mask by the nurse, or the client when outside the client's room, is unnecessary because C. difficile is not transmitted by the respiratory route. The door does not need to be kept shut.

the nurse has given dietary instructions to a client to minimize the risk of osteoporosis. the nurse determines that the client understands the recommended changes if the client verbalizes to increase intake of which food?

cottage cheese