Roseman Fundamentals of Nursing
To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe and from the earlobe to the: A) umbilicus. B) xiphoid process. C) manubrium plus 10 to 20 cm more. D) xiphoid process plus 20 to 30 cm more.
D
A nurse is providing perineal care for a female client who has an indwelling catheter. Which of the following areas should the nurse cleanse last? A) Urethral meatus B) Labia minora C) Perineum D) Anus
D)
A nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? A) Measure the stoma B) Cover the stoma with gauze C) Remove the backing on the skin barrier D) Cleanse the stoma and the peristomal skin
D)
A nurse should recognize that which of the following findings is an indication for oxygen therapy? A) Respiratory rate 32/min B) PaO2 90mmHg C) FiO2 65% for 4 days D) Oxygen saturation 90%
D)
You review possible complications that can occur with enteral tube feeding. Nursing interventions to decrease the likelihood of these complications include which of the following? A) Evaluating tube feeding tolerance by checking gastric residue every 8 hr and diluting the feeding for residual greater than 100mL. B) Identifying a displaced tube by obtaining a gastrointestinal aspirate for pH measurement. C) Preventing diarrhea by consulting with the dietician to change the formula to one that does not contain fiber.
B While the gold standard for verifying tube placement is radiography, a secondary verification method includes determining the gastric pH.
A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must: A) Clean the mask with soapy water once daily B) Reposition the elastic band frequently C) Apply petroleum jelly around and inside the nares D) Make sure there is adequate condensation in the tubing.
B)
A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take? A) Instruct the client to retain the fluid B) Lower the container to allow the solution to flow back out C) Help the client to a toilet or bedside commode D) Wait 5 min and install another 100 mL of fluid.
B)
A nurse is caring for a client who has a paralytic ileus and requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe? A) Nasogastric tube B) Nasointestinal tube C) Percutaneous endoscopic gastrostomy tube D) Percutaneous endoscopic jejunostomy tube
B)
A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client? A) Distilled water for humidification B) A tracheostomy collar C) A nasal cannula D) An aerosol mask
B)
A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? A) Adducting the arm so that it lies next to the clients side. B) Flexing the shoulder by raising the arm from a side position to a 180 degree angle. C) Abducting the arm to a 90 degree angle from the side of the body. D) Circumducting the shoulder in a 180 degree half circle.
B)
A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange? A) Assessment B) Diagnosis C) Planning D) Evaluation
B)
A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? A) Tricyclic antidepressants B) Corticosteroids C) Beta Blockers D) Anticholinergics
B)
A nurse is caring for a client who has mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? A) Wear a respirator B) Protect their eyes C) Put on clean gloves D) Wear shoe covers
B)
A nurse is caring for a client who requires long-term central venous access and is an avid swimmer. Which of the following central venous access devices is the best choice for this client? A) A tunneled central catheter B) An implanted port C) A nontunneled percutaneous central catheter D) A peripherally inserted central catheter
B)
A nurse is caring for apatient who has a central venous catheter and suddenly develops dyspnea, tachycardia, and dizziness. The nurse suspects an air embolism and clamps the catheter immediately. The nurse should reposition the client into which of the following positions? A) Supine with a pillow beneath the knees. B) On their left side in Trendelenberg position C) Upright and leaning over the overbed table D) On their right side with the head of the bed elevated 15 degrees.
B)
A nurse is documenting data about a deep necrotic wound on a client's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following findings should the nurse document? A) Keloid B) Slough C) Granulation D) Eschar
B)
A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from a bed to a chair. For which of the following actions by the AP should the nurse intervene? A) Places a removable cover over the sling. B) Leaves the bed in the lowest position throughout the procedure. C) Locks the hydraulic valve before attaching the sling to the lift. D) Raises the head of the bed to a sitting position just before transfer.
B)
A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? A) Grasp the penis at the base B) Lift the penis perpendicular to the body C) Hold the penis parallel to the clients body D) Lift the penis to a 45 degree angle to the client's body
B)
A nurse is preparing to remove a clients indwelling urinary catheter. Which of the following actions should the nurse take? A) Pull the catheter out as quickly as possible. B) Deflate the balloon completely before removal. C) Cut the inflation port to deflate the balloon D) Tell the client to expect a tugging sensation on removal.
B)
A nurse is providing teaching about risk for aspiration with a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? A) A feeling of fullness B) Persistent coughing C) Discomfort in the naris D) Postfeeding belching
B)
A nurse is washing their hands with soap and water prior to repositioning the client in bed. During the handwashing procedure, it is important to take which of the following actions? A) Make sure that the water is hot. B) Wash for at least 15 second C) Use a liquid soap preparation D) Remove rings and watches first.
B)
A nurse should identify that which of the following areas of the hands requires special attention during the prescrub wash? A) The area between each finger B) The area under each fingernail C) The palm of each hand D) The back of the hands
B)
After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take? A) Cleanse their hands with an alcohol-based gel B) Wash their hands with soap and water C) Brush off the soil against a cloth surface D) Use a wet paper towel to remove the soil.
B)
The client tells the nurse, "I don't need oral care because I haven't eaten anything." Which of the following responses should the nurse make? A) "Since you are not eating, we can wait and do it before bedtime" B) "Oral care is still important even though you are not eating" C) Ill give you one sip of water to swish around your mouth and then you can spit it out" D) We will wait until your family gets here to help."
B)
When donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand? A) Slipping the fingers beneath the cuff maintains the gloves' sterility B) The inner edge of the cuff will lie against the skin and thus will not be sterile C) Gloving the dominant hand first allows for better control over the process D) The hand has been surgically scrubbed and is considered uncontaminated.
B)
When opening a sterile pack, which of the following actions by the nurse might compromise the sterility of the instruments and supplies inside the pack? A) Allowing movement of team members around the field B) Holding the sterile pack below waist or table level C) Keeping sterile items away from the edge of the table. D) Opening the sterile pack just prior to the procedure.
B)
Which of the following dietary modifications should an adolescent who participates in sports implement? A) Increase fats to 30% to 40% of daily kilocalories. B) Drink water before and after sports activities. C) Keep protein intake at the same level. D) Decrease carbohydrates to 30% to 40% of daily kilocalories.
B)
Which of the following relates to the nutritional needs of an older adult client? A) Vitamin supplementation becomes increasingly essential in advancing age B) Older adults require fewer calories per day than younger adults do C) Dairy products become more difficult to digest as age advances.
B)
You should teach a client with a radial fracture that to facilitate healing, she should increase intake of which of the following: A) Folic acid B) Vitamin C C) Thiamine
B) Aids in tissue building and many metabolic reactions
Which of the following actions should you perform first in preparation for inserting the nasogastric (NG) tube? A) Lubricate the end of the tube with water-based jelly B) Evaluate the patency of the client's nares. C) Ask the client to extend his neck back against the pillow.
B) Before beginning the insertion procedure, select the most appropriate naris by asking the client to occlude one nostril and breather normally through the other. The tube will pass more easily through the more patent naris.
A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include? A) Apply hydrocortisone cream to the skin when changing the appliance B) Empty the pouch when it is less than half full C) Wash the peristomal area frequently with deodorizing soap and water D) Choose a time shortly after a meal for replacing the pouch
B) The nurse should instruct the client to empty the pouch when it is between 1/3 to 1/2 full because waiting to empty the pouch until it is more than 1/2 full increases the risk of leakage. Leakage of Ileostomy effluent is irritating to peristomal skin.
You begin the continuous feeding using a feeding pump. Management of continuous enteral feeding includes which of the following? A) Changing the feeding bag every 72 hr. B) Flushing the tube with 30mL of water every 4 hr to prevent clogging. C) Checking pH every 2 hr.
B) The tube should be flushed every 4 to 6 hr with 30 to 50 mL of water during continuous feeding. This can be done manually, or many pumps can be programmed to flush the tube.
Which of the following actions helps ensure the safe administration of enteral formula intermittently via NG tube? A) Identifying the correct client by having client state their provider's name. B) Ensuring proper NG tube placement according to facility policy. C) Adding a small amount of blue dye to the formula.
B) This action helps minimize the risk of aspiration, a major complication resulting from the administration of enteral formula.
A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client? A) Simple face mask B) Nasal cannula C) Venturi mask D) Face tent
C
After initial verification of the NG tube's placement by x-ray, you should also verify placement by performing which of the following actions? A) Assessing for normal bowel sounds. B) Auscultating while flushing 30mL of air through the tube to hear swooshing sounds. C) Testing the pH of an aspirated fluid sample from the NG tube.
C
A charge nurse is reviewing anthropometric values with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "Isolated measurements of height and weight are of greater significance than changes over time." B) "A weight increase of 4 pounds in a client who has renal failure indicates retention of 1,000 mililiters of fluid." C) "The client should be weighed on the same scale at the same time each day." D) "The ratio of height-to-wrist circumference is the most accurate way to identify obesity."
C)
A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include? A) Lean on the crutches to support your body weight when standing. B) Fully extend your arms when holding onto the hand grips. C) Hold the crutches on your unaffected side when preparing to sit in a chair. D) Hold the crutches 9 inches in front of and to the side of each foot.
C)
A nurse in the emergency department is caring for a client who was in a motor-vehicle crash. The provider determines that the client needs immediate central venous access for fluid and blood replacement. Which of the following central venous access devices should the nurse anticipate being inserted? A) A tunneled central catheter B) An implanted port C) A nontunneled percutaneous central catheter D) A peripherally inserted central catheter
C)
A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? A) Stretch the sheath portion of the condom catheter along the length of the penis B) Secure the sheath portion with adhesive tape C) Leave a space between the penis and sheath portion tip D) Reposition the foreskin after application
C)
A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive? A) Placing a transparent dressing over the pressure injury B) Applying hydrocolloids to the wound bed C) Pulsating lavage D) Using a topical enzyme solution in the wound bed
C)
A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding. Which of the following types of dressing should the nurse select to help promote hemostasis? A) Transparent B) Hydrogel C) Alginate D) Dry gauze
C)
A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement? A) Measure the pH of gastric aspirate. B) Auscultate the epigastric area while injecting air. C) Obtain an x-ray. D) Place the open end of the tube in a cup of water.
C)
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique? A) Positioning the chair slightly behind the nurse so that the seat faces the client's bed. B) Placing the chair's left leg in front of the right leg just prior to the transfer. C) Aligning the nurse's knees with the client's knees just before the transfer. D) Grasping the client under their axillae to assist them to their feet.
C)
A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? A) Lift up on both sides of the skin barrier simultaneously B) Release one corner of the barrier and pull it quickly over the stoma C) Push the skin away from the barrier while removing it D) Gently roll the barrier end-over-end across the stoma
C)
A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure? A) Cecostomy B) Loop colostomy C) Ileostomy D) Descending colostomy
C)
What should the nurse do to maintain standard precautions? A) Rinse gloves that become visibly soiled during use. B) Use an antimicrobial soap for routine handwashing C) Disinfect hands immediately after removing gloves D) Keep gloves on when touching environmental surfaces.
C)
Which of the following products can affect the permeability of latex gloves? A) Antimicrobial soap and water B) Alcohol based antiseptic gel C) Petroleum based hand lotion D) Water based hand lotion
C)
Which of the following statements is true about communication? A) Culture and lifestyle do not influence the communication process. B) Younger and older adults require the same communication techniques. C) Communication is a powerful therapeutic tool and an essential nursing skill that influences others and achieves positive health. D) When caring for clients, in order to effectively communicate, the nurse's message to the client is the most important one.
C)
To minimize the risk of trauma and discomfort for the client when removing the NG tube, which of the following actions should you take? A) Slowly rotate the tube 180 degrees while pulling back on it. B) Use the pull-pause method to remove the tube gradually. C) Fold the tube into itself while quickly pulling back.
C) Folding the tube prevents tube contents from draining into the patient's oropharynx. Quick removal minimizes discomfort.
Because our 81 year old patient is at high risk for aspiration, which of the following actions should we take? A) Administer half-strength enteral formula B) Position the client in a left lateral position. C) Elevate the head of the client's bed to a minimum of 30 degrees.
C) This action enlists the aid of gravity in preventing aspiration.
After you have introduced the prescribed amount of enteral formula through the NG tube, you promote patency of the tube by doing which of the following? A) Clamping the NG tube B) Applying a clean cap to the open end of the NG tube C) Flushing the NG tub with 30 to 60 mL of water
C) This action rinses the formula from the tube and helps minimize the possibility of clogging
A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? A) Flush the feeding tube with 30 mL of water. B) Add blue food coloring to the enteral formula. C) Ensure the formula is at room temperature. D) Place the client in Fowler's position.
D)
A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? A) Irrigate the catheter B) Assess for peripheral edema C) Palpate for bladder distention D) Check the catheter for kinks
D)
A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection? A) Massage reddened areas of the client's skin. B) Wash eye from the outer canthus to the inner canthus. C) Wash the client from the shoulder down to the fingertips with smooth, short strokes. D) Clean the least soiled areas prior to cleaning the most soiled areas.
D)
A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? A) Wrap both arms around the client's arms and shoulders. B) Move both feet together when the client begins to fall. C) Protect the client's extremities while lowering them to the floor. D) Extend one leg and allow the client to slide down the leg to the floor.
D)
A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take? A) Place the stockings on the client after the client ambulates to the restroom. B) Ensure the client's toes are visible after placing the stockings on the client. C) After applying the stockings, place two fingers between the client's leg and stocking to check the fit. D) Measure the client's calf circumference and leg length from heel to knee.
D)
A nurse is caring for a client who has an implanted port that needs to be accesses for an infusion. Which of the following actions should the nurse take? A) Use a standard medium-gauge needle to access the port. B) Insert the primed needle into the port at a 45 degree angle. C) Withdraw the needle after insertion, leaving the needle's sheath in place for the infusion. D) Cover the device and needle with a sterile transparent dressing.
D)
A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care? A) Leave nonbleeding wounds open to the air B) Administer a corticosteroid medication C) Initiate mechanical debridement D) Apply oxygen at 2L/min via nasal cannula
D)
A nurse is preparing to flush and change the dressing on a client's central venous catheter. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis? A) To promote the catheter's patency B) To assess the skin's integrity around the catheter site C) To provide a clean, dry environment for the catheter D) To control the introduction of micro-organisms at the catheter site
D)
A nurse is preparing to obtain a blood sample from a client who has a triple-lumen central catheter in place. Which of the following actions should the nurse take? A) Discard the first 35mL of aspirated blood before collecting the sample. B) Place the client in trendelenberg position while withdrawing the blood sample. C) Withdraw the blood sample from the lumen that has the smallest diameter. D) Turn off the distal infusions for 1 to 5 min before obtaining the blood sample.
D)
A nurse is preparing to wash their hands prior to surgery. For which of the following reasons should the nurse keep their hands above their elbows? A) To prevent them from coming into contact with a contaminated object B) To facilitate the application of sufficient friction to the hands C) To provide good visualization of the hands as they are scrubbed D) To encourage water and soap to flow away from the clean hands.
D)
A nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the right... A) starts the flow of oxygen B) Provides the maximal oxygen flow C) Provides the minimal oxygen flow D) Stops the flow of oxygen
D)
A nurse is providing teaching to an assistive personnel (AP) about the use of sterile gloves. Which of the following instructions regarding the open-gloving method should the nurse give? A) Ask another team member to assist with donning gloves. B) Choose a pair of gloves at least one size smaller than usual. C) Grasp only the underside of the cuff with your ungloved hand. D) Grasp only the inside of the glove with your ungloved hand.
D)
A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to minimize the pain of dressing changes? A) Wet-to-dry B) Abdominal pads C) Dry gauze D) Hydrogel
D)
A nurse is staging a pressure injury over a client's right heel area. The pressure injury has no eschar or slough and no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following: A) Unstageable B) A suspected deep tissue injury C) Stage 4 D) Stage 3
D)
A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence? A) Use an oil-based lotion on the peristomal area B) Apply the skin barrier when the skin is slightly moist C) Leave the residue from the previous appliance on the skin D) Press gently around the barrier for 30 second to 1 min
D)
Contact precautions should be implemented for an adult client who has been hospitalized for which of the following: A) Hepatitis B B) Measles C) Meningitis D) Infectious diarrhea
D)
What is the primary purpose of the outcome identification and planning step of the nursing process? A) To collect and analyze data to establish a database. B) To interpret and analyze data to identify health problems. C) To write appropriate patient-centered nursing diagnoses. D) To design a plan of care for and with the patient.
D)
When teaching the guardian of a toddler about feeding and eating, the nurse should include which of the following safety measures? A) Do not give the child peanut butter. B) Have the child drink 28 to 32 oz of milk daily. C) Give the child 8 to 12 oz of fruit juice daily. D) Do not offer the child raw vegetables.
D)
Which of the following is the primary reason for asking the client to keep a 3- to 7-day food diary? A) To allow the client to rely on health professionals to identify problem areas B) To determine any changes in the client's appetite C) To evaluate any significant changes in body weight D) To assess the pattern of intake and compare with daily reference intakes
D)
A nurse is preparing to open a sterile package of instruments. Identify the order in which the nurse should perform the following steps: A) Open the side flaps B) Open the flap closest to their body C) Open the flap furthest from their body D) Position the tray so that the top flap is farthest away form their body
D) C) A) B)
A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? A) Modular B) Elemental C) Polymeric D) Specialty
B)
A nurse is caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this client undergo which of the following? A) Chest x-ray B) Swallowing examination C) Nasogastric tube insertion D) Olfactory nerve evaluation
B) Clients at high risk for aspiration include those with a decreased level of consciousness. This client has some periods of decreased alertness, thus a swallowing examination is essential to determine their ability to ingest food safely by mouth.
A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching? A) Expect the effluent from the sigmoid colostomy to be loose and continuous. B) Use irrigation to help establish a regular bowel pattern. C) Change the stoma's appliance every other day D) Expect effluent from the newly created stoma within 24 hr after surgery.
B) Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance.
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experiencing social isolation. Which of the following interventions should the nurse recommend? A) Encourage the client to go to the dining room at meal times to talk with other clients. B) Suggest that the client watch television while feedings are being administered. C) Remind the client that they can have visitors after feeding administration times. D) Ask the facility chaplain to speak with the client.
A)
A nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes? A) Moisture from excessive diaphoresis can cause skin breakdown B) Moisture on the sheets can cause discomfort to the client C) It provides an opportunity to frequently evaluate the skin on the client's backside. D) It provides an opportunity to turn the client from side to side to facilitate cleaning potential fluid from the lungs.
A)
A nurse is caring for a client who has a central venous access device in place. Which of the following routine interventions should the nurse use to prevent lumen occlusion? A) Catheter rupture B) Catheter Migration C) Pneumothorax D) Phlebitis
A)
A nurse is caring for a client who has a central venous catheter. When flushing the catheter, the nurse should use a 10-mL syringe to prevent which of the following complications associated with central vascular access devices? A) Catheter rupture B) Catheter migration C) Pheumothorax D) Phlebitis
A)
A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hours. Which of the following assessment findings helps indicate that oxygen therapy has been effective? A) Respiratory rate 14/min B) SaO2 90% C) Cardiac output 5.6L/min D) PaCO2 68mmHg
A)
A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the ight ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury? A) Barrier creams B) Antifungal ointment C) Chemical debridement agent D) Antibiotic agent
A)
A nurse is caring for a client who has health-associate infection (HAI). Which of the following describes an exogenous HAI? A) A salmonella infection that occurs after eating contaminated food form the cafeteria B) An infection that occurs during a therapeutic procedure C) A yeast infection that occurs while receiving broad spectrum antibiotics D) A urinary tract infection that occurs after a sterile catheter insertion.
A)
A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? A) Closing off the glottis B) Preventing curling of the tube in the mouth C) Allowing the client to breathe through the mouth C) Opening the lower esophageal sphincter
A)
A nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The client tells the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? A) Consume foods that are low in fiber content B) Take an ounce of mineral oil twice a day C) Add buttermilk and cranberry juice to the diet D) Increase water intake to 3 to 3.5L per day.
A)
Which of the following actions should the nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing? A) Auscultate the client's lungs B) Place the tip of the tongue depressor on the clients posterior tongue. C) Inspect the client's uvula and soft palate with a penlight. D) Place fingers on the client's throat at the level of the larynx and ask the client to swallow.
A)
Which of the following assessment findings is likely to have a negative, long-term effect on a client's nutritional status? A) Poor dental health B) Family history of obesity C) Preference for a vegetarian lifestyle
A)
Which of the following findings is likely to have had a negative impact on the client's nutritional status? A) Osteoarthritis in wrists and hands B) Allergy to wheat C) History of GERD
A)
Which of the following interventions should the nurse use at mealtimes for a client who has a visual impairment? A) Identify the food location as though the plate were a clock. B) Direct the order in which food items are consumed. C) Have the client tilt their head forward while eating. D) Avoid talking to the client during mealtime.
A)
Which of the following is an advantage of using alcohol-based gel? A) It takes less time to use than washing with soap and water B) It removes gross contamination better than soap and water does C) Its protective nature reduces the need for frequent handwashing D) It provides adequate protection before surgical applications
A)
Which of the following types of output is first expected from an ileostomy postoperatively? A) Loose, liquid stools after 1-2 days B) Serous discharge after 6-8 hours C) Formed to semi-formed stool within 2 to 5 days D) Pasty yellow-brown stool within 3 to 4 days
A)
While waiting for a sterile procedure to begin, how should a nurse position their hands and arms? A) With hands clasped together in front of the body above waist level. B) At the sides of the body with hands pointed downward. C) Folded across the chest with hands on shoulders. D) With hands clasped together in the back of the body at waist level.
A)
A nurse is teaching a client who had bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary elimination? A) Kock's pouch B) Ileal conduit C) Cutaneous ureterostomy D) Nephrostomy
A) A Kock's pouch is a continent ileal bladder conduit that does not require an external drainage collection device because the client self-catheterizes every 2 to 4 hr to remove urine
After reviewing the providers prescriptions, you hang the feeding bag and tubing on the pole. Prior to initiating the feeding, which of the following actions should you take? A) Fill the bag with enough formula to last over a 4- to 8-hr period. B) Keep formula in the refrigerator until just before feeding begins. C) Notify the provider if bowel sounds are decreased prior to starting tube feeding.
A) Filling the bag with only enough formula for 4 hr will decrease the risk of bacterial infection.
After major oral surgery, you should explain to the teenage patient and parents that which of the following types of commercially prepared formula will be used to provide complete nutrition? A) Polymeric B) Modular C) Elemental
A) This formula provides whole nutrients to the client who has an intact and functioning gastrointestinal tract.
To regulate the flow of enteral formula through the NG tube, you open the tubing and do which of the following? A) Adjust the syringe height to adjust the rate of feeding flow. B) Apply gentle pressure with the syringe's plunger to direct the formula through the tube. C) Introduce more formula gradually into the syringe as the fluid level drops.
A) The syringe method delivers the feeding through gravity drainage. Raising the syringe will speed the rate of flow; lowering the syringe slows the feeding rate.
To determine the length of the tube that will achieve the proper insertion depth, which of the following actions should you take? A) Measure the distance from the client's naris to his ear lobe to the tip of his xiphoid process. B) Mark the location on the tube that is 1 1/2 times the distance from the client's nose to his xiphoid process. C) Use a disposable ruler to measure form the client's nose to umbilicus.
A) This total measurement is the approximate length of tube to insert.
A nurse is documenting data about a healing wound on a patient's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as: A) Serosanguineous B) Sanguineous C) Serous D) Purulent
A)
You explain to your patient that the provider has prescribed a small-bore nasogastric tube for which of the following reasons? A) It does not cause discomfort upon insertion. B) It is best suited for short-term enteral feeding therapy. C) Tube placement can be verified by injecting air through the tube and auscultating for gurgling sound.
B This is the primary reason for selection, since the small-bore nasogastric tube is appropriate for therapy lasting less that 4 weeks.
A nurse is caring for a group of clients. The nurse should identify which of the following clients requires an enteral tube feeding? A) A client who has a paralytic ileus B) A client who has recently experienced facial trauma C) A client who has dysphagia D) A client who has a decreased appetite
C)
A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? A) Prone B) Dorsal recumbent C) Right lateral with both knees at chest D) Left lateral with the right leg flexed
D)
Which of the following strategies for enhancing the intake of healthy foods is appropriate for an adolescent? A) Encouraging the adolescent to consume snack foods from the grains food group B) Permitting the adolescent to skip breakfast to enhance appetite at later meals C) Making healthful food choices more convenient and available for the adolescent D) Allowing the adolescent complete autonomy in making food choices
C)
A nurse is performing a complete bed bath for a client. Which of the following actions should the nurse take? A) Raise the room temperature B) Completely remove the linens C) Add soap to the water in the basin before beginning the bath D) Bathe one side of the body at a time.
A
A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? A) Place the client in a dorsal recumbent position on a bedpan. B) Administer the enema while the client sits on a toilet C) Administer an antidiarrheal medication 3 hr prior to the enema D) Instill 200mL of fluid over an hour at 15-min intervals
A
A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? A) Warm the enema solution prior to instillation. B) Prepare 1500 mL of enema fluid C) Use tap water as the enema fluid D) Hang the enema container 24 inches above the anus
A
A nurse is reviewing a client's laboratory values. Which of the following information is correct regarding albumin levels and nutritional status? A) Albumin level is a poor short-term indicator of protein status. B) Hydration status does not affect a client's albumin level. C) An albumin level of 3.2 g/dL is within the expected reference range. D) Albumin level is calculated by keeping a 24-hr record of protein intake.
A
To facilitate the insertion of the nasogastric (NG) tube, which of the following actions should you take? A) Instruct the client to swallow during tube insertion. B) Have the client extend head after the tube passed through nasopharynx. C) Apply gentle force when meeting resistance.
A) Swallowing, especially by sipping water, closes the epiglottis over the trachea and thus helps direct the tube to the esophagus rather than to the airways.
To minimize the transmission of microorganisms while inserting the nasogastric (NG) tube, which of the following actions should you take? A) Wear clean gloves during the procedure. B) Obtain culture of the nasal cavity prior to insertion. C) Suction the client's nose and mouth prior to insertion.
A) This action is an effective deterrent to the transmission of microorganisms.
A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? A) Cleansing B) Return flow C) Medicated D) Oil-retention
B
A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear? A) A sterile gown B) Goggles C) A face shield D) An N95 respirator
C
A nurse is caring for a client who has impaired swallowing due to a cerebrovascular accident. Which of the following intervention should the nurse use to assist the client with feeding? A) Provide the client with a straw. B) Offer the client thin fluids. C) Elevate the head of the bed 45° to 90°. D) Place food in the weaker side of the mouth.
C
A nurse is planning morning hygiene for a postoperative client. Which of the following actions should the nurse take? A) Inform the client when morning hygiene is provided at the hospital. B) Schedule the client's morning hygiene care at the same time as their room mate. C) Ask the client in what order they typically perform their morning routine. D) Plan to provide care before the next scheduled dose of pain medication.
C
A nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. Which of the following statements by the newly licensed nurse indicates and understanding of the teaching? A) Ill swab the client's mouth with lemon glycerin swabs B) I'll swab the client's mouth with mouthwash C) Ill swab the clients mouth with chlorhexidine D) Ill swab the clients lips with a very small amount of mineral oil
C
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A) Measure the clients vital signs B) Notify the primary care provider C) Lower the enema fluid container D) Stop the enema instillation
C
The nurse is collecting information from Mr. Smith who has dementia; Mr. Smith's daughter Susan is at the bedside. Which of the following statements by the nurse recognizes the client's value as an individual? A) "Susan, can you tell me how long your father has been this way?" B) "Susan, I have to go and read your father's old charts before we talk." C) "Mr. Smith, tell me what you do to take care of yourself." D) "Mr. Smith, I know you can't answer my questions, but it's okay."
C)
A nurse is observing an assistive personnel make a client's bed while the client is out of the room. Which of the following actions by the AP indicates and understanding of the procedure? A) The AP records the task when it is completed B) The AP wears sterile gloves while making the bed C) The AP changes the client's pillowcase D) The AP reuses the client's clean blanket and spread.
D
A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? A) the duration of the procedure B) 10 to 15 min C) Until the client feels the urge to defecate D) At least 30 min
D
A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding? A) Limit the time the formula hangs to 8 hr. B) Flush the tube every 8 hr. C) Deliver the formula at a brisk rate. D) Allow the feeding bag to empty before refilling it.
A)
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure? A) Bear down B) Take deep breaths C) Sip water D) Tighten the perineum
A)
A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include? A) "Place the oxygen tank in a clutter-free environment" B) "Keep the oxygen tank at least 6 feet away from a heat source" C) "Ensure you are close to electricity to use your oxygen tank" D) "Turn the valve on the oxygen tank until an alarm sounds"
A)
A nurse should identify that which of the following is the goal of surgical asepsis? A) To create and maintain a micro-organism-free environment B) To kill all micro-organisms on all instruments involved in a procedure C) To reduce the presence of pathogenic organisms in the environment D) To minimize exposure to the client's blood during an invasive procedure.
A)
A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? A) Move their leg behind their body. B) Move their legs forward and up. C) Move their leg medially toward their other leg. D) Turn their foot and leg away from their other leg.
A)
Administering oxygen therapy with a nonrebreather mask has which of the following advantages? A) Offers the highest oxygen concentration of the low flow systems B) Provides oxygen concentrations of 40 to 60 % C) Incorporates a design that requires minimal monitoring of the client D) Is designed for safety once the mask's valves and flaps are sealed.
A)
After completing a procedure that required donning PPE consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately? A) The gloves B) The gown C) The face shield D) The N95 respirator
A)
During assessment of a client's vital signs, the nurse notes a pulse rate of 120 beats per minute. Which nursing action is priority when interpreting and analyzing this client's pulse rate? A) Compare the client's pulse rate to the standard range. B) Notify the client's healthcare provider immediately. C) Document the pulse rate on the appropriate graphic form in the client's medical record. D) Ask another nurse to verify the pulse rate.
A)
Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings? A) Elevated blood pressure B) Decreased respiratory rate C) Cyanosis D) Peripheral edema
A)
To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry? A) Drying provides the full antiseptic effort B) Residual alcohol can easily stain clothing C) Excess gel could transfer to the client D) Slippery gel can make the nurse drop supplies
A)
To minimize the transmission of microorganisms during the enteral formula feeding through the NG tube, which of the following actions should you take? A) Cleanse the top of the canned formula with an alcohol swab before opening it. B) Wear a personal protective gown and mask during the procedure. C) Change the syringe or feeding bag every 48 hours.
A)
What is the primary purpose of the medical record (client chart)? A) Communication B) Advocacy C) Research D) Education
A)
A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy? A) Poor skin turgor B) Copious respiratory secretions C) Cracks in the oral mucosa D) Elevated heart rate
C)
A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? A) A client who has persistent urinary tract infections B) A client who has urge incontinence C) A client who is in the ICU for a gastrointestinal bleed. D) A client who has incontinence due to cognitive decline.
C)