THEORY WEEK 8

52. A primary health-care provider orders 250 mL 0.9% sodium chloride to be administered over 30 minutes to challenge a patient's kidneys to produce urine. The nurse obtains an electronic infusion device to administer the solution. At what rate should the nurse program the infusion device? Record your answer using a whole number.

500 mL.hr

The nurse has completed client teaching about draining a continent ileostomy. Which client statement indicates that teaching has been effective? (Select all that apply.)

"To help with drainage, I will bear down as if having a bowel movement.", "I will lower the external end of the catheter at least 12 inches below my stoma.", "It will take 5-10 minutes for complete emptying."

43. A nurse is collecting a bowel elimination history from a newly admitted patient with a medical diagnosis of possible bowel obstruction. Which question takes priority?

"When was the last time you moved your bowels?"

The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient?

"You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?

24-hour recall

71. Which statement by a patient with an ileostomy alerts the nurse to the need for further education?

"I'm going to irrigate my stoma so I have a bowel movement every morning."

49. A primary health-care provider orders a tap-water enema for a patient. The patient asks about the purpose of the enema. Which specific information about the purpose of a tap-water enema should be included in the nurse's response?

"It empties the bowel of stool."

44. A patient is experiencing constipation. Which independent nursing actions facilitate defecation of a hard stool? Select all that apply.

Applying a lubricant to the anus, Placing a warm wet washcloth against the perennial area, Encouraging the patient to rock forward and back while defecating

17. Which should the nurse do before collecting a stool sample for occult blood?

Ask the patient to void.

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

Assess when client generally eats meals.

A client reports a nauseous feeling during a physical assessment. What is the first thing the nurse should do to distract the client's attention from this unpleasant sensation?

Assist the client in taking deep breaths.

23. A nurse is obtaining a health history from a patient. Which information reflects healthy behaviors? Select all that apply.

Consuming 4 eggs a week, Eating foods low in fat, Substituting fish for meat in the diet

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The healthcare provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? (Select all that apply.)

Contact the healthcare provider to ask for an order for catheter discontinuation., Perform, or allow client to perform, perinneal hygiene at least once daily.

The nursing assistant reports that a client on furosemide has voided 4000 mL in a 24-hour period. What is the appropriate nursing action?

Contact the healthcare provider to decrease furosemide.

24. A nurse is counseling a patient with the diagnosis of osteoporosis. In addition to calcium, which vitamin supplement should the nurse anticipate that the primary health-care provider will prescribe for this patient?

D

77. A nurse discourages a patient from straining excessively when attempting to have a bowel movement. Which undesirable physiological response is the primary reason why straining on defecation should be avoided?

Dysrhythmia

34. A school nurse is preparing a health class about vitamins. Which information about vitamins that is based on a scientific principle should the nurse include?

Eating a variety of foods prevents the need for supplements

59. A nurse is assisting a patient with a regular bedpan. Which nursing actions are essential? Select all that apply.

Elevate the head of the bed to the Fowler position after the patient is on the bedpan, Remain outside the curtains of the bed until the patient is done using the bedpan, Raise the side rails on both sides of the bed after the patient is positioned on the bedpan.

56. A nurse should use a fracture bedpan for patients with which conditions? Select all that apply.

Fractured hip, Spinal cord injury

38. Which is an effective nursing intervention to prevent urinary tract infections?

Encourage patients to drink several quarts of fluid daily.

72. A nurse is assessing a patient who has a distended abdomen resulting from flatulence. The patient has an order for a regular diet and an activity order for out of bed. Which can the nurse do to promote passage of the intestinal gas?

Encourage the patient to ambulate

A postsurgical client has been admitted to the unit with an indwelling urinary catheter that was inserted in the operating room and which is scheduled for removal the following morning. How can the nurse best avoid backflow or urine into the client's bladder and subsequent infection?

Ensure that the collection bag is always lower than the client's bladder.

31. A nurse is caring for a female patient on bedrest who has a urinary retention catheter. Which should the nurse do? Select all that apply.

Ensure the tubing is positioned over the leg, Secure the tubing to the patient's leg.

15. An obese resident of a nursing home who is receiving a 1,500-calorie weight reduction diet has not lost weight in the past 2 weeks. Which should the nurse do first ?

Keep a log of the oral intake for 3 days.

The nurse is caring for a client with dysphagia. What is a primary responsibility of the nurse with regard to feeding the client?

Keep oral and pharyngeal suctioning equipment at the client's bedside.

5. A nurse is caring for a patient with a condom catheter. Which nursing actions are important? Select all that apply.

Ensuring that the adhesive band is snug, not tight, Leaving one inch between the glans penis and drainage tubing, Avoiding kinks in the collection tubing

14. A patient has a urinary retention catheter. Which is most important when the nurse cares for this patient?

Ensuring that the catheter remains connected to the collection bag

27. An occupational nurse is facilitating a weight reduction group discussion. Which should the nurse explain is the most common contributing factor of obesity?

Excessive caloric intake

7. Which information about a patient is communicated when a nurse documents that the patient has polyuria?

Excreting excessive amounts of urine

The physician has prescribed routine exercises for an elderly client to perform on a daily basis. What is a benefit of exercising for an elderly client?

Exercise helps in increasing appetite.

27. A nurse is teaching a patient with a cardiac condition to avoid the Valsalva maneuver. Which should the nurse teach the patient to do?

Exhale while contracting the abdominal muscles

68. An older adult with an indwelling urinary catheter is receiving 75 mL of 0.9% sodium chloride hourly. The patient has had several hospital admissions in the last year for dehydration. The nurse is concerned about the patient's renal function. What is the best intervention by the nurse to assess this patient's renal functioning?

Monitor the patient's urine output hourly

41. A nurse must obtain a clean-catch urine specimen from one patient and a urine specimen via a straight catheterization from another. Which intervention is not performed for both when obtaining these specimens?

Wear sterile gloves

A postsurgical client is recovering in hospital following bowel surgery. The client's family is eager to bring the client some of the client's favorite foods to make the client's stay more pleasant and has asked the nurse whether this practice is acceptable. The client is currently on a clear liquid diet, which will be changed as the client tolerates intake. What food item is currently acceptable within this hospital diet?

black tea

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood

34. A patient is admitted with lower gastrointestinal tract bleeding. Which characteristic of the stool supports this diagnosis?

bright red-tinged stool

A nurse is assessing and documenting the eating habits of a client with repeated reports of flatus. Which food item produces gas that could lead to flatus?

cabbage

A nurse is caring for a client with excessive abdominal fat. The nurse should inform the client about a risk associated with excessive abdominal fat. What is that risk?

cardiovascular disease

A nurse is caring for a client who reports chest pain. Which test levels would indicate whether the client is at risk for cardiac and vascular disease?

cholesterol

A hospital client went five days without having a bowel movement despite maintaining adequate food and fluid intake. The nurse obtained an order for hypotonic cleansing enemas as needed and has administered two in succession, each with good effect. The nurse should be wary of administering more enemas because of the risk of causing:

electrolyte imbalances

A nurse is caring for a male client whose prostatic hypertrophy has resulted in impaired urinary elimination. The nurse is aware of the vital importance of maintaining healthy urinary production and elimination because the functions of the urinary system include:

eliminating the waste products of cellular metabolism.

17. A patient is admitted to the hospital with a history of liver dysfunction associated with hepatitis. With which metabolic problem does the nurse anticipate that this patient may have a problem?

emulsifying fats

3. A nurse is teaching a patient about the importance of balancing protein, carbohydrates, and fats in the diet. The nurse identifies that the teaching about carbohydrates is understood when the patient states that carbohydrates are known for providing which of the following

energy

During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?

essential fatty acid

26. An older adult tends to bruise easily and the primary health-care provider recommends that the patient eat foods high in vitamin K. In addition to teaching the patient about food sources of vitamin K, the nurse should include nutrients that must be ingested for vitamin K to be absorbed. Which foods that increase the absorption of vitamin K should be included in the teaching plan?

fats

A nurse is caring for a client who has a large, hardened mass of stool interfering with defecation, making it impossible for the client to pass feces voluntarily. How should the nurse document this condition?

fecal impaction

36. A nurse is caring for a patient who is confused and disoriented. Which type of food containing chicken is most appropriate for this patient?

fingers

A nurse is caring for a 65-year-old male client who is postoperative day 1 following a total hip replacement. Which should the nurse use in order to assist the client to eliminate urine?

fracture pan

A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate?

functional

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence?

functional

47. A nurse must measure the intake and output (I&O) of a patient who has a urinary retention catheter. Which equipment is most appropriate to use to measure urine output from a urinary retention catheter accurately?

graduate

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

greater than normal urinary volume

3. A nurse determines that the teaching about a guaiac test of stool is understood when the patient states that it identifies the presence of which of the following?

hidden blood

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline

38. A patient is diagnosed with iron deficiency anemia. Which major cause of iron deficiency will influence a focused assessment by the nurse?

inadequate diets

A nurse is caring for a client with primary constipation. Which factor is responsible for primary constipation?

inadequate intake of liquid

11. A nurse identifies that a patient's colostomy stoma is pale. Which should the nurse do?

Notify the surgeon

A 65-year-old client confides experiencing urinary incontinence to the nurse. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem?

Openly discuss adult undergarments with the client.

A client in a health care facility has had a urinary catheter in situ for the past several days. The client's nurse has amended the client's plan of care to reflect the use of the device. What nursing diagnosis is a priority in this aspect of the client's care?

Risk for infection

A nurse is assisting a client when he is draining a continent ileostomy. The catheter suddenly becomes plugged with stool. Which action should the nurse take to rectify the problem?

Rotate the catheter tip inside the stoma.

An elderly client has been experiencing urinary hesitancy and this has resulted in the client's bladder become over distended with urine. What intervention should the nurse attempt before resorting to the insertion of a urinary catheter?

Run water from the tap in the client's room to stimulate the urge to void.

36. A nurse is caring for a patient with an intestinal stoma. Which intervention is most important?

Selecting a bag with an appropriate-size stoma opening

A nurse is providing home care for a middle-age client with fecal incontinence. The client's friends have come to visit her, but the client avoids meeting them. Which nursing diagnosis should the nurse identify?

Situational Low Self-Esteem

A client who visits a health care facility for a routine assessment reports to the nurse that he is unable to control his urinary elimination. This has resulted in him soiling his clothes and has led to a lot of embarrassment. How should the nurse document the client's condition?

incontinence

The nurse is caring for an 18-year-old client with a urinary tract infection. What is a factor that affects the pattern of urine elimination in this client?

integrity of the spinal cord

8. Which is unrelated to the balance of calcium in the body?

iron

58. Which word is specific regarding how a soapsuds enema works on the mucosa of the bowel?

irritating

A nurse notes that the volume of the client's urinary elimination is less than 300 mL/day. What could be the possible cause for the low volume of urination by the client?

kidney dysfunction

The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient?

low sodium diet

14. A nurse is caring for a patient who is expending energy that is greater than the patient's caloric intake. Which human response will occur?

malnutrition

40. A patient is anorexic because of stomatitis related to chemotherapy. Which should the nurse be most concerned about when planning care for this patient?

malnutrition

11. A nurse teaches a postoperative patient about foods high in protein that will promote wound healing. Which food selection by the patient indicates that the teaching was effective? Select all that apply

meat, cheese

43. A patient has a decreased hemoglobin level because of a low intake of dietary iron. Which foods should the nurse teach the patient are excellent sources of iron? Select all that apply.

meat, spinach

12. An older adult is admitted to the hospital for multiple health problems. Assessment reveals that the patient has no teeth and is having difficulty eating. Which diet should the nurse encourage the primary health-care provider to order for this patient?

mechanical soft

24. A nurse is implementing an ordered bowel preparation for a patient who is scheduled for a colonoscopy. Which is the most serious consequence that is prevented by an effective bowel preparation?

misdiagnosis

When caring for a client with fecal incontinence, the nurse provides an absorbent pad to protect clothing and bed linens. The nurse knows that fecal incontinence is the result of:

neurologic changes that impair muscle activity.

6. Which clinical manifestation identifi ed by the nurse commonly is associated with excessive production of antidiuretic hormone (ADH)?

oliguria

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere

A client reports experiencing uncomfortable, frequent episodes of flatulence to the nurse. Which foods will the nurse recommend that the client avoid? (Select all that apply.)

onions, cucumbers, cabbage, lentils

26. A patient with fl atulence is concerned about the production of unpleasant odors. Which should the nurse encourage the patient to avoid? Select all that apply

onions, eggs, asparagus

A nurse is caring for a constipated client who has abdominal distention. Which is another sign accompanying constipation?

oozing liquid stool

A nurse is caring for a client with pseudoconstipation. What can cause pseudoconstipation in a client?

overuse of suppositories

Which clients, at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? (Select all that apply.)

people with substance abuse problems, older adults living on fixed incomes, pregnant teenagers

33. A nurse is providing for the nutritional needs of several patients. Which problems crease patients' caloric requirements? Select all that apply.

pneumonia, burns

2. A patient is scheduled for surgery and the nurse is teaching the patient about the importance of vitamin C in wound healing. Which sources of vitamin C should the nurse include in the teaching plan? Select all that apply.

potatoes, papayas

A nurse notes that vomiting occurs with great force in a client with gastrointestinal bleeding. How should the nurse document this condition?

projectile vomiting

62. A nurse identifi es that the patient has overflow incontinence. Which factor contributes to this clinical manifestation?

prostate enlargement

53. A nurse reviews the results of a patient's urinalysis. Which constituent found in urine indicates the presence of an abnormality?

protein

16. A nurse identifies that a vegetarian understands the importance of eating kidney beans when the patient indicates that they are essential because they contain which nutrient?

proteins

42. A patient is diagnosed with a vitamin A deficiency. Which type of pie should the nurse encourage the patient to ingest?

pumpkin

31. A primary health-care provider orders a clear liquid diet for a patient. Which foods should the nurse teach the patient to avoid when following this diet? Select all that apply.

pureed soup, icecream

A laboratory test of a client's urine indicates the presence of pus in the urine. Which term is used to describe this type of urine?

pyuria

A nurse at a health care facility provides continence training to a client. During the training, the nurse plans a trial schedule for voiding that correlates with the time when the client is usually incontinent. What is a possible reason for the nurse's action?

reduces potential for unintentional voiding

A nurse is educating a client on how to irrigate his colostomy. The nurse informs the client that the colostomy should be irrigated in order to:

regulate the timing of bowel movements.

A nurse is caring for a pregnant client who is a strict vegetarian. What type of diet should the client follow?

rich in protein

9. A patient of Latino heritage is prescribed a low-fat diet. The patient tells the nurse, "I am going to have a hard time giving up my favorite family recipes." Which food should the nurse recommend that is low in fat and generally is included in the Latino culture?

salsa

30. A nurse teaches a patient about the prescribed low-fat diet. Which foods selected by the patient indicate that the teaching was understood? Select all that apply.

scallops, turkey, flounder

18. A primary health-care provider orders a low-residue diet for a patient with an inflammatory bowel disease. Which foods should the nurse teach the patient to include in the diet? Select all that apply.

scrambled eggs, iceberg lettuce

19. Which assessment is not related to monitoring both urine and stool?

shape

35. A patient has a high serum cholesterol level. Which foods should the nurse teach the patient to avoid ? Select all that apply.

shrimp, liver

60. A nurse is assessing the urinary status of a patient. Which sign indicates that additional nursing assessments are necessary?

specific gravity of 1.035

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?

straight catheter

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?

strongly aromatic, dark amber

50. When a nurse assesses a patient, which clinical manifestations support the presence of urinary retention? Select all that apply.

suprapubic distension, frequent small voidings

The nurse is caring for a client who uses a urostomy to eliminate urine from the body. Which should the nurse use when changing the urinary appliance?

tampons

Which client's laboratory data indicates the need to include interventions in the nursing plan of care specifically aimed at cardiac and vascular disease?

total serum cholesterol of 180 mg/dL; HDL 32 mg/100 mg/dL

When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk? (Select all that apply.)

triglyceride level, lipoprotein level, cholesterol level

An African American is at an increased risk for which of the following? (Select all that apply.)

type 2 diabetes, hypertension, metabolic syndrome, vitamin D deficiency

A nurse is caring for a client with a history of cardiac and vascular disease. Which fats should the nurse allow in the client's diet for his condition?

unsaturated fats

30. A patient's urine is cloudy, is amber, and has an unpleasant odor. Which problem may this information indicate that requires the nurse to make a focused assessment?

urinary tract infection

39. A patient tells the nurse, "I have to urinate as soon as I get the urge to go." For which contributing factor to urinary urgency should the nurse implement a focused assessment?

urinary tract infection

When feeding a client, the nurse arranges for finger foods to be prepared for the client. The nurse is caring for what type of client?

visually impaired client

The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse anticipate will be ordered?

vitamin B12

29. Which vitamin should a nurse teach a patient does not require fat in the diet to be absorbed?

vitamin C

A nurse is caring for a client who is a vegan at the health care facility. What must be included in the client's diet?

vitamin D

75. A patient is admitted to the emergency department because of hypertension and oliguria. For which additional clinical manifestation associated with this cluster of information should the nurse assess the patient?

weight gain

28. A nurse is providing dietary teaching to a patient with diverticulitis who has an order for a low-fi ber diet. Which food selected by the patient indicates that the dietary teaching was understood? Select all that apply

white rice, pasta, soft tofu

67. A patient is reporting burning on urination. Which question should the nurse ask to best obtain information about the patient's dysuria?

"Can you tell me about the problems you have been having with urination?"

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? (Select all that apply.)

"Have you started a new medication?" , "What are your normal bowel habits?", "Do you use laxatives?"

33. Which patient statement supports the nurse's conclusion that a patient understands the need to reestablish bowel fl ora after a week of diarrhea?

"I should eat a container of yogurt every day for a few days."

73. Which statements by a patient with diverticulosis alert the nurse that the patient needs additional health teaching? Select all that apply.

"I should hold my breath and bear down when having a bowel movement.", "I should avoid eating high-fiber cereal."

The healthcare provider notifies a client of a diagnosis of glycosuria. When the provider leaves the room, the client states to the nurse, "I don't know what glycosuria means." What is the appropriate nursing response?

"Laboratory findings indicate there is glucose in your urine."

A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention?

"My favorite drink is coffee with sugar."

A nursing student is teaching healthy nutrition to a client who is vegetarian. Which statement by the nursing student requires the nursing instructor to intervene?

"Obesity is closely linked with vegetarianism."

A client is discussing vitamin and mineral intake with the nurse. Which client statement requires nursing intervention?

"Taking megadoses of vitamins will help me increase muscle mass quickly."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"This only happened one time, so it is nothing to worry about."

A client has been given Cologuard testing supplies. What teaching will the nurse provide about the purpose for this test?

"This test detects mutant DNA from tumor cells present in stool."

A client has been given fecal immunochemical test (FIT) testing supplies. What teaching will the nurse provide about the purpose for this test?

"This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer."

6. A primary health-care provider prescribes folic acid 0.8 mg PO once daily for a tient with anemia. Unit-dose tablets of 0.4 mg/tablet are available. How many tablets should the nurse administer?

2 tablets

13. A patient is admitted to the hospital with a diagnosis of alcoholism. The primary health-care provider prescribes thiamine hydrochloride (vitamin B 1) 50 mg IM three times a day. The drug is supplied 100 mg/mL. How many mL will the nurse administer per dose.

0.5 mL

21. An adult female patient with which total cholesterol level requires health teaching about a low-cholesterol diet?

210 mL/dL

A nurse must obtain the serum glucose level of a patient with diabetes mellitus. The nurse completes all the initial preparations for the procedure including verifying the order, identifying the patient, and washing the hands. Place the following steps in the order in which they should be performed. 1. Don clean gloves. 2. Wipe away the first drop with sterile gauze. 3. Hold the patient's finger in a dependent position. 4. Drop the second drop of blood on the reagent strip. 5. Puncture the side of the end of a finger with a sterile lancet. 6. Wipe the intended puncture side with an approved antiseptic.

1,3,6,5,2,4

39. A young adult woman tells the nurse that she has been taking St. John's wort for several weeks for depression. Which should the nurse teach the patient that is important to know about taking St. John's wort? Select all that apply

1. St. John's wort should not be taken without an evaluation by a primary health-care provider., Apply sunscreen to skin exposed to the sun., Discontinue it 2 weeks before surgery with general anesthesia , Use an additional method of birth control if taking an oral contraceptive

A nurse is changing the ostomy appliance of a client who had her ostomy created several days ago following a hemicolectomy. The nurse has measured the size of the client's stoma and is trimming the new faceplate to ensure comfort and adequate adhesion. The opening in the faceplate should be:

1/8 to 1/4 in larger than the diameter of the stoma.

35. A primary health-care provider prescribes docusate sodium in liquid form for a patient who is constipated but has diffi culty swallowing tablets. The prescription is for 200 mg daily to be divided into two doses, one in the a.m. and one at hour of sleep. The package insert states that there is 50 mg/5 mL. How much solution of docusate sodium should the nurse administer per dose?

10 mL

20. A nurse must obtain a urine specimen for a culture and sensitivity test from a patient who has an indwelling urinary catheter. Place the following steps in the order in which they should be performed. 1. Wash your hands and don clean gloves. 2. Remove the clamp from the drainage tubing. 3. Drain the urine in the tubing into the drainage bag. 4. Clamp the drainage tubing below the specimen port for 15 to 30 minutes. 5. Swab the specimen port with an antiseptic and aspirate urine via a sterile syringe. 6. Transfer the urine to a sterile specimen cup and discard the syringe into a sharps container

3,4,1,5,6,2

The nurse is caring for four clients. Which does the nurse identify as highest risk for development of cardiometabolic syndrome?

36-year old with obesity who smokes

4. A primary health-care provider prescribes furosemide 40 mg to be added to 50 mL of D 5 W to infuse at a rate of 3 mg/minute. Furosemide for IV infusion is 10 mg/mL. The nurse uses a secondary infusion set that has a drop factor of 10. How many drops per minute should the nurse administer?

40 gtt/min

21. A nurse is performing a physical assessment of a patient concerning the gastrointestinal system. Place the following interventions in the order in which they should be performed. 1. Palpate the abdomen. 2. Inspect the anus and perianal area. 3. Percuss the abdomen for the quality of sounds. 4. Auscultate the entire abdomen for bowel sounds. 5. Observe the contour and symmetry of the abdomen.

5,2,4,3,1

The nurse is providing health teaching for four clients. Which client will the nurse teach that should consider a colonoscopy screening?

50-year-old client who family history of polyps

A primary health-care provider orders a bladder ultrasound scan be performed after a patient voids to determine the amount of residual urine. The nurse explains the test to the patient. Place the following steps in the order that they should be performed by the nurse. 1. Clean the patient's abdomen to remove the gel and clean the scan head with isopropyl alcohol. 2. Put 5 mL of conducting gel on the patient's symphysis pubis and place the scan head on the gel. 3. Aim the scan head toward the patient's coccyx and press the scan head button. 4. Drape the patient exposing only the lower abdomen and suprapubic area. 5. Obtain the bladder volume and repeat the measurement several times. 6. Place the patient in the supine position.

6,4,2,3,5,1

The nurse is caring for four older adult clients. Which does the nurse identify as highest risk for cardiometabolic syndrome?

70-year old with a body mass index (BMI) of 34.8

48. A patient who had prostate surgery has a continuous bladder irrigation (CBI) in place. The nurse maintains the CBI at 200 mL/hour of GU irrigant as ordered. The urine drainage bag was emptied several times during the course of the shift for a total of 3,200 mL. How many milliliters should the nurse calculate was urine at the end of the 12-hour shift?

800 mL

A nurse is preparing to administer an acetaminophen suppository. For which client would a suppository be preferable to oral medication administration?

A client who has dysphagia following a stroke but who has a fever.

For which client would a cleansing enema most likely be indicated?

A client who is scheduled to be screened for colorectal cancer the following morning.

Concurrent Health Problems Diabetes mellitus for 10 years Obstructive lung disease (COPD) for 6 years Prescribed Medications Ipratropium 17 mcg aerosol inhaler, 2 inhalations four times a day Oxycodone oral solution 15 mg PO every 6 hours whenever necessary NPH insulin 20 units subcutaneously 8 a.m. Regular insulin 8 units subcutaneously 8 a.m. Regular insulin coverage subcutaneously before meals and at hour of sleep <150 mg/dL to 0 units 151-200 mg/dL to 3 units 201-250 mg/dL to 5 units 251-300 mg/dL to 7 units 301-350 mg/dL to 9 units >351: Call provider Physical Assessment 11:50 a.m.: Breath sounds indicate slight wheezing over right sternal border Respirations: 22 breaths per minute, unlabored Serum glucose fi nger stick: 235 mg/dL Incisional pain of 3 on pain scale of 0 to 10 A nurse is caring for a postoperative patient. The nurse reviews the patient's concurrent health problems, checks the medications prescribed by the primary health-care provider, and performs a focused assessment. Which should the nurse do at 12 p.m.?

Administer 5 units of regular insulin subcutaneously to the patient.

When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation?

Affects absorption of fat-soluble vitamins

69. A nurse is caring for a group of patients with a variety of gastrointestinal problems. Which of the following can cause both diarrhea and constipation? Select all that apply.

Cancer of the large intestines, Side effects of medications

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?

Clamp the tube for a brief period.

22. A nurse is assessing a patient who is admitted to the hospital with withdrawal from alcohol. Which effect of alcohol on the body will influence the patient's plan of care?

Decreases the absorption of many important nutrients

A nurse performs catheter irrigation for a client at a health care facility only after verifying that a medical order has been written. Why should the nurse take this precaution?

Demonstrates legal limits of nursing

4. A nurse is caring for a patient receiving bolus enteral feedings several times daily. Which nursing intervention is most important to help prevent diarrhea?

Discard the refrigerated opened cans of formula after 24 hours

37. A nurse is caring for a group of patients. Which patient factor should the nurse identify as placing a patient at risk for bowel incontinence?

Disoriented to time, place, and person

A nurse is administering a prescribed hypertonic saline enema to a client with constipation. Which is a function of hypertonic saline enema?

Draws fluid from body tissues into the bowel

A nurse is preparing a discharge note for an older adult client with constipation. Which suggestion should the nurse write in the client's discharge note for a healthier bowel elimination habit?

Drink 8 to 10 glasses of liquid daily.

9. Which action is important for the nurse to teach patients about the intake of bran to facilitate defecation?

Drink at least 8 glasses of fluids each day

In preparing a client to utilize fecal occult blood testing (FOBT) supplies, what teaching will the nurse provide?

Refrain from eating red meat 3 days before testing.

28. A patient has been blind in one eye for several years because of the complications associated with diabetes mellitus. The patient is admitted to the hospital with a detached retina and resulting loss of sight in the other eye. Which should the nurse do to assist this patient with meals?

Explain to the patient where items are located on the plate according to the hours of a clock.

57. A patient had a colonoscopy with several polyps excised for biopsies. The nurse teaches the patient routine post-procedure expectations. Which physical responses should the nurse instruct the patient to report to the primary health-care provider? Select all that apply.

Extensive abdominal bloating, Continuous abdominal cramping

A nurse is caring for a client with Alzheimer's disease. What action should the nurse perform when feeding a client with Alzheimer's disease?

Guide the hand with the food to the client's mouth if necessary.

During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency?

Hair loss and hair that is easily removed from the scalp

65. Which outcome is most appropriate for a patient with perceived constipation?

Have a bowel movement without the use of a laxative.

25. A primary health-care provider discusses the need for a cystoscopy with a patient. Which is most important for the nurse to do when caring for this patient before the procedure?

Have the patient sign an informed consent form before the procedure

41. A patient of Asian heritage is recommended to follow a low-fat diet to lose weight. Which food low in fat generally is consumed by members of an Asian population?

Hot and sour soup

25. A patient without any identified current health problems is having a yearly physical examination. The laboratory results indicate the presence of ketosis. Which rationale explains the presence of ketosis in this otherwise healthy adult?

Inadequate intake of carbohydrates

51. A patient returns from the surgical unit after a transurethral resection of the prostate gland. The nurse reviews the primary health-care provider's orders, obtains the patient's vital signs, and performs a focused patient assessment. Which is the best intervention by the nurse? PATIENT'S CLINICAL RECORD Primary Health-Care Provider's Orders Regular diet Vital signs every 4 hours IV morphine via PCA pump: basal rate 1.5 mg/hour; PCA dose 1 mg; lockout interval 12 minutes; maximum dose over 4 hours, 26 mg IVF: 0.9% sodium chloride 125 mL/hour Docusate sodium 100 mg PO once daily Out of bed to chair in p.m., ambulate twice a day Continuous compression devices to lower extremities when in bed Continuous bladder irrigation 0.9% sodium chloride to run at rate to keep output pink Patient's Vital Signs Temperature: 100.2°F, oral Pulse: 88 beats per minute Respiration: 20 breaths per minute Blood pressure: 136/80 mm Hg Focused Physical Assessment IVF: 0.9% sodium chloride at 125 mL/hour, insertion site right forearm with no signs of infiltration or infection. Continuous compression devices in place. Pedal pulses palpable, toes pink and warm to touch. Patient reporting abdominal pain of 2 on scale of 0 to 10 with occasional severe abdominal cramps. CBI in progress at 150 mL per hour. Urinary drainage is light red with numerous clots.

Increase the fl ow rate of the continuous bladder irrigation.

10. A nurse is evaluating the effectiveness of a nutritional program for a patient with anemia. Which clinical finding is a short-term indicator of an improved nutritional status?

Increasing transferrin level

A nurse is caring for a visually impaired client. How should the nurse manage the feeding for this client?

Inform the client about what kind of food is being offered with each mouthful.

A nurse needs to administer an oil retention enema to a client. Which intervention should the nurse perform if disposable equipment is unavailable?

Insert a 14F to 22F tube into the rectum.

A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impaction?

Inserted a lubricated, gloved finger into the rectum.

45. A nurse is inserting an indwelling urinary catheter into a male patient. The nurse feels firm resistance while inserting the urinary catheter through the penis. What should the nurse do?

Interrupt the procedure and notify the primary health-care provider

64. A nurse performs a physical assessment of a newly admitted patient who is incontinent of stool. For which characteristic related to bowel incontinence should the nurse assess the patient?

Involuntary passage of stool

32. A nurse is caring for two patients. One patient has reflex incontinence and the other has total incontinence. Which characteristic is common to both reflex incontinence and total incontinence?

Loss of urine without awareness of bladder fullness

1. A nurse is reviewing the laboratory findings of a patient to assess the patient's nutritional status. Which laboratory result from among the following tests is an indicator of inadequate protein intake?

Low serum albumin

16. A primary health-care provider orders a return-fl ow enema (Harris fl ush/drip) for an adult patient with fl atulence. When preparing to administer this enema the nurse compares the steps of a return-flow enema with cleansing enemas. Which nursing intervention is unique to a return-flow enema?

Lower the solution container after instilling about 150 mL of solution

8. Which should the nurse do when administering a small-volume hypertonic enema to an adult?

Maintain the compression of the enema container until after withdrawing the tube.

The nurse is teaching a parent of a toddler about healthy eating habits. Which practices will the nurse recommend? (Select all that apply.)

Make time available for food preparation., Educate self and family about nutrition., Establish patterns for meals., Encourage healthy body image

76. When planning nursing care, which factors in the patient's history place the patient at risk for stress incontinence? Select all that apply

Menopause, Six vaginal births

A nurse is caring for a client with an abdominal injury at a health care facility. The client tells the nurse that he passed blood-stained stool. Which nursing action is appropriate when a client reports blood in the stool?

Perform a screening test on stool samples.

46. A nurse must collect a specimen for the presence of pinworms. Which action is essential to ensure accuracy of the specimen?

Perform the procedure the first thing in the morning before the first bowel movement

61. A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs?

Positioning a bedside commode near the bed

13. A school nurse is planning a health class about bodily functions. Which information should be included regarding the purpose of mucus in the gastrointestinal tract?

Protects the gastric mucosa

54. Which nursing actions should be implemented by a nurse to facilitate bladder continence for a male patient who is cognitively impaired? Select all that apply

Provide clothing that is easy to manipulate, Offer toileting reminders every 2 hours.

32. Which is the most common independent nursing intervention to help a hospitalized debilitated older adult maintain body weight?

Providing assistance with the intake of meals

2. A nurse must obtain a urine specimen from a patient. Which nursing intervention is the greatest help to most people who need to void for a urine test?

Providing for privacy

15. A patient has urinary incontinence. Which is the best nursing intervention for this patient?

Providing skin care immediately after soiling

23. A nurse is to administer an oil-retention enema, a tap-water enema, and a returnflow enema to three different patients. Which nursing interventions should be performed with all three enemas? Select all that apply.

Pull the curtain around the patient's bed and drape the patient, Use water-soluble jelly to lubricate the tip of the rectal probe, Place the patient in the left side-lying position

44. An older adult states that he is experiencing all the signs and symptoms of an enlarged prostate and is interested in taking the herbal supplement saw palmetto. Which is important for the nurse to teach the patient about treatment with saw palmetto? Select all that apply.

Some patients report an improvement in erectile dysfunction after taking saw palmetto., Taking saw palmetto is generally safe as a dietary supplement., It should not be taken until after a workup by a urologist.

PATIENT'S CLINICAL RECORD Patient History Married for 18 years Has 5 children between the ages of 7 and 17: 3 single births and a set of twins Works as a cashier 4 days a week Patient Interview Patient states that she drinks a glass of wine with dinner. When the hemorrhoids became increasingly painful and a continuous problem she decided to do something about them. States she sometimes takes a stool softener when she is constipated. Focused Assessment Patient is 60 pounds more than ideal body weight for height. Three external hemorrhoids are bright red, swollen, and oozing blood. Patient states, "My rectal area is itchy and painful." A patient is attending the health clinic for treatment of hemorrhoids. The nurse reviews the patient's history, interviews the patient, and performs a focused assessment. Which factors does the nurse conclude may have influenced the development of the hemorrhoids? Select all that apply.

Stands for long periods of time at work, Has had multiple pregnancies, Is obese, Tends to have constipation

74. A nurse is teaching a patient how to irrigate a colostomy. The patient asks why it is necessary to use the cone attachment to the irrigation catheter. What information should the nurse include in a response to this question?

Stops enema solution from flowing out of the bowel during the procedure

A 69-year-old man had a transurethral resection of the prostate early this morning and now has continuous bladder irrigation running. What is the primary goal of this form of irrigation?

The client's catheter will remain patent and free of blood clots.

The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern?

The patient has lost 10 pounds (4.5 kg) during the last month.

40. A confused patient is incontinent of urine and stool and smears the stool on the bed linens and bed rails. Which should be the initial patient goal?

The patient will be clean and dry continuously.

During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations?

This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight.

70. A nurse identifies that a patient has tarry stools. Which problem should the nurse conclude that the patient is experiencing?

Upper gastrointestinal bleeding

63. A primary health-care provider orders a urine specimen for culture and sensitivity via a straight catheter for a patient. Which should the nurse do when collecting this urine specimen?

Use a sterile specimen container.

12. A nurse is teaching a patient with a history of constipation about the excessive use of laxatives. Which effect of laxatives should the nurse include as the primary reason why their use should be avoided?

Weakens the natural response to defecation

The nurse is teaching an older adult female client about urinary care. What teaching will the nurse include?

Wipe from the urinary area towards the rectum.

When providing for a client's nutritional needs, the nurse arranges for finger foods to be prepared for the client. The nurse is likely caring for what type of client?

a client with dementia

A 78-year-old woman who lives alone has been admitted to the hospital with a diagnosis of failure to thrive. Assessment reveals that the woman has malnutrition, a problem related to her lack of finances, transportation, and a social support network. Malnutrition is defined as:

a condition related to a chronic lack of sufficient nutrients.

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

a flexible sheath that is rolled around the penis

A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample?

a sample of urine that is considered sterile

29. Which should a nurse teach the patient to avoid to prevent urinary diuresis? Select all that apply

alcohol, caffeine

A client visits a health care facility reporting loss of appetite following a prolonged illness. How should the nurse document the client's condition?

anorexia

66. A nurse is caring for a group of patients with a variety of urinary problems. Which patient's physical response should cause the most concern?

anuria

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

37. A patient has multiple fractures from a skiing accident. To best facilitate bone growth the nurse should encourage the patient to eat more foods high in calcium. Which foods selected by the patient indicate an understanding of foods that are high in calcium? Select all that apply.

cooked spinach, cottage cheese, low fat yogurt

42. A patient is experiencing bladder irritability. Which fl uid should the nurse teach the patient to include in the diet?

cranberry juice

1. Which clinical manifestation can a nurse expect when a postoperative patient experiences stress associated with surgery?

decreased urinary output

10. A nurse is caring for a patient who is experiencing diarrhea. About which physiological response to diarrhea should the nurse be most concerned?

dehydration

19. A primary health-care provider identifi es that a patient may have a fluoride deficiency. Which physical characteristic supports this conclusion?

dental caries

7. A nurse is caring for patients with a variety of nutrition-related problems. Which problem eventually may require a patient to have a nasogastric feeding tube inserted?

difficulty swallowing

A nurse is caring for a client at a health care facility who experiences urinary urgency. What is a possible cause of the client's condition?

diminished bladder capacity

A hospital client with impaired mobility has rung the call bell for assistance with transferring from the bed to a commode in order to have a bowel movement. The urge to defecate is triggered by:

distention of the rectum by stool.

55. A nurse is performing a physical assessment on a newly admitted patient. Which problem identified by the nurse is often associated with urinary incontinence?

disturbed self-esteem

The nurse is caring for a client who reports urinary incontinence over the past 2 months. In reviewing the electronic health record, which new prescriptions will the nurse look for that may be related to the concern? (Select all that apply.)

diuretics, antidepressants, antihypertensive, sleeping pills

A nurse is caring for a client who is reporting nausea. Which is a sign of nausea?

dizziness and perspiration

A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to:

drink adequate noncaffeinated and nonalcoholic beverages.