NR224 Final Exam 2020

1.          A nurse is teaching a client how to perform personal ileostomy care prior to discharge.  The client says “I don’t think that I am going to be able to take care of this myself.”  Which is the most appropriate response from the nurse?

a.          In time you will be better at this than I am.

b.          Don’t worry about it, most clients feel like you do at first.

c.           What part of the ileostomy care are you having trouble with?

d.          I agree.  This is a difficult process.

Question 2The adult child of a client who has had a colon resection will be caring for their parent at home.  The client’s son tells the nurse “I don’t know how I am going to care for my mom now”.  Which is the best nursing response?

a.          A home health nurse will be stopping by tomorrow to answer your questions.

b.          Your mother has been taught to care for her colostomy independently.

c.           What part of your mother’s care are you concerned with?

d.          It is quite simple.  I’ll change the colostomy bag before she is discharged.

Question 3A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from PACU.  The float nurse is most qualified to care for which client?

a.          A client who is postoperative following a lobectomy and has a chest tube

b.          A client who is being discharged to a long-term care facility

c.           A client who needs teaching prior to initiating cardiac rehabilitation activities

d.          A client who needs teaching about insulin self-administration

Question 4A client asks the nurse what causes constipation.  Choose the best response by the nurse.

a.          Constipation occurs when the bowel absorbs too much water

b.          Eating too many processed foods cause constipation

c.           When the bowel releases too much water it causes constipation

d.          Using over the counter laxatives causes constipation

Question 5The nurse caring for a post-operative client performs an abdominal assessment.  The nurse does not hear any bowel sounds over the left lower quadrant of the abdomen.  What is the most likely reason for this?

a.          The client has been NPO for several hours

b.          Post-operative clients may develop an ileus resulting in absent bowel sounds

c.           There is gas in the abdomen

d.          The client emptied their bowels before surgery

 

 

Question 6The nurse admits a client who is to undergo a colonoscopy.  The nurse understands that this will be required in preparation for the procedure.

a.          NPO status for 24 hours

b.          A complete bowel cleanse

c.           Clear liquids after midnight

d.          A fleet enema to prep the bowel

Question 7A nurse is teaching a client about colorectal cancer testing.  The nurse expects the provider to first perform this test for colorectal screening.

a.          Colonoscopy

b.          Barium enema

c.           Fecal occult blood test

d.          Cat scan of the lower intestine

Question 8A nurse is caring for a client with a newly placed colostomy.  The nurse teaches the client they may have formed stool after the bowel has healed because the surgeon placed the stoma where?

a.          Ascending colon

b.          Transverse colon

c.           Descending colon

d.          Sigmoid colon

Question 9

The nurse is administering a tap water enema to a client in preparation for bowel surgery.  The nurse correctly positions the enema bag containing the fluid where?

a.          12 inches above the anus for a regular enemaou Answered

b.          6-10 inches above the anus for a high enema

c.           To shoulder height then lower it 6 inches

d.          On an IV pole 18 inches above the bed

 Question 10The nurse correctly positions a client for a fleets enema by placing them in this position:

a.          Supine with the knees flexed

b.          Prone with the right leg flexed

c.           On the left side with the right leg flexed

d.          On the right side with both knees flexed

Question 11The nurse is preparing a new ostomy flange for the client’s abdomen.  Choose the correct action by the nurse.

a.          Scrub the skin on the abdomen with antiseptic soapnswered

b.          Report the appearance of a red, moist stoma

c.           After measuring the diameter of the stoma cut the opening of the wafer

d.          Tape the wafer in place in a window-pane format

Question 12The nurse would plan to perform more frequent perineal care to prevent skin breakdown for this client.

a.          Client with an indwelling catheter

b.          Client who uses a walker to ambulate

c.           Client with urinary frequency

d.          Client with an incision on their abdomen

Question 13A female nurse is upset because a male client has requested only a male nurse help them with personal care.  What is the best response from the charge nurse?

a.          The female nurse should ask the client what they did to offend them.

b.          The client may have gender identity issues.

c.           The client may have been abused by their mother.

d.          The client’s religious beliefs may prevent a female care-giver.

Question 14Select the priority nursing intervention for performing a complete bed bath on a client.

a.          Provide for privacy

b.          Allow the client to do as much of the bath as they can

c.           Identify the client with 2 identifiers before beginning

d.          Ask another nurse to assist with the bathing

Question 15Choose the adjunct therapy that can help improve circulation and assist in debridement of wounds.

a.          Hydrotherapy

b.          Electrical stimulation therapy

c.           Phototherapy

d.          Ultrasound therapy

Hydrotherapy uses warm water to both provide stimulation to increase circulation and gently washes loose tissue away from wounds.  EST therapy stimulates nerve endings to treat pain and promote healing.  Phototherapy uses ultraviolet light to treat some skin disorders.  Ultrasound therapy uses sonic waves to treat pain.

Question 16A nurse is providing oral care for a client who is immobile.  Choose the correct nursing action for this client.

a.          Apply petroleum jelly to the client’s lips after oral care

b.          Turn the client on the side before starting oral care

c.           Use the thumb and index finger to keep the client’s mouth open

d.          Use a stiff toothbrush to clean the client’s teeth

Question 17The nurse caring for a client with C. Difficile must use which personal protective equipment?

a.          Gown only

b.          Gown and surgical mask

c.           Mask and clean gloves

d.          Gown and clean gloves

Question 18The nurse is providing enteric feeding to a client.  A priority action on the part of the nurse to prevent infection is this:

a.          Use a bottle of feeding solution that has been kept refrigerated

b.          Use only a sterile irrigation syringe to flush before and after feeding

c.           Perform handwashing before and after administering the feeding

d.          Insert a new feeding tube every 24 hours

A priority nursing action before performing any nursing intervention is to do handwashing.  Feeding solutions do not always need refrigeration and they can spoil even under refrigeration.  It is not necessary to use a sterile irrigation to flush during feedings.  Feeding tubes are replaced only when they become occluded and cannot be cleared or when determined by the provider.

Question 19Choose the correct statement regarding sterile gloves.

a.          Sterile gloves do not require handwashing prior to donning

b.          The outside of the glove may only be touched by another sterile glove

c.           If there is a tear in the package the glove may still be used

d.          Once the gloves have been used they may be reused after washing

Question 20A student nurse notices a family member walking into a room under contact isolation.  The student stops the visitor and instructs them how to don the appropriate protective equipment.  The student is practicing this:

a.          Malpractice

b.          Humility

c.           Accountability

d.          Feasibility

 Question 21A nurse is caring for a client who has a Clostridium difficile infection.  Which cleansing agent should the nurse use for hand hygiene?

a.          Chlorhexidine

b.          Povidone-iodine

c.           Hand soap

d.          Alcohol-based hand rub

Question 22The nurse is teaching a nursing assistant on correct use of personal protective equipment (PPE).  The nurse knows the teaching was understood when the NA demonstrates this:

a.          Wears gloves whenever coming into contact with a client

b.          Wears gloves and a gown when bathing a client with open skin lesions

c.           Wears gloves constantly to avoid having to wash hands

d.          Wears gloves when delivering a lunch tray

Question 23

The nurse is teaching students the importance of hand hygiene.  Choose the most correct statement.

a.          “If you wear gloves you do not need to wash your hands”

b.          “Rub all surfaces of your hands with an alcohol rub for 20-30 seconds”

c.           “Use an alcohol rub if your hands are visibly soiled”

d.          “If you don’t have an infection, your hands won’t infect others”

Question 24

The nurse is preparing to exit the room of a client who has been placed on contact precautions.  Identify the sequence to be followed when removing the personal protective equipment (PPE).

1.  Wash hands

2.  Place discarded PPE in the designated trash container

3.  Remove gloves

4.  Remove the gown

5.  Remove protective eyewear if used

a.          3, 4, 5, 2, 1

b.          1, 3, 4, 5, 2

c.           3, 5, 4, 2, 1

d.          1, 3, 5, 4, 2

Question 25The nurse uses medical asepsis when caring for clients when they do this.

a.          Use sterile equipment to start an intravenous line

b.          Maintain a sterile field

c.           Properly empty and discard wound drains

d.          Hand a surgeon surgical instruments

 

Question 26

A nurse is teaching a group of new mothers on infant care.  The nurse includes which information on teaching about infection prevention.

a.          Infants will not get sick if you keep them at home.

b.          Handwashing before caring for the baby is only necessary if someone in the house is sick.

c.           Infants have immature immune systems and are more susceptible to infections than older children.

d.          Placing infants in the same room as a sibling who is sick will help them develop immunity.

Infants do not have well-developed immune systems and all steps should be taken to prevent unnecessary exposure to illness to prevent infection.

Question 27

An older client tells the nurse that they never get a flu shot because at their age, they’ve had every kind of flu there is.  Choose the best response from the nurse.

a.          Flu viruses are specific and you may not be immune to newer strains.

b.          Older adults have natural immunity and don’t need immunization.

c.           Older adults who contract the flu are less sick than younger adults.

d.          The risk is greater that an older adult will contract the flu from getting immunized.

Question 28The nurse is caring for an older adult who complains they don’t eat as much as they used to.  Their overall physical and mental condition is good.  Choose the best response from the nurse.

a.          Try to eat your meals with a companion.  Having company often improves the appetite.

b.          It must be difficult cooking for yourself.  You can always freeze left-overs.

c.           Older adults have fewer energy needs.  It’s not unusual to eat less than you used to.

d.          Make an appointment with your provider if you start to lose weight.

 Question 29

A nurse is assessing a young woman diagnosed with anorexia nervosa.  The nurse suspects the client is not eating all of the food on their prescribed diet when they observe this:

a.          They make frequent bathroom visits after meals

b.          Food waste is often found in the trash after family visits

c.           The client does not gain any weight between weigh-ins

d.          The client has very specific meal preferences

Question 30

The nurse caring for a new mother is teaching about proper nutrition for the infant.  Choose the best statement regarding infant nutrition.

 

a.          Infant formulas are the same as breast milkect!

b.          Breast milk is recommended for infants up to 12 months of age

c.           Solid foods may be introduced at 3 months

d.          Avoid using breast milk that has been pumped as it is not as nutritious

Question 31The nurse is performing a mini-nutritional assessment for a newly admitted client from a nursing home.  The best description of this type of assessment is what?

a.          It helps the nurse identify the client’s favorite foods

 b.         It is a quick method of identifying malnutrition and risks for malnutrition

c.           To identify caregivers in need of diet teaching

d.          To assist with food selection and meal planning

Question 32

The nurse is assessing a client’s peripheral circulation.  Choose where the nurse will palpate a popliteal pulse.

a.          Top of the footrrect!

b.          Behind the knee

c.           In the groin

d.          At the ankle

Question 33The nursing assistant reports these vital signs to a nurse:  tympanic temperature 98.8ºF, pulse 92 bpm, respiratory rate 18 breaths/min, blood pressure 98/58.  What does the nurse do next?

a.          Retake Temperature

b.          Recheck Pulse

c.           Assess Respirations

d.          Retake Blood Pressure

Question 34

A nurse instructs a group of new mothers to make sure the infant is covered up whenever in an air-conditioned space.  Choose the best rationale for this action.

a.          Some infants get cold faster than others

b.          Covering the infant protects them against respiratory infection

c.           Newborns and infants have poor thermoregulation

d.          Newborns and infants have poor thermoregulation and must be kept covered in cooler environments.

Question 35

The nurse is caring for a client with an irregular radial pulse.  What action should the nurse take next?

a.          Assess the apical pulse for a full minute

b.          Use a doppler device on the radial pulse

c.           Assess the radial pulse for a full minute

d.          Ask another nurse to recheck the pulse

Question 36A client is prescribed a medication that has adrenergic effects.  Choose the effect on the vital signs that this drug can have.

a.          Decreased pulse

b.          Low blood pressure

c.           Increased temperature

d.          Increased heart rate

Question 37A nurse is preparing to administer a medication prescribed to treat the client’s tachycardia.  The nurse should perform this action before giving the medication.

a.          Assess the blood pressure

b.          Assess the client for pain

c.           Assess the oxygen saturation

d.          Assess an apical pulse

Question 38A nurse assigns the nursing assistant the task of collecting vital signs on several clients.  Select the client for whom the nurse should assess vital signs.

  a.        A client being discharged from the hospital this morning

b.          A surgical client who is stable and 3 days post-op

c.           A maternity client who just delivered her infant

d.          A client who has just been transferred to the rehab unit for therapy

Question 39A group of student nurses is learning about adrenergic cardiovascular effects.  Choose the chemicals most likely to cause these effects.

epinepherine and norepinephrine

serotonin and dopamine

prostaglandins

histamines

 Question 40A nurse caring for an older client who has been a smoker for several years can expect to assess this abnormal vital sign.

Decreased respiratory rate

Increased blood pressure

Decreased pulse

Increased oxygen saturation

 Question 41

A young teen is injured playing football when he is shoved into a goalpost and suffers a head injury.  The nurse is concerned that this part of the brain may have suffered damage that can impact respirations.

The frontal lobe

 The parietal lobe

 The medulla oblongata

 The meninges

 Question 42A nursing assistant has just taken a client’s blood pressure and suspects the reading is not accurate.  Choose a valid reason for blood pressure error.

Rechecking both arms to compare readings

Smoothly deflating the cuff after taking the measurement

Using a large cuff for a client who has large upper arms

Reinflating the cuff before allowing it to complete deflate

Question 43A nurse caring for a client who is short of breath places the client in this position to facilitate lung expansion.

Prone

Supine

Lateral

Fowlers

 Question 44A nurse is caring for a client who is on fall precautions.  An appropriate alternate solution to the use of restraints would be what?

Turning on the TV so the client is distracted

 Using a bed or wheelchair alarm

Assigning a double room so the other client can watch them

Dimming the hall lights at night

Question 45A nurse is teaching other healthcare workers about the acronym for fire safety:  R.A.C.E.  The nurse explains that the letter “E” stand for what?

Explain

Eliminate

Extinguish

Evaluate

R.A.C.E. stands for Rescue, Activate, Confine and Extinguish

Question 46A nurse witnesses a client having a seizure.  What is the nurse’s priority action?

Turn the client on their side

Insert a mouth guard or bite-block

Restrain the client to prevent injury

Stay with the client and call for help

Question 47The nurse prepares to help a client with crutch-walking.  The nurse correctly places the crutches in this position:

Directly in front of and parallel to the client

6 inches in front of and 6 inches to the side of each foot

With the elbow straight

 Snug against each armpit

Question 48The nurse is caring for a client with a deep, infected wound.  The provider has prescribed wound irrigations be performed with each dressing change.  Choose the best nursing action.

Flood the wound with warm tap water

 

Use a sterile irrigation syringe to instill a solution of povidone iodine and water

Use sterile saline to thoroughly flush the wound bed

Wash the wound bed with soap and water and rinse well

 Question 49A nurse is preparing to discharge a client who has been hospitalized to treat a Stage IV decubitus ulcer.  Select the best statement from the nurse regarding the client’s wound.

Your wound was a Stage IV but now is has healed to a Stage III

You will need to continue to keep pressure off the wound area

Once the wound is completely healed the tissue will be stronger than ever

It is normal to smell a foul odor from your dressing

Question 50A nurse caring for a client with a Stage III pressure ulcer notes a foul odor coming from the room.  What does the nurse do next?

Notify the provider the wound is infected

Perform a complete assessment including vital signs and lab values

Consult with the wound care nurse for a change in wound care for the client

Do a focused assessment of the wound

Question 51The nurse is preparing to teach a client how to do their own wound care once discharged home.  Choose the best statement regarding wound packing.

The wound should be packed with several dry sterile gauze pads

Wound packing must be tightly compacted to facilitate healing

 Pack the wound loosely with saline moistened sterile gauze

 Avoid packing any tunnels or undermining

Question 52A nurse is discharging a client following surgical removal of the gall bladder.  The nurse defines this type of wound healing as what?

Primary intention

Secondary intention

Tertiary intention

Preliminary intention

Question 53A nurse has admitted a client to the hospital from home.  During assessment the nurse notes a reddened, warm spot on the client’s coccyx.  Choose an appropriate nursing action to address this finding.

  Massage the client’s coccyx twice a shift

 Reposition the client off their coccyx every two hours

 

Order an off-loading mattress to relieve pressure on the coccyx

Use a pillow as a cushion on the client’s bedside chair

Question 54 A clinic nurse is assessing a client who complains of a large blister on their left heel following participation in a 5K race.  Choose the best nursing action to treat this wound.

 Use a sterile needle to break the blister then apply a dry sterile dressing

 Instruct the client to leave the wound open to the air

 Protect the wound with a dry sterile gauze pad

Carefully cut away the blistered skin and leave it open to the air

Question 55A nurse is caring for a client with a Stage III pressure ulcer.  The nurse will measure and record what data in the client’s medical record?

Length, width and depth of the wound and any undermining or tunnelling

Length and width of the wound with undermining noted

Length, width and depth of the wound

Length and width of the wound with tunnelling and undermining noted

Question 56A client asks the nurse about bilevel positive airway pressure (BiPap) devices as the provider just prescribed one for them.  Choose the best explanation from the nurse.

It provides negative pressure on inspiration and positive pressure on expiration

BiPap provides both negative and positive pressure on inspiration

It provides positive pressure on inspiration and expiration

BiPap senses the client’s breathing and regulates it

Question 57The nurse is preparing to perform tracheal suctioning on a client.  Select the best position in which to place this client.

Lateral

Semi-fowlers

Supine

Sims

 

 

Question 58The nurse is suctioning a client when the oxygen saturation drops below 90%.  Select the action the nurse should perform next.

Complete the suctioning as quickly as possible

Increase oxygen flowing through the suction catheter

Remove the suction catheter and hyperoxygenate the client

Complete the suctioning and then hyperoxygenate the client

Question 59The nurse assesses a client having an anxiety attack who complains of numbness around the lips and tingling in the fingers.  The nurse correctly recognizes these as signs of what?

Hypoventilation

Tachycardia

Hypoglycemia

Hyperventilation

Question 60A nurse is teaching a group of post-operative clients how to correctly use the incentive spirometer.  What does the nurse include in the teaching?

Blow as hard as you can into the device

Wash your hands before and after using the device

Hold your breath for 10 seconds after taking a deep breath

Use the device whenever you feel the need to cough

Question 61The nurse is preparing to discharge a client home who will be using an oxygen concentrator.  The nurse teaches the client to do what to maintain safety while using oxygen?

Always check the regulator before using oxygen

Increase the liters per minute when you feel short of breath

Only smoke in the room with oxygen if you use 2 liters or less per minute

Wear synthetic clothing to prevent static electricity

Question 62A nurse admits a client with bacterial pneumonia.  The nurse recognizes the client is most at risk for this:

Infection

Hypoxia

Hypovolemia

Metabolic alkalosis

 Question 63The nurse is caring for several clients in the urgent care clinic.  The nurse understands that this group is most likely to suffer oxygenation problems.

 

 

Infants and toddlers

Middle school children

Teens and young adults

Older adults

Question 64The nursing student is developing a plan of care for a client whose diagnosis is ineffective airway clearance related to retained pulmonary secretions as evidenced by the production of thick, yellow sputum.  An appropriate nursing action for this client is what?

Elevate the head of the bed 30º

Restrict fluids to 1000 mL/day

Encourage the client to cough and deep breathe

Medicate the client with a cough suppressant

 Question 65The nurse teaching a group of students explains the purpose of postural drainage for a client with oxygenation problems.  The best explanation for the use of postural drainage is what?

To provide a more comfortable position when sleeping

To use gravity to pool secretions in the lower lobes

To avoid suctioning the client

To improve clearance of secretions

Question 66The nurse is caring for a client who is able to cough productively, but unable to expectorate or swallow the sputum.  Choose the appropriate nursing intervention and device.

Oral Suctioning

Oral Suctioning

Oral Suctioning

Tracheal Suctioning

Question 67The nurse must select a prescribed oxygen delivery device that provides low flow oxygen at 60%.  Select the correct device.

The nurse will select a partial rebreather which can deliver 60% oxygen.  A- is a venturi mask which is high flow and can deliver 24%-50%.  B- is a nasal cannula that delivers 24%-44%.  C- is a simple face mask that can deliver 35%-50%.

Question 68 A nurse in a long-term care facility instructs nurses about using an assistive device during ambulation.  Choose the correct way to instruct ambulating with a cane.

The cane should move first, then the client

The client should hold the can on the weaker side of the body

The grip should be level with the client’s waist 

The client moves the strong leg first than the weak one

Question 69A nurse is preparing to move a client who is only partially able to assist up in bed.  Which method should the nurse plan to use?

One nurse lifting as the client pushes with their feet

Two nurses lifting the client under the shoulders

One nurse lifting the client’s legs as the client uses a trapeze bar

Two nurses use a friction-reducing device

Question 70Plantar flexion contractures can best be prevented through the use of this device.

Trochanter roll

Sheepskin heel pad

Abduction pillow

Footboard or plantar boot

 Question 71A nurse who is applying a gait belt before ambulating a client will correctly place the belt in this position:

Tightly just below the ribs

 Snugly just above the client’s hips

Loosely above the abdomen

Tightly just below the client’s hips

Question 72A nurse is helping to ambulate a client who frequently loses balance while walking.  Choose the best device to aid in safety for this client.

Gait belt

Jacket harness

Four-wheel walker

Cane

Question 73A client frequently attemps to remove his intravenous catheter.  A family member asks the nurse to apply restraints.  Choose the most appropriate response from the nurse.

 

“I’ll provide more stimulation in the environment”

“I will call the provider for an order”

 “I will cover the catheter to distract the client’s attention away from it”

 “I will wait and see if the behavior continues”

Question 74A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage.  The nurse notes no urine output in the past 2 hours.  Which action should the nurse take first?

Check to determine if the catheter tubing is kinked

Palpate the bladder

Obtain a prescription to irrigate the catheter with 0.9% sodium chloride

Encourage the client to drink more fluids

 Question 75The nurse is preparing a client for a diagnostic testing of urinary function.  The nurse must make sure a consent form is on the client’s chart for this test:

Urinalysis

Renal X-ray

IV pyelogram

Urine culture

Question 76The nurse receives intake and output reports on several clients from the nursing assistant.  Select the output which the nurse should report to the provider.

120 mL in 4 hours

500 mL in 6 hours

300 mL in 4 hours

100 mL in 6 hours

Question 77A client reports to the nurse that they feel the need to urinate but can’t.  Select the priority nursing intervention for this client.

Perform a bladder scan

Palpate the bladder for distention

Collect urine for a urinalysis

Perform a straight catheterization

Question 78The nurse is assigning care to a nursing assistant (NA) for a client with an indwelling urinary catheter.  The nurse instructs the NA to do this in order to best prevent catheter associated urinary tract infection:

Tape the catheter to the upper thigh

 

Offer the client oral fluids every hour

Use medical asepsis to change the drainage bag

Perform good perineal care daily

Keeping the perineum and catheter clean is the best way to prevent a CAUTI in a catheterized client.

Question 79A client with this type of urinary diversion requires the nurse to instruct them how to self-catheterize.

Ileal conduit

Continent urinary reservoir

Nephrostomy

Ileostomy

Question 80The nurse can delegate this intervention to the nursing assistant.

Empty and record output from a urinary drain bag

Remove a foley catheter once the balloon is deflated

Change the drain bag on a foley catheter

Perform a straight catheterization to collect a urine sample

Question 81While caring for a post-procedure client who underwent a cystoscopy a few hours ago, the nurse notes pink-tinged urine in the client’s urinal.  Select the priority nursing action.

Immediately contact the provider who performed the procedure

Empty the urinal and record the amount voided

Encourage the client to restrict oral fluids

Start IV fluids to rehydrate the client

Question 82A nurse caring for an older adult male client understands that this is an expected physiological change.

Foul smelling urine

Brown urine

Renal calculi

Decreased bladder capacity

Question 83The nurse is teaching a group of home care providers about caring for the older adult with urine incontinence.  The nurse includes this statement in the teaching:

It is best to have the client wear adult diapers

Unless contraindicated, restrict oral fluids to 1 liter per day

 Kegel exercises are not effective for older adults to prevent incontinence

Establishing a toileting plan can help limit episodes of incontinence

Question 84A nurse is doing preoperative teaching for a client about to undergo abdominal surgery.  The nurse will insert a foley catheter prior to taking the client to the preoperative area.  The best rationale for this intervention is what?

To prevent bladder distention during surgery

To prevent the client from voiding on the surgical table

To collect urine specimens during the surgery

To maintain the client’s comfort throughout the procedure

Question 85The nurse is caring for a female client who requires the insertion of an indwelling urinary catheter.  The nurse will place the client in this position to best facilitate catheter insertion.

Semi-fowlers

Supine

Dorsal recumbent

Sims

Question 86The nurse is caring for a post-operative client and notes a moderate amount of serous drainage on the dressing 24 hours after surgery.  What is an appropriate nursing action?

Notify the surgeon that you suspect the client has an infection

Leave the dressing intact

Remove the dressing and leave the wound open to air

Change the dressing

Question 87The nurse is assessing a wound that is 75% covered with eschar.  What treatment does the nurse expect to be ordered?

  Clean several times a day with normal saline and sterile gauze

Apply a dry sterile dressing daily to the wound

 

 

 

Prepare the client for surgical debridement

Stage the wound as a Stage IV pressure ulcer

Question 88The nurse is preparing to administer enteric feeding through a nasogastric tube.  What does the nurse do after checking the placement of the tube?

  Position the client with head of the bed elevated to 20 degrees

Chill the feeding solution before giving it

Flush the tube with 30 ml of sterile or tap water

Offer the client sips of water during the feeding

Question 89The nurse is inserting a nasogastric tube when the client begins to gag.  What does the nurse do next after stopping the insertion?

Have the client take a deep breath

Check the mouth for a curled tube

Administer an antiemetic

Remove the tube and call provider

Question 90The nurse is preparing to insert a straight catheter into a male client.  Which action is appropriate?

Ask the client to void into a sterile container

Insert the catheter slowly if the client has an erection

Hold the penis parallel to the scrotum during insertion

Retract the foreskin if present before cleaning the glans

 Question 91The nurse is teaching teen-age girls about nutrition.  Which nutrient do teen girls need more of that teen boys do not?

Iron 

Calcium

Protein

Potassium

Question 92The nurse is assessing an older client for dysphagia.  What sign indicates the client may have dysphagia?

Memory loss

Constipation 

Drooling

Weight gain

Question 93The nursing assistant is feeding a client with dysphagia.  What can the nurse teach the assistant to help prevent choking during feeding?

Check the mouth for food after feeding 

Select hot, pureed foods to improve appetite

Offer sips of ice water through a straw

Use only finger foods the client can feed themselves

Question 94A client tells the nurse they are still constipated despite increasing fiber in their diet.  What is an appropriate question to ask the client?

What kind of fiber are you eating?

How many glasses of water do you drink a day?

What time of day are you eating the most fiber?

Are you eating cooked or raw fiber?

Question 95 The nurse is providing a bath for a client who is bedbound.  The nurse understands these care benefits from good hygiene:  {Select all that apply}

Provides comfort

Prevents infection

Prevents pressure ulcers

Provides rest

Promotes communication

Question 96 The nurse is teaching a group of home care workers about pressure ulcer formation.  Choose the condition(s) that place a client at risk for pressure ulcer formation.  {Select all that apply}

Fecal incontinence

Dehydration 

Wound infection

Malnutrition

Use of an assistive device

Question 97A nurse is caring for a group of clients.  Choose the client most likely to suffer from inadequate oxygenation {Select all that apply}

Accident victim with heavy blood loss

Client with blood clots in the lungs

Teen with seasonal allergies

Child recovering from drowning

Older adult with heart failure

Question 98 A client suddenly starts to slide down to the floor while ambulating.  Choose the correct actions by the nurse to prevent injury to both themselves and the client. {Select all that apply}

Stand in front of the client to prevent foward falling motion

Stand with feet apart in a wide base behind the client

Push out against the client to ease their fall

Extend one leg out to allow the client to slide against it

Bend your knees and lower the client slowly to the floor

Question 99 The nurse is preparing to collect a sterile urine specimen from a client’s foley catheter.  Choose the correct actions the nurse will perform. {Select all that apply}

Wash hands and apply clean gloves

 Clamp the drain tube for 30 minutes

Use a 10 mL syringe to withdraw urine from the drain port

Transfer the urine to a sterile specimen container

Correctly label the specimen with client’s name, date of birth, the date, time and your initials

Question 100 The nurse is helping a client select items for lunch from a clear liquid diet menu.  Which items are allowed on this diet?  {Select all that apply}

Pudding

Chicken broth 

Jello

Cream of wheat

Black coffee