Exam Review
- A nurse assisting with a staff in-service is discussing aspiration. Which of the following descriptions should the nurse include in the teaching as a manifestation dysphagiaA)Coughing, choking gagging, and drooling foodB)Swallowing more than once after taking a bite of foodC)Swallowing liquid immediately after taking a sip of a beverageD)Highly sensitive gag reflex
- A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?A)Check to see if the suction equipment is workingB)Remove and reinsert the NG tubeC)Request a prescription for a medication to ease the client's anxietyD)irrigate the NG tube with 100 mL of sterile water.
- When irrigating a percutaneous endoscopic gastrostomy (PEG) tube with an intermittent bolus feeding which of the following steps should be taken?A)Remove the PEG tube from the stoma and clean it with soap and water.B)Administer the bolus feeding through the PEG tube without flushing it first.C)Use a syringe to flush the tube with 30 m of water before and after the bolus feedingD)Skip the flushing step of the PEG tube is already patent
- A nurse is caring for a client who has tolerated a clear liquid diet but not voided for 8 hours following surgery. Which of the following actions should the nurse take first?A)Provide assistance to bathroom.B)Perform a bladder scanC)Offer the client fluids.D)Insert an indwelling urinary catheter.
Exam Review
- When determining the length of the nasogastric tube for insertion, the nurse should measure the distance from the tip of the clients nose to the earlobe and from the earlobe to theA)Symphysis PubisB)UmbilicusC)Brachial ArteryD)Xiphoid process
- A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?A)Elevate the head of the bed.B)Return gastric content into the gastrostomy tubeC)Measure stomach contentsD)Flush the tube with water.
- A nurse is reinforcing teaching with a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?A)Dairy productsB)Fresh vegetablesC)Caffeinated beveragesD)Red meat
- A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast. 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)Correct Answer:1, 140 mL
Exam Review
- A nurse is planning to apply a female external urinary catheter for a client. Once the external catheter is in place, which of the following actions should the nurse plan take?A)Replace the external urinary catheter once each dayB)Connect the catheter to continuous wall suctionC)insert the catheter into the client's urethraD)Apply a barrier cream to the client's perineal skin
- A nurse is assisting with teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?A)"The end of the stoma will be painful after this procedure."B)"You will have a stoma in your left lower abdomen."C)"You should expect your stoma to be a purple color."D)"Your colostomy produce watery stool.”
- A nurse is assisting with evaluating a newly licensed nurse drain an ileostomy bag for a client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?A)Wears sterile gloves to drain the ileostomy bagB)Cleans the end of the ileostomy pouch before clampingC)Empties the ileostomy bag when it is three-fourths fullD)Washes the skin surrounding the client's ileostomy with hot water
- A nurse is planning care for a client who has dysphagia. The nurse should plan to assist with the request of a referral to which of the following members of the health care team?A)Respiratory therapistB)Speech therapistC)Physical therapistD)Dentist
Exam Review
- A nurse is assisting with teaching a client who has constipation, which of the following statements should the nurse include?A)"Consume a low-fiber dietB)"Increase your daily fluid intake."C)"Reduce your daily activity."D)Try to defecate at different times of the day.
- A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?A)Position the head of the client's bed at 15°B)Change the feeding bag every 24 hr.C)Flush the tube with sterile sodium chloride solution every 4 hr.D)Check the gastric residual every 12 hr.
- A nurse is caring for a client who is postoperative and has a prescription for a clear liquid diet. The nurse enters the client's room to find he has just received a dietary tray. Which of the following items on the tray should the nurse remove?A)Cranberry juiceB)Orange gelatinC)Beef brothD)Vanilla pudding
- A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?A)Assist the client to the left Sims' position.B)Put on sterile gloves.C)Hang the enema container 61 cm (24 in) above the anusD)Insert the tubing about 15 cm (6 in) into the anus.
Exam Review
- A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?A)Promote active range-of-motion activities.B)Add fluid and fiber to the diet.C)Avoid gas-producing foods.D)Request that the provider prescribe a stool softener.
- A nurse is reinforcing teaching with a client who has received treatment for kidney stones. The nurse should remind the client to increase intake of which of the following?A)ProteinB)WaterC)SodiumD)Tea
- A nurse is preparing to obtain a 24-hr urine collection from a client. Which of the following actions should the nurse plan to take?A)Discard the client's last void of the collection time period.B)include toilet paper with the collected urineC)Save the first void at the start of the collection time periodD)The nurse should discard the first void to obtain an accurate specimen
- A nurse is caring for a client who has a body mass index (BMI) of 27. The nurse should place the client in which of the following BMI categories?A)UnderweightB)Healthy weightC)ObeseD)Overweight
Exam Review
- A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?A)Urge incontinenceB)Overflow incontinenceC)Stress incontinenceD)Reflex incontinence
- A nurse is caring for a client who tells the nurse she experiences urinary incontinence when she sneezes. The nurse recognizes this is an expected finding for which of the following types of incontinence?A)Urge incontinenceB)Stress incontinenceC)Reflex incontinenceD)Overflow incontinence
- A nurse is assisting with teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?A)"The end of the stoma will be painful after this procedureB)"You should expect your stoma to be a purple color."C)"You will have sold stool pass through your stoma."D)"You will have a stoma placed in your right lower abdomen."
- A nurse is caring for older adult clients at a long-term care facility. Which of the following assessments should the nurse consider when monitoring clients for urinary retention?A)[Select All that Apply)B)Voiding patternC)Dribbling of urineD)Color of the urineE)Bladder distensionF)Proteinuria