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NURS 210 Exam 2
A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include? The most common oral hygiene problem is gingivitis. The client's ability to obtain dental care is unaffected by their visual impairment. The visually impaired client has better oral hygiene than those clients without visual impairment. The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health. - ansThe nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health. A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action? Intramuscular Oral Buccal Intravenous - ansoral A client drinks 8 oz of water. Which of the following is a correct conversion of the client's intake? 1 pint 4 Tbsp 2 cups 240 mL - ans240 mL a client in a provider's office tells the nurse that " I fast for several days each week to help control my weight." The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? increasing the metabolism of medications over time increasing the protein binding response increasing medications transit time through the intestines decreasing the excretion of medications - ansincreasing the protein binding response A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? Cleansing Return-flow Medicated
Oil-retention - ansReturn-flow A client who lives in a long-term care facility is receiving intermittent enteral feedings and is a experiencing social isolation. Which of the following interventions should the nurse recommend? Encourage the client to go to the dining room at meal times to talk with other clients. Suggest that the client watch television while feedings are being administered. Remind the client that they can have visitors after feeding administration times. Ask the facility chaplain to speak with the client. - ansEncourage the client to go to the dining room at meal times to talk with other clients. A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? extinguish the fire close the windows in the client's room close the client's door activate the fire alarm - ansactivate the fire alarm A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply.) "I will observe for adverse effects" "I will monitor for therapeutic effects" "I will prescribe the appropriate dose" "I will change the dose if adverse effects occur" "I will refuse to give a medication if I believe it is unsafe." - ans"I will observe for adverse effects" "I will monitor for therapeutic effects" "I will refuse to give a medication if I believe it is unsafe." A nurse has a handwritten prescription that is difficult to read. Which of the following actions should the nurse take to avoid an error in medication administration? Ask another nurse to decipher the prescription. Call the provider for clarification of the prescription. Rely on their knowledge of the client to get the prescription right. Inquire at the facility pharmacy about the prescription. - ansCall the provider for clarification of the prescription. A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take? Administer the medication whenever the client reports specific manifestations, such as pain. Administer the medication at specific times until directed by health care provider. Administer the medication at regular intervals of 4 hr.
"You will be on this diet as long as the provider feels you need to be." "You might be on this diet for a week or two." "You should not be on this diet for more than a few days." "You should speak with the provider about your concern." - ans"You should not be on this diet for more than a few days." A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? 2.5 cm to 3.75 cm (1 to 1.5 in) 5 cm to 7.5 cm (2 to 3 in) 7.5 cm to 10 cm (3 to 4 in) 10 cm to 12.5 cm (4 to 5 in) - ans7.5 cm to 10 cm (3 to 4 in) A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? Flush the feeding tube with 30 mL of water. Add blue food coloring to the enteral formula. Ensure the formula is at room temperature. Place the client in Fowler's position. - ansPlace the client in Fowler's position. A nurse is administering aspirin 81 mg PO daily as prescribed. The medication is scheduled for 0800 hours. Which of the following demonstrates proper use of one of the six rights of medication administration? The nurse performs the first check of the correct dosage at the client's bedside. The nurse identifies the client by stating the client's name as written on the medication administration record. The nurse documents that the aspirin was given at 0825. The nurse opens the 81 mg aspirin unit dose package prior to entering the client's room.
- ansThe nurse documents that the aspirin was given at 0825. A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? Stretch the sheath portion of the condom catheter along the length of the penis. Secure the sheath portion with adhesive tape. Leave a space between the penis and sheath portion tip. Reposition the foreskin after application. - ansLeave a space between the penis and sheath portion tip. A nurse is assessing a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings? Dark yellow, cloudy urine Pale yellow, clear urine Urine with a strong odor Urine with a slight red tint - ansPale yellow, clear urine
a nurse is assessing a client who has had diarrhea for 4 days. which of the following findings should the nurse expect? ( select all that apply) Bradycardia Hypotension elevated temperature poor skin turgor peripheral edema - ansHypotension elevated temperature poor skin turgor A nurse is assessing a client who has stress incontinence. Which of the following findings should the nurse expect with this client? Urine leakage prior to reaching the toilet Urine leakage following coughing Urine leakage as a result of nerve damage Urine leakage due to not reaching the toilet in time from a physical impairment - ansUrine leakage following coughing A nurse is assessing a client who is experiencing digestive issues. Which of the following findings should the nurse expect? (Select all that apply). Nausea Abdominal pain Diarrhea Reports of bloating Reports of excessive salivation - ansNausea Abdominal pain Diarrhea Reports of bloating A nurse is assessing a client's cranial nerves. which of the following client actions is an indication that cranial nerve I is intact? The client can stick their tongue out the client can smile symmetrically the client can hear whispered words the client can identify a minty scent - ansthe client can identify a minty scent A nurse is assessing a client's hair and notes that it is brittle. Which of the following should the nurse determine about the client's nutritional intake? The client is not getting enough vitamin A. The client has insufficient protein in their diet. The client needs more vitamin D from sun exposure. The client needs to eat five servings of fruits and vegetables daily. - ansThe client has insufficient protein in their diet.
Check the client's reading comprehension level. Use medical terminology to instruct the client about the patch. - ansAsk the client what they know about the nitroglycerin patch. Determine the client's ability to apply the patch. Check the client's reading comprehension level. A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include? Place a new transdermal patch over the same site as an old patch. Apply no more than two transdermal patches at a time. Expect the transdermal medication to absorb rapidly. Wear clean gloves to apply the transdermal medication. - ansWear clean gloves to apply the transdermal medication. A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? A. Wrap both arms around the client's arms and shoulders. B. Move both feet together when the client begins to fall. C. Protect the client's extremities while lowering them to the floor. D. Extend one leg and allow the client to slide down the leg to the floor. - ansD. Extend one leg and allow the client to slide down the leg to the floor. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) Auscultate bowel sounds Assist the client to an upright position Test the pH of gastric aspirate Warm the formula to body temperature Discard any residual gastric contents - ansAuscultate bowel sounds Assist the client to an upright position Test the pH of gastric aspirate A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) I feel lightheaded I feel as though my heart is racing I feel a little short of breath The nurse technician told me that my blood pressure was 150/ I think my ankles are less swollen - ansI feel as though my heart is racing I feel a little short of breath The nurse technician told me that my blood pressure was 150/
A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function? Administer an enema Administer a laxative Perform colostomy irrigation Insert a rectal tube - ansPerform colostomy irrigation A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? Modular Elemental Polymeric Specialty - ansElemental A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide? "You should eat white bread." "You can drink 2 cups of milk per day." "You should limit broccoli to 3 cups per week." "You can have four servings of oatmeal per week." - ans"You should eat white bread." A nurse is caring for a client who has a history of irritable bowel syndrome and reports that their last bowel movement was 5 days ago. The nurse should identify this as which of the following types of altered elimination pattern? Encopresis Diarrhea Fecal incontinence Constipation - ansConstipation A nurse is caring for a client who has a new prescription for parenteral nutrition. The client states, "I am scared that I will be on this therapy for the rest of my life." Which of the following responses should the nurse make? "There is a good chance you will have to be on this therapy for the rest of your life." "Parenteral nutrition is very common and should not interfere with your daily activities." "This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change." "I am sure you will need parenteral nutrition temporarily." - ans"This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change." A nurse is caring for a client who has a prescription for a vitamin K injection. The nurse should identify that vitamin K is naturally produced in which of the following locations in the body? Small intestine
A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take? Assist the client as needed to ensure proper hygiene is performed. Aggressively rub the skinfolds dry to manage moisture. Use a lye soap bar to cleanse the skinfolds and the rash area. Apply moisturizer to the skinfolds and rash area. - ansAssist the client as needed to ensure proper hygiene is performed. A nurse is caring for a client who has been hospitalized and is performing active range- of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder? A. Adducting the arm so that it lies next to the client's side B. Flexing the shoulder by raising the arm from a side position to a 180° angle C. Abducting the arm to a 90° angle from the side of the body D. Circumducting the shoulder in a 180° half circle - ansB. Flexing the shoulder by raising the arm from a side position to a 180° angle a nurse is caring for a client who has been sitting in a chair for 1 hour period. which of the following complications is a greatest risk to the client? decreased subcutaneous fat muscle atrophy pressure injury fecal impaction - ansPressure injury A nurse is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution? Instruct the client to lie on their right side with their left leg pulled up to their chest. Instruct the client to lie on their left side with their right leg pulled up to their chest. Instruct the client to lie on their left side with both legs pulled up to their chest. Instruct the client to lie on their right side with both legs pulled up to their chest. - ansInstruct the client to lie on their left side with their right leg pulled up to their chest. A nurse is caring for a client who has constipation. Which of the following diets should the nurse encourage the client to follow? Low fat High protein High fiber Low carbohydrate - anshigh fiber A nurse is caring for a client who has COPD. For which of the following inhalation medication delivery methods is it important for the nurse to assess the patient's ability to inhale deeply before administering the medication? Dry powder inhaler (DPI) Nasal spray Metered dose inhaler (MDI) with attached spacer
Use of a nebulizer via a mask - ansDry powder inhaler (DPI) A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium? (Select all that apply). Apples Bananas Dried beans Spinach Tomatoes - ansBananas Dried beans Spinach Tomatoes A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client? The nurse should perform personal hygiene tasks for the client. The client has a minor loss of strength on the right side of the body. The nurse should have the client remove clothing from the unaffected side first. Oral care is much easier for the client to perform than bathing. - ansThe nurse should have the client remove clothing from the unaffected side first. A nurse is caring for a client who is at risk for aspiration. which of the following actions should the nurse take? give the client thin liquids instruct the client to tuck their chin when swallowing have the client use a straw encourage the client to lie down and rest after meals - ansinstruct the client to tuck their chin when swallowing A nurse is caring for a client who is at risk for suicide. which of the following actions should the nurse take? ( select all that apply) place the client on around the clock surveillance remove objects from the room that the client could use to harm themselves search items brought into the client's room by visitors refrain from asking the client if they intend to harm themselves screen the client for a suicidal ideation - ansplace the client on around the clock surveillance remove objects from the room that the client could use to harm themselves search items brought into the client's room by visitors screen the client for a suicidal ideation A nurse is caring for a client who is one day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? Meperidine 75 mg IM
The antibiotic decreases a client's immunity level, resulting in diarrhea. - ansThe antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow. a nurse is caring for a client who is receiving continuous enteral feedings. which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? also take breath sounds stop the feeding obtain a chest x-ray initiate oxygen therapy - ansstop the feeding A nurse is caring for a client who is receiving tube feedings via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating? Keep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding. Verify the initial tube placement with an x-ray after the first feeding. Check the client's tube feeding tolerance every 12 hr. Check the pH of the gastric contents each day. - ansKeep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding. A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take Ensure the nurse caring for the client is of the same sex. Leave the water running while the client takes a bath. Allow the client time for prayer immediately following bath time. Discuss with the client their individual perspective on health and illness. - ansDiscuss with the client their individual perspective on health and illness. A nurse is caring for a client who reports occasionally having dark, tea-colored urine at home. The nurse identifies that which of the following activities can contribute to this finding? Attending a yoga class Consuming alcohol Drinking 2,000 mL of fluid in a day Consuming fish for dinner - ansconsuming alcohol A nurse is caring for a client who requires a low residue diet. the nurse should expect to see which of the following Foods on the client's meal tray? cooked barley pureed broccoli vanilla custard lentil soup - ansvanilla custard A nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO diet prescription
for the client. Which of the following should the nurse identify as the rationale for the provider's prescription? The client is at risk for aspiration due to the upcoming surgery. The client is at risk for dysphagia due to the upcoming surgery. The nutrients consumed as a part of the regular diet will interact with the sedation used in the procedure. The client reports having to drink a few sips of water before the procedure. - ansThe client is at risk for aspiration due to the upcoming surgery. A nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamin." Which of the following responses should the nurse make? "If taken four or more days a week, a multivitamin provides all the nutrients you need." "As long as you take a multivitamin daily, you do not need to eat a varied diet each day." "A multivitamin should not be used in place of a nutritious diet." "As long as the multivitamin isn't generic, it can replace unhealthy dietary choices." - ans"A multivitamin should not be used in place of a nutritious diet." A nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make? "A lack of protein can cause a problem with cavities." "Cavities can be caused by a diet low in vitamin C." "Increasing your consumption of leafy green vegetables and tomatoes can help with this." "Drinking sugary beverages can make you prone to cavities." - ans"Drinking sugary beverages can make you prone to cavities." A nurse is caring for a client who states, "I only eat a diet high in protein and carbohydrates." Which of the following responses should the nurse make? "Make sure to get enough servings of red meat in your diet daily." "Your diet is varied but should also be high in calorie intake." "A varied diet should be high in protein and carbohydrate consumption." "A nutritious diet should include carbohydrates, protein, fiber, and healthy fats." - ans"A nutritious diet should include carbohydrates, protein, fiber, and healthy fats." A nurse is caring for a client who weighs 176 lbs and is 5 ft 3 in. calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese. - ans31.2 = obese A nurse is caring for a client who will perform fecal occult blood testing at home. which of the following information should be included when explaining the procedure to the client? eating more protein is optimal prior to testing one stool specimen is sufficient for testing a red color change indicates a positive test
Older adults Young adults - ansUncircumcised infants School-age children Older adults A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? A client who has a paralytic ileus A client who has recently experienced facial trauma A client who has dysphagia A client who has a decreased appetite - ansA client who has dysphagia A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity? A client who has a respiratory infection A client who has rheumatoid arthritis A client who has impaired kidney function A client who has hyperthyroidism - ansA client who has impaired kidney function A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse suspect to receive a prescription for urinary catheterization? A client who has a persistent urinary tract infection. A client who has urge incontinence. A client who is in the ICU for a gastrointestinal bleed. A client who has incontinence due to cognitive decline. - ansA client who is in the ICU for a gastrointestinal bleed. A nurse is caring for a nondiabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the client's blood glucose and it is 67 mg/dL. Which of the following actions should the nurse take next? Recheck the blood sugar in 15 min. Provide the client with a 15-g carbohydrate snack. Report the client's blood glucose level to the provider. Document the client's blood glucose level. - ansProvide the client with a 15-g carbohydrate snack. A nurse is caring for a patient who has been prescribed a fluticasone propinate (Flovent HFA) inhaler with a spacer. The patient asks the nurse why the spacer is needed with the inhaler. Which of the following responses by the nurse is correct? "By using a spacer, you can take the medication correctly without any spills." "You can inhale five or more puffs in 1 minute when using a spacer." "By using a spacer, you eliminate the need for mouth rinsing after administration." "More medication is delivered to the lungs when you use a spacer." - ans"More medication is delivered to the lungs when you use a spacer."
A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age-related change that can contribute to this occurrence? Reduced blood supply Loss of kidney tissue Loss of nephrons Loss of bladder tone - ansloss of bladder tone A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make? "That is unusual. As clients age, they are typically more receptive to bathing." "It is fine if the client does not bathe regularly at home." "Give the client choices regarding their bathing preferences to encourage them to bathe." "Provide the client with the reasons why they need to bathe." - ans"Give the client choices regarding their bathing preferences to encourage them to bathe." A nurse is caring for client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (Select all that apply.) Increasing daily fiber intake can help alleviate the issue of constipation. Eating more whole grains can promote regular bowel movements. Consume 10 g of fiber per day. Foods such as white rice increase fiber intake. Decreasing daily fiber intake can help alleviate digestive discomfort. - ansIncreasing daily fiber intake can help alleviate the issue of constipation. Eating more whole grains can promote regular bowel movements. A nurse is checking a client's allergy bracelet before administering a medication and finds the client as allergic to that medication. the nurse does not administer the medication to the client. this is an example of which of the following unexpected events? Near-miss event client safety event adverse event Sentinel event - ansnear miss event A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first? Notify the client's provider. Stop the infusion of the vancomycin. Administer diphenhydramine to the client. Document the incident in the client's chart. - ansStop the infusion of the vancomycin. A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse reviewing the demonstration indicates understanding of the procedure?
A nurse is educating a client about a new temporary ileostomy. Which of the following statements by the client indicates an understanding of the teaching? "My ileostomy has an internal reservoir that collects waste." "My ileostomy is allowing my colon time to heal from the surgery." "My ileostomy must be accessed with a catheter to drain the waste." "My ileostomy is designed to be a permanent solution." - ans"My ileostomy is allowing my colon time to heal from the surgery." A nurse is educating a client who has paraplegia about urinary catheter use. Which of the following catheter types should the nurse include the teaching to help facilitate urinary elimination for this client? Suprapubic catheter Indwelling catheter Condom catheter Intermittent catheter - ansIntermittent catheter A nurse is educating a newly licensed nurse about The Joint Commission's National Patient Safety Goals. Which of the following goals does the nurse include when providing the education? Preventing diabetes Preventing surgical-site infections Preventing myocardial infarctions Preventing cerebrovascular accidents - ansPreventing surgical-site infections A nurse is evaluating a client's bladder training program. Which of the following statements by the client indicates the bladder training was successful? "I am having accidents daily." "I am voiding a small amount when I visit the bathroom." "I continue to visit the bathroom every hour." "I am experiencing less than one urinary accident per week." - ans"I am experiencing less than one urinary accident per week." a nurse is evaluating a client's understanding of the use of a sequential compression device. which of the following client statements indicates client understanding? this device will keep me from getting sores on my skin this device will keep the blood pumping through my leg with this device on, my leg muscles won't get weak this device is going to keep my joints in good shape - ansthis device will keep the blood pumping through my leg A nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. The client's food had a total of 72 g of carbohydrates and 9 g of fiber. How many net carbohydrates did the client consume? 81 63 8
72 - ans A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? Closing off the glottis Preventing curling of the tube in the mouth Allowing the client to breathe through the mouth Opening the lower esophageal sphincter - ansClosing off the glottis A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement Measure the pH of gastric aspirate. Auscultate the epigastric area while injecting air. Obtain an x-ray. Place the open end of the tube in a cup of water. - ansObtain an x-ray. A nurse is instructing a client who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) Hold the cane on the right side Keep two points of support on the floor Place the cane 38 cm (15 in) in front of the feet before advancing After advancing the cane, move the weaker leg forward Advance the stronger leg so that it aligns evenly with the cane - ansHold the cane on the right side Keep two points of support on the floor After advancing the cane, move the weaker leg forward a nurse is instructing a client who has diabetes mellitus about foot care. which of the following guidelines should the nurse include? ( select all that apply) inspect the feet daily use moisturizing lotion on the feet wash the feet with warm water and let them air dry use over the counter products to treat abrasions wear cotton socks - ansinspect the feet daily use moisturizing lotion on the feet wear cotton socks A nurse is observing an assistant personnel AP make a client's bed while the client is out of the room. Which of the following actions by the AP indicates an understanding of the procedure? The AP records the task when it is completed. The AP wears sterile gloves while making the bed. The AP changes the client's pillowcase.
