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Terms in this set (53)
A nurse is assessing a client who is receiving TPN therapy via an infusion pump. Which of the following actions should the nurse take?
a) Obtain the client's blood glucose every 12 hr.
b) Change the IV tubing every 24 hr.
c) Change the IV site dressing every 4 days.
d) Weigh the client every other day.
b) Change the IV tubing every 24 hr.
A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client?
a) Remove the parenteral nutrition solution from the refrigerator 2 hr before infusion.
b) Remove unused parenteral nutrition after 12 hr of use.
c) Monitor daily laboratory values and report as
needed.
d) Monitor the flow rate of the parenteral nutrition carefully and increase the rate as needed if it falls behind.
c) Monitor daily laboratory values and report as needed.
A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
a) Disconnect the tube from the wall suction.
b) Perform hand hygiene.
c) Provide mouth care to the
client.
d) Verify the provider's prescription to discontinue the tube.
d) Verify the provider's prescription to discontinue the tube.
A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes that is being done to resolve which of the following conditions?
a) Electrolyte imbalance
b) Diarrhea
c) Constipation
d)
Delayed gastric emptying
b) Diarrhea
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following lab findings should the nurse expect to be altered?
a) Creatine kinase
b) Troponin
c) Total bilirubin
d) Albumin
d) Albumin
A nurse is teaching a client who has a prescription of an NG tube to treat a pyloric obstruction. Which of the following rationales for the use of the NG tube should the nurse include in the teaching?
a) Determine the pH of the gastric secretions.
b) Supply nutrients via tube feedings.
c) Decompress the stomach.
d) Administer medications.
c) Decompress the stomach.
A nurse is planning care for a client who is to start receiving TPN. Which of the following interventions should the nurse include in the plan of care?
a) Use a 1.2 micron filter when infusing TPN with fat emulsions added.
b) Allow 18 hr for the lipids to infuse when not mixed with the TPN solution.
c) Change the TPN solution after 36 hr.
d) Change the TPN tubing every 48 hr.
a) Use a 1.2 micron filter when infusing TPN with fat emulsions added.
A nurse is administering several meds via a client's GI tube. At which of the following times should the nurse instill 15-30mL of warm water? (Select all that apply.)
a) After each medication
b) Before aspirating gastric contents
c) When the flow of the medication by gravity slows
d) Prior to administering each medication
e) After giving multiple medications
a) After each medication
d) Prior to administering each medication
e) After giving
multiple medications
A nurse is teaching a client who is obese about orlistat. The nurse should instruct the client to report which of the following findings as an adverse effect of the med?
a) Drowsiness
b) Constipation
c) Oily fecal spotting
d) Dark-colored stools
c) Oily fecal spotting
A nurse is caring for a client who came to the ER with abdominal distention and is now on the med-surge unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?
a) Request a prescription for a medication to ease the client's anxiety.
b) Irrigate the NG tube with 100 mL of sterile water.
c) Check to see if the suction equipment is working.
d) Remove and reinsert the NG tube.
c) Check to see if the suction equipment is working.
A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. What reading should the nurse expect?
4.0
A nurse is assessing a client who is receiving TPN. Which of the following findings should the nurse recognize as a complication of this therapy?
a) Hyperglycemia
b) Aspiration
c) Diarrhea
d) Stomatitis
a) Hyperglycemia
A nurse is preparing to administer 3 liquid meds to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?
a) Mix the three meds together prior to administering.
b) Dilute each medication with 10 mL of tap water.
c) Maintain the head of the
bed in a flat position for 30 min following medication administration.
d) Flush the NG feeding tube with 30 mL of water immediately following medication administration
d) Flush the NG feeding tube with 30 mL of water immediately following medication administration
A nurse is preparing a client for placement of a catheter for TPN. Which of the following access sites should the nurse plan to prepare for catheter insertion?
a) Left antecubital vein
b) Right subclavian vein
c) Right femoral artery
d) Left arm radial artery
b) Right subclavian vein
A nurse is assessing 4 female clients for obesity. Which of the following clients have manifestations of obesity?
a) A client who has a body fat of 22%
b) A client who has a BMI of 28
c) A client who has a waist circumference of 81.3 cm (32
in)
d) A client who weighs 28% above ideal body weight
d) A client who weighs 28% above ideal body weight
A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching?
a) "I will allow him to be in the position where he is most comfortable during the
feeding."
b) "I will elevate the head of the bed 10 degrees during the feeding."
c) "I will turn him on his left side during the feeding."
d) "I will have him sit in his chair during the feeding."
d) "I will have him sit in his chair during the feeding."
A nurse is preparing ti initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?
a) Reconstitute the formula with tap water.
b) Discard unused formula after 8 hr.
c) Administer 200 mL of formula during the initial infusion.
d) Give the initial feeding over 15 min.
b) Discard unused formula after 8 hr.
A nurse is assessing a client and discovers the infusion pump with the client's TPN solution is not infusing. The nurse should monitor the client for which of the following conditions?
a) Excessive thirst and urination
b) Shakiness and diaphoresis
c) Fever and chills
d) Hypertension and crackles
b) Shakiness and diaphoresis
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 take prior to administering the tube feeding?
a) Warm the feeding solution to body
temperature.
b) Place the client in low Fowler's position.
c) Discard any residual gastric contents.
d) Test the pH of gastric aspirate.
d) Test the pH of gastric aspirate.
A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?
a) The nurse initiates the feeding after aspirating
50 mL of gastric residual.
b) The nurse irrigates the NG tube with tap water after feeding.
c) The nurse administers the feeding through a syringe barrel by gravity.
d) The nurse allows the client to rest in a supine position during feeding.
d) The nurse allows the client to rest in a supine position during feeding.
A nurse is preparing to administer TPN 1800 mL to infuse over 24HR. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
75 mL/hr
A nurse is caring for a client who has cancer and is receiving TPN. Which of the following lab values indicates the treatment is effective?
a) Hct 43%
b) WBC 8,000/uL
c) Albumin 4.2 g/dL
d) Calcium 9.4 mg/dL
c) Albumin 4.2 g/dL
A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following lab values indicates the client needs a change in formula?
a) Hematocrit 42%
b) Urine specific gravity 1.022
c) BUN 28 mg/dL
d) Sodium 142 mEq/L
c) BUN 28 mg/dL
A nurse is caring for 4 clients who have drainage tubes. Which of the following clients should the nurse recognizes as being at risk for hypokalemia?
a) The client who has a tracheostomy tube attached to humidified oxygen
b) The client who has an indwelling urinary catheter to gravity drainage
c) The client who has a chest tube to water seal
d) The client who has a NG tube to suction
d) The client who has a NG tube to suction
A nurse prepares to replace the nearly empty container of TPN for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?
a) Lactated Ringer's
b) 3% sodium chloride
c) Dextrose 10% in water
d) 0.9% sodium chloride
c) Dextrose 10% in water
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
a) To confirm the placement of the NG tube
b) To remove gastric acid that might cause dyspepsia
c) To determine the client's electrolyte balance
d) To identify delayed gastric emptying
d) To identify delayed gastric emptying
A nurse is planning care for a client who has a decreased LOC. The client is receiving continuous enteral feedings via a GI tube due to an inability to swallow. Which of the following is the priority action by the nurse?
a) Observe client's respiratory status.
b) Elevate the head of the client's bed 30° to 45°.
c) Monitor intake and output every 8 hr.
d) Check residual volume every 4 to 6 hr
b) Elevate the head of the client's bed 30° to 45°.
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
a) Electrical cords are placed along the walls.
b) Scatter rugs are present in the kitchen.
c) Handrails are present in the bathroom.
d) Uses a microwave for cooking.
b) Scatter rugs are present in the kitchen.
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report...
a) loss of central vision.
b) having a loss of peripheral vision.
c) seeing bright flashes of light and floaters.
d) having a decreased ability to perceive colors.
d) having a decreased ability to perceive colors.
A nurse is caring for a client who has otitis media. Which of the following assessment findings should the nurse expect?
a) Tugging on the affected ear lobe
b) Clear drainage from the affected ear
c) Pain when manipulating the affected ear lobe
d) Erythema and edema of the affected ear
a) Tugging on the affected ear lobe
A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching?
a) "Without treatment, glaucoma can cause blindness."
b) "Double vision is a common symptom of glaucoma."
c) "Glaucoma is caused by inadequate production of fluid within the eye."
d) "Use of eye drops will improve vision over time."
a) "Without treatment, glaucoma can cause blindness."
A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage form the ear). The nurse should recognize the client has manifestations of which of the following conditions?
a) Mastoiditis
b) Ménière's disease
c) Acoustic neuroma
d) Perforated tympanic membrane
d) Perforated tympanic membrane
Manifestations of mastoiditis include...
-pain
and swelling behind the ear
-fever
-hearing loss
-ear drainage
Manifestations of Ménière's disease include...
-tinnitus
-hearing loss
-vertigo
-nystagmus
A nurse is caring for a client who has Meniere's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
a) "Yes, you are free to
move around as you wish."
b) "No, you are on strict bedrest and must not be up."
c) "Please ring for assistance when you wish to get out of bed."
d) "We will have to get a prescription from your provider."
c) "Please ring for assistance when you wish to get out of bed."
A nurse in an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?
a) Take ibuprofen for eye discomfort.
b) Creamy white drainage is an indication of infection.
c) Notify the provider immediately if the operative eye itches.
d) The client should wear dark glasses while outdoors.
d) The client should wear dark glasses while outdoors.
A nurse is reviewing discharge instruction with a client following a right cataract extraction. Which of the following instructions should the nurse include?
a) Sleep on the abdomen to facilitate wound healing.
b) Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
c) Bend at the waist to pick objects up from the floor.
d) Notify the surgeon if white drainage develops on the eyelids.
b) Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
A nurse is planning care for a client 1 day post-op following a detached retinal repair. Which of the following instructions should the nurse include in the plan?
a) Encourage coughing, and deep-breathing.
b) Allow the client to ambulate.
c) Remove the eye patch during the day.
d) Avoid reading and writing.
d) Avoid reading and writing.
A nurse is providing post-op teaching to a client who is scheduled for cataract surgery. Which of the following info should the nurse include?
a) "Bloodshot eyes on the day of surgery should be reported to the provider."
b) "Warm compresses should be applied to the eye three times daily."
c) "Photophobia is expected for 2 to 3 days."
d) "Vision will be greatly improved on the day of surgery."
d) "Vision will be greatly improved on the day of surgery."
A nurse is planning care for a client who has a detached retina and is pre-op for a surgical repair. The nurse should prepare to administer which of the following meds?
a) Phenylephrine
b) Latanoprost
c) Pilocarpine
d) Timolol
a) Phenylephrine
meds for treatment of glaucoma:
Latanoprost
Pilocarpine
Timolol
A nurse is caring for a client who is post-op following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority?
a) Notify the surgeon.
b) Instill an antibiotic solution in both eyes.
c) Clean eye from inner to outer canthus.
d) Apply a non-pressure patch to the affected eye.
a) Notify the surgeon.
A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take?
a) Speak loudly and into the client's good ear.
b) Use sign language when communicating with the client.
c) Speak directly to the client in a normal, clear voice.
d) Sit by the client's side and speak very slowly.
c) Speak directly to the client in a normal, clear voice.
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
a) Speak using his usual tone of voice.
b) Stand directly in front of the client.
c) Rephrase statements the client does not hear.
d) Determine if the client uses hearing aids.
d) Determine if the client uses hearing aids.
A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include?
a) "Take aspirin for discomfort."
b) "Restrict lifting objects greater than 10 pounds."
c) "Expect reduced vision for 48 hours after procedure."
d) "Apply warm compresses for discomfort."
b) "Restrict lifting objects greater than 10 pounds."
A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take?
a) Apply pressure to the bridge of the nose after administration.
b) Wipe the eye from the outer canthus to the inner canthus before instillation.
c) Drop prescribed amount of med into the conjunctival sac.
d) Protect the distal portion of the eyedropper using clean technique.
c) Drop prescribed amount of med into the conjunctival sac.
A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?
a) Green-blue discharge in the ear canal
b) Increased temperature
c) Sudden pain relief
d) Popping sensation when swallowing
c) Sudden pain relief
A nurse at an ophthalmology clinic is providing teaching to a client who has an open-angled glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?
a) Administer the meds by touching the tip of the dropper to the sclera of the eye.
b) Hold pressure on the conjunctiva sac for 2 min following application of drops.
c) Administer the meds 5 min apart.
d) It is not necessary to remove contact lenses before administering meds.
c) Administer the meds 5 min apart.
A home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include?
a) "Rest in bed for at least 2 days."
b) "Keep your head up and straight."
c) "Deep breathe and cough four times a day."
d) "Lie on the side of the surgery when in bed."
b) "Keep your head up and straight."
A nurse at an ophthalmic clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?
a) The med is to be applied when the client is experiencing eye pain.
b) The med will be used until the client's intraocular pressure returns to normal.
c) The med should be applied on a regular schedule for the rest of the client's life.
d) The med
is to be used for approximately 10 days, followed by a gradual tapering off.
c) The med should be applied on a regular schedule for the rest of the client's life.
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
a) "My eye really itches, but I'm trying not to rub it."
b) "I need something for the
pain in my eye. I can't stand it."
c) "It's hard to see with a patch on one eye. I'm afraid of falling."
d) "The bright light in this room is really bothering me."
b) "I need something for the pain in my eye. I can't stand it."
A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
a) "I will clean the hearing aids with alcohol wipes."
b) "I will not use hairspray if I am wearing the hearing aids."
c) "I will change the batteries once a week."
d) "I will expect the hearing aids to whistle when I cup my hand over them."
a) "I will clean the hearing aids with alcohol wipes."
A nurse is taking care of a client who is scheduled for surgery to repair retinal detachment. Which of the following pre-op instructions should the nurse include?
a) Keep both eyes patched.
b) Restrict head movement.
c) Eye drops to constrict the pupils will be prescribed.
d) Apply cool compresses.
b) Restrict head movement.
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