Nursing interventions and assessments
Which is the correct order to complete an abdominal
assessment?
A.Inspection, auscultation, percussion, and palpation
B.Auscultation, inspection palpation, and percussion
C.Percussion, palpation, inspection, and auscultation
D.Palpation, percussion, auscultation, and inspection
A.Inspection, auscultation, percussion, and palpation
For a client on continuous tube feeding the nurse determined that tube placement should be checked every?
Hour
12 hours
24 hours
Shift
4. shift
Which is often the first sign of urinary tract infection in older adults?
Urgency
Behavioral changes
Burning while urinating
Back pain
2. Behavioral changes
A nurse is caring for a client who has celiac disease. Which of the following foods should the nurse remove from the client's meal tray?
A. Wheat toast
B. Tapioca pudding
C. Hard-boiled eggs
D. Mashed potatoes
A. Wheat toast
Retention of which electrolyte is the most life threatening effect of renal failure
Sodium
Calcium
Potassium
Phosphorus
3. Potassium
The nurse is to discontinue a NG tube that had been used for decompression. What is the first action the nurse should take?
Pull the tube out about 6 to 8 inches
Flush the tube with 10 ml of water
Remove the tape from the nose of the client
Provide oral hygiene
2. Flush the tube with 10 ml of water
The most significant complication related to continuous tube feeding is?
An interruption in fat metabolism and lipoprotein synthesis
The increased potential for aspiration
A disturbance of intestinal and hepatic metabolism
The interruption of GI integrity
2. The increased potential for aspiration
Which term best describes a total urine output less than 500 ml in 24 hours
Polyuria
Nocturia
Oliguria
dysuria
3. Oliguria
A nurse is providing instructions regarding reduced dietary intake of potassium for a client who has chronic kidney disease. Which of the following food selections is appropriate for the nurse to recommend to the client?
1. 1 cup cubed cantaloupe
2. 1 cup boiled spinach
3. 1 baked potato
4. 1 large apple
4. 1 large apple
The following appears on the medical record of a male patient receiving parenteral nutrition. which lab value is out of the normal range?
WBC: 6500/cu mm
Potassium 4.3 mEq/L
Magnesium 2.0 mg/dL
Calcium 8.8 mg/dL
Glucose 190 mg/dL
Glucose 190 mg/dL
A nurse is caring for a client who had a percutaneous endoscopic gastrostomy (PEG) tube and is receiving intermittent feedings. Prior to the initiating of the feeding, which of the following actions should the nurse take first?
Flush the tube with water
Aspirate the tube for residual contents
Place the client in semi fowler's position
Cleanse the skin around the tube site
3. Place the client in semi fowler's position
The nurse determines one or two bowel sounds in 2 minutes should be documented as?
normal
Hyperactive
hypoactive
Absent
3. hypoactive
A nurse is caring for a client immediately following a kidney transplant. The nurse should identify which of the following client findings as a possible indication of a delay in functioning of the transplanted kidney?
1. Blood pressure 110/58 mm Hg
2. Incisional tenderness
3. Pink and bloody urine
4. Urine output 30 mL/2 hr
4. Urine output 30 mL/2 hr
A nurse is caring for a client who is 2 days postoperative following a gastric bypass. The nurse notes that bowel sounds are present. Which of the following foods should the nurse provide at the initial feeding?
A. Vanilla pudding
B. Apple juice
C. Diet ginger ale
D. Clear liquids
D. Clear liquids
What is the normal adult bladder capacity?
A.50 to 100 mL
B.100 to 200 mL
C.300 to 500 mL
D.600 to 800 mL
C.300 to 500 mL
A nurse is caring for a client who is dehydrated and is receiving a continuous tube feeding through a pump at 75 mL/hr. When the nurse checks the client at 0800, which of the following findings requires intervention by the nurse?
A. A full pitcher of water sitting on the client's bedside table within the client's reach
B. The disposable feeding bag is from the previous day at 1000 and contains 200mL of feeding
C. The client is lying on the right side with a visible dependent loop in the feeding tube
D. The head of the bed is elevate 20 degrees
D. The head of the bed is elevate 20 degrees
A nurse is assisting with the care of a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following physical therapy. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for which of the following findings?
A. Hypertension
B. Excessive thirst
C. Fever
D. Diaphoresis
D. Diaphoresis
When the bladder contains 400 to 500 mL of urine, this is referred to as?
Anuria
Specific gravity
Functional capacity
Renal clearance
3. Functional capacity
A nurse is reinforcing teaching with a client who has diverticulitis about preventing an acute attack. Which of the following foods should the nurse recommend?
A. Foods high in vitamin C
B. Foods low in fat
C. Foods high in fiber
D. Foods low in calories
C. Foods high in fiber
A nurse is caring for a client who has an acute kidney injury. Which of the following laboratory findings should the nurse report to the provider?
1. serum potassium 5.0 mEq/L
2. Serum calcium 9.0 mg/dL
3. Serum creatinine 4.0 mg/dL
4. Serum amylase 84 IU/L
3. Serum creatinine 4.0 mg/dL
A patient has undergone a renal biopsy. After the test, while the patient is resting, the patient reports severe pain in the back, arms, and shoulders. Which intervention should be offered by the nurse?
Provide analgesics to the patient
Enable the patient to sit up and ambulate
Distract the patient’s attention from the pain
Assess the patient’s back and shoulder areas for signs of internal bleeding
4. Assess the patient’s back and shoulder areas for signs of internal bleeding
A nurse is checking on her patient who was admitted with a bowel obstruction. The client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occurred?
A. Elevated blood pressure
B. Bowel sounds increased in frequency and pitch
C. Rigid abdomen
D. Emesis of undigested food
C. Rigid abdomen
A 24-hour urine collection is scheduled to start at 0100. When should the nurse start the procedure?
A. At 0100, with or without a specimen
B. At the first specimen that was voided at 0400
C. 2 hours after the urine was discarded
D. After discarding the 0100 specimen
D. After discarding the 0100 specimen
A client who can’t tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, what must the nurse remain alert for?
Diaphoresis, vomiting and diarrhea
High BP, vomiting and fever
Chills, stomach pain
Right upper quadrant pain and vomiting
1. Diaphoresis, vomiting and diarrhea
A nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure?
A. Prothrombin time
B. Serum lipase
C. Bilirubin
D. Calcium
A. Prothrombin time