NUR 2032 Exam 3 Study Guide Chapters 26, 27, 28, 34, 47, 48, 49

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NUR 2032 Exam 3 Study Guide Chapters 26, 27, 28, 34, 47, 48, 49 Chapters 26, 27, 28, 34, 47, 48, 49 1 NUR 2032 Exam 3 Study Guide Chapter 26 Kozier & Erb‘s Fundamentals of Nursing, 10/E Chapte... r 26 Question 1 A nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. On what should the nurse focus to improve communication skills? 1. Pace 2. Intonation 3. Simplicity 4. Clarity Rationale 3: Simplicity includes the use of commonly understood words, brevity, and completeness. A ―bowel prep‖ may be completely meaningless to a client, but telling him that he needs to drink a gallon of laxative-like medication gets the point across better. Esophagogastroscopy is a complicated word. Using words like ―small camera looking down your throat into your stomach‖ will make much more sense to the client. Question 2 The nurse observes during a dressing change that the client‘s wound has become infected. When asked by the client how the wound looks, the nurse says ―it looks fine‖ but the nurse‘s facial expression doesn‘t support the response. Which aspect of communication should this nurse improve? 1. Adaptability 2. Credibility 3. Timing and relevance 4. Clarity and brevityChapters 26, 27, 28, 34, 47, 48, 49 2 Rationale 1: Adaptability is adjusting tone of speech and facial expression to match the spoken message. Clearly, if the nurse‘s face doesn‘t match his words, the client will identify a problem with the situation. Question 3 A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The client‘s spouse is in the room when the code team arrives. Which statement by the nurse to the spouse is the best in this situation? 1. ―I know you‘re worried about your loved one. I‘m sure this is a difficult situation for you. Do you have any questions right now?‖ 2. ―Your spouse‘s heart stopped. All these people are here to help get it started.‖ 3. ―Your spouse‘s physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now.‖ 4. ―Is there someone you would like to call? I‘m sure this is a scary situation and you may feel more comfortable if someone were with you during this time.‖ Rationale 2: Clarity and brevity provide a message that is simple and clear. Question 4 The nurse enters a client‘s room and finds that the telephone is lying in the client‘s lap, tissues are wadded up on the bed, and the client‘s eyes are red and watery. What is the best response by the nurse? 1. ―Can I hang that phone up for you?‖ 2. ―Well, it‘s a beautiful day outside. Let‘s open the blinds.‖ 3. ―Has your doctor been in to talk to you yet?‖ 4. ―You look upset. Is there anything you‘d like to talk about?‖ Rationale 4: Nonverbal communication, or body language, often tells the nurse more about what a person is feeling than what is actually said. The interpretation of such observations requires validation with the client. Question 5Chapters 26, 27, 28, 34, 47, 48, 49 3 A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate? 1. ―If you look better, you might feel better.‖ 2. ―Taking a shower might wash away some of that gloom and doom.‖ 3. ―This is a positive sign. I‘ll be right back with your supplies.‖ 4. ―Your spouse will be glad to see that you‘re feeling better.‖ Rationale 3: How a person dresses or looks may be an indicator of how the person feels. A change in grooming habits may signal that the client is feeling better. Question 6 A nurse is working in a pediatric clinic and has to explain a nebulizer treatment to a child. Which approach should the nurse use? 1. Give the child‘s parent a full explanation, but make sure the child hears what is said. 2. Let the child handle the equipment first, then demonstrate on the child‘s doll. 3. Start the treatment, but make sure that the parent is there to comfort the child if she becomes afraid. 4. Make sure that the physician is available for questions. Rationale 2: The knowledge of the client‘s developmental stage will allow the nurse to modify the message accordingly. The use of dolls and games with simple language may help explain a procedure to a child. Question 7 A nurse is giving a demonstration of new equipment to the rest of the nursing unit. Which level of proxemics should the nurse use? 1. Intimate 2. Personal 3. Social 4. PublicChapters 26, 27, 28, 34, 47, 48, 49 4 Rationale 3: Social distance is characterized by a clear, visual perception of the whole person and generally 4 to 12 feet in distance. Social distance is important in accomplishing the business of the day. It is expedient in communicating with several people at the same time or within a short time, which would be the case in this situation. Question 8 A nurse must perform a catheterization on a male client. Which zone of proximity should the nurse use for this intervention? 1. Personal distance 2. Intimate distance 3. Social distance 4. Public distance Rationale 2: Intimate distance is characterized by body contact and used frequently by nurses when they are required to perform a procedure. Distance in this category is touching to 11/2 feet. Question 9 A nurse enters a client‘s room and asks about his level of pain. The client, grimacing, says ―It‘s fine.‖ Which communication factor is the client struggling with? 1. Territoriality 2. Environment 3. Congruence 4. Attitude Rationale 3: In congruent communication, the verbal and nonverbal aspects of the message match. Saying his pain level is ―fine,‖ but then showing with facial grimacing that it is not, would be in conflict. Question 10 A nurse is working with an elderly male client on a medical unit. Which statement demonstrates elderspeak by the nurse? 1. ―It‘s time for us to go to physical therapy.‖Chapters 26, 27, 28, 34, 47, 48, 49 5 2. ―I think it would be better if you were planning to go to a nursing home after discharge.‖ 3. ―Your children must really love their dad.‖ 4. ―Your wife must be having trouble adjusting to your illness.‖ Rationale 1: Elderspeak is a speech style, similar to baby, talk that gives a message of dependence and incompetence to older adults. Characteristics of elderspeak include inappropriate terms of endearment, inappropriate plural pronoun use (it‘s time for us to go to physical therapy), tag questions, and slow, loud speech. Question 11 A client has just lost her second baby to preterm complications. Which statement demonstrates the best therapeutic response for the nurse to make? 1. ―Don‘t be so sad. You can always try again.‖ 2. ―Didn‘t your doctor advise you about genetic counseling?‖ 3. ―I know how you feel. I have children of my own.‖ 4. ―I am so sad for you. I‘ll stay with you for a while if you need to talk.‖ Rationale 4: Therapeutic communication promotes understanding and is client directed. Nurses need to respond to the feelings expressed by the client. Sometimes clients need time to deal with their feelings and the best thing the nurse can provide is presence and listening. Question 12 The nurse is conducting an admission interview. Which response indicates that the nurse is attentively listening to the client‘s explanations? 1. ―Can you explain what your symptoms are like?‖ 2. ―When was the last time you saw a doctor for this?‖ 3. ―Uh-huh,‖ while nodding the head 4. ―I‘m sorry, say that again?‖ Rationale 3: A nurse can convey attentiveness in listening to clients in various ways. Common responses are nodding the head, uttering ―uh-huh‖ or ―mmm,‖ repeating the words the client has used, or saying ―I see what you mean.‖Chapters 26, 27, 28, 34, 47, 48, 49 6 Question 13 The nurse is engaging a client in the introductory phase of the helping relationship. Which stages will be completed during this phase? Standard Text: Select all that apply. 1. Opening the relationship 2. Clarifying the problem 3. Structuring and formulating the contract 4. Planning before the interview 5. Understanding thoughts and feelings Rationale 1: The introductory phase, also referred to as the orientation phase or prehelping phase, sets the tone for the rest of the relationship. The relationship opens during this phase. Rationale 2: The introductory phase, also referred to as the orientation phase or prehelping phase, sets the tone for the rest of the relationship. Clarifying the problem occurs during this phase. Rationale 3: The introductory phase, also referred to as the orientation phase or prehelping phase, sets the tone for the rest of the relationship. Structuring and formulating the contract occurs during this phase. Question 14 During an interaction between a nurse and client, the nurse conveys respect and an attitude that shows the nurse takes the client‘s opinions seriously. In which stage of the working relationship are the nurse and client engaged? 1. Exploring and understanding thoughts and feelings 2. Facilitating and taking action 3. Confrontation 4. Concreteness Rationale 1: The working phase has two major stages. Exploring and understanding thoughts and feelings would occur during the working relationship. Question 15Chapters 26, 27, 28, 34, 47, 48, 49 7 Several nurses have been assigned to develop a rotation schedule that provides adequate staffing of all shifts. In which type of group are these nurses functioning? 1. Self-help group 2. Task group 3. Teaching group 4. Therapy group Rationale 2: The task group is one of the most common types of work-related groups to which nurses belong. The focus of such groups is the completion of a specific task. Question 16 The nurse is identifying communication strategies for a client unable to speak. What would be appropriate for the client in this situation? 1. Using a picture board to facilitate communication 2. Facing the client when speaking 3. Employing an interpreter 4. Making sure that the language spoken is the client‘s dominant language Rationale 1: The picture board would be of assistance because it does not rely on verbal communication. Question 17 A nurse needs to evaluate the effectiveness of a teaching session with a client. Which approach would provide the best feedback? 1. Client communication 2. Process recording 3. Therapeutic communication 4. Verbal communication Rationale 2: A process recording is a word-for-word account of a conversation. It includes all verbal and nonverbal interactions of both the client and nurse. It would be appropriate to use for evaluating the effectiveness of a teaching session.Chapters 26, 27, 28, 34, 47, 48, 49 8 Question 18 During a health history, a client admits to taking nutritional supplements instead of prescribed medication. Which responses by the nurse indicate effective communication? Standard Text: Select all that apply. 1. ―What you did was wrong.‖ 2. ―Who do you think you are?‖ 3. ―You shouldn‘t have done that.‖ 4. ―Tell me more about the supplements.‖ 5. ―Explain the reasoning behind your decision.‖ Rationale 4: Asking the client to tell more about the supplements is an open-ended statement and encourages communication. Rationale 5: Asking the client to explain the reasoning behind the decision is an open-ended statement and encourages communication. Question 19 The nurse needs to communicate information about a client‘s status to a physician. Which approach demonstrates assertive communication by the nurse? 1. ―You need to check the laboratory results of the client in room 423.‖ 2. ―You should visit with the client‘s family about the upcoming procedure.‖ 3. ―We need to be more aware of the situation among the client and the client‘s family.‖ 4. ―I am concerned that the client does not have adequate pain management.‖ Rationale 4: An important characteristic of assertive communication includes the use of ―I‖ statements versus ―you‖ statements. ―I‖ statements encourage discussion. Question 20 The nurse wants to gain information about a client‘s situation. Which question should the nurse use to maximize communication with this patient?Chapters 26, 27, 28, 34, 47, 48, 49 9 1. ―What brings you to the hospital?‖ 2. ―Are you having pain?‖ 3. ―Does your pain feel better or worse today?‖ 4. ―Is there anything I can do for you?‖ Rationale 1: An open-ended question is one that cannot be answered with a simple yes/no or a oneword response. Often they begin with the words What, Describe for me, Explain, or Tell me about…. Question 21 The nurse is communicating with an older client. Which actions demonstrate that the nurse understands the best approaches to communicate with this client? Standard Text: Select all that apply. 1. Asking, ―What can I do to make you feel safe?‖ 2. Observed intently listening to the client describe how being alone makes her feel 3. Offering to take the client ―out for a walk‖ 4. Consistently arranging for the client to have her hair done 5. Managing to get a copy of the client‘s favorite magazine Rationale 1: Good communication with the client will result in knowing what makes a difference to her. With this valuable knowledge, the nurse can reduce vulnerability and enhance the quality of life. Rationale 2: Good communication with the client will result in knowing what makes a difference to her. With this valuable knowledge, the nurse can reduce vulnerability and enhance the quality of life. Rationale 5: Good communication with the client will result in knowing what makes a difference to her. With this valuable knowledge, the nurse can reduce vulnerability and enhance the quality of life. Question 22 The nurse is beginning a helping relationship with a newly admitted client. Which behaviors should the nurse demonstrate that support this type of relationship? Standard Text: Select all that apply. 1. Becoming familiar with the client‘s social history by reading the admission interviewChapters 26, 27, 28, 34, 47, 48, 49 10 2. Orienting the client to the physical layout of the facility as well as to the facility‘s policies 3. Gaining the client‘s trust by consistently keeping promises to return and ―visit‖ 4. Respecting the client‘s wish to be alone after hearing about the loss of a family friend 5. Asking to remain with the client when he is experiencing symptoms of the flu Rationale 1: A caring relationship consists of four phases; preparing for the relationship is part of the pre-interaction phase. Rationale 3: A caring relationship consists of four phases; gaining trust is part of the introductory phase. Rationale 4: A caring relationship consists of four phases; showing respect for a client and his wishes is part of the ongoing maintaining phase. Rationale 5: A caring relationship consists of four phases; showing concern for a client and his wishes is part of the ongoing maintaining phase. Question 23 The graduate nurse is thinking about leaving a new job because of actions demonstrated by the nurse manager. Which actions should the graduate nurse identify as bullying? Standard Text: Select all that apply. 1. Pairing the graduate with a seasoned nurse to assist with learning new skills 2. Asking the graduate to participate in client rounds with the new interns on the care area 3. Confronting the graduate by stating that refusing an assignment is grounds for dismissal 4. Stating that requests for vacation time will be denied because the nurse asks too many questions 5. Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing Rationale 3: Confronting the graduate by stating that refusing an assignment is grounds for dismissal is bullying behavior. It is intended to intimidate the graduate. Rationale 4: Stating that requests for vacation time will be denied because the nurse asks too many questions is bullying behavior. It is intended to humiliate the graduate. Rationale 5: Assigning the graduate nurse a complicated client with needs that the graduate is not comfortable performing is bullying behavior. It is intended to degrade and undermine, and creates a risk to the safety of a client.Chapters 26, 27, 28, 34, 47, 48, 49 11 Chapter 27 Kozier & Erb‘s Fundamentals of Nursing, 10/E Chapter 27 Question 1 The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance? 1. ―I‘m glad to know about my medications. It makes taking them a lot easier.‖ 2. ―I already knew most of what you told me.‖ 3. ―I think you should have waited until I was ready to go home. Maybe I‘d remember better.‖ 4. ―If I take my medications as prescribed, I‘ll feel better.‖ Rationale 1: Compliance is best illustrated when the person recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why they‘re prescribed and improves the possibility for following the prescribed regimen. Question 2 A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information? 1. Past statistics about organ donors 2. Written pamphlets 3. Directions about how to become an organ donor 4. Information on how this group can influence their children Rationale 3: An adult is more oriented to learning when the material is useful immediately, not sometime in the future. For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities such as influencing their children. Question 3Chapters 26, 27, 28, 34, 47, 48, 49 12 The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning? 1. Thorndike‘s behaviorism 2. Skinner‘s positive reinforcement 3. Pavlov‘s conditioning response 4. Bandura‘s imitation Rationale 4: Bandura claims that most learning comes from observation and instruction. Imitation is the process by which individuals copy or reproduce what they have observed. Question 4 A nursing student is presenting a teaching project to the class using each of Bloom‘s domains. The student has several activities included in the project. Which activity is an example of the affective domain? 1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education. 2. All members must list the technical skills they‘ve learned. 3. Members must demonstrate a favorite nursing skill at the end of the class period. 4. Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class. Rationale 1: The affective domain of Bloom‘s theory of learning is also known as the ―feeling‖ domain. It includes emotional responses to tasks such as feelings, emotions, interests, attitudes, and appreciations. Question 5 A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. When mastering the use of this device, the client will demonstrate learning in which of Bloom‘s domains? 1. Cognitive 2. Psychomotor 3. AffectiveChapters 26, 27, 28, 34, 47, 48, 49 13 4. Imitation Rationale 2: The psychomotor domain is the ―skill‖ domain and includes motor skills, such as being able to use an incentive spirometer. Question 6 A nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which client exhibits the highest motivation? 1. An individual who has been struggling with following nursing directives regarding discharge goals 2. The client who has just moved in and is already waiting for discharge 3. A client who is excited to learn about his new prosthesis 4. A client who has been there the longest and is a great ―coach‖ for newcomers Rationale 3: Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally greatest when a person recognizes a need and believes the need will be met through learning. The client who is excited to learn about his prosthesis understands that learning about it will help take his recovery to a high level. Question 7 A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny babies while they are still in the hospital. Which statement by a parent reflects a readiness to learn? 1. ―I‘m so afraid I‘ll hurt my baby with all these tubes.‖ 2. ―I want to make sure my spouse is here, in case I don‘t hear everything that‘s said.‖ 3. ―When my baby is just a little bigger, I‘ll be able to handle him.‖ 4. ―You‘ll give us written instructions before we go home, correct?‖ Rationale 2: Readiness to learn is the demonstration of behaviors or cues that reflect a learner‘s motivation, desire, and ability to learn at a specific time. The client who wants the spouse involved is demonstrating motivation and willingness, but also wants support from the spouse as well. Question 8 The nurse is instructing a client on self-administration of insulin. Which statement regarding feedback will be most beneficial to the client?Chapters 26, 27, 28, 34, 47, 48, 49 14 1. ―You know, there are children who can learn to do this.‖ 2. ―Maybe it would be better if we taught your spouse to help you with this.― 3. ―Next time, dart the needle in your skin, instead of pushing it in.‖ 4. ―If you don‘t learn this, you can‘t be discharged.‖ Rationale 3: Feedback should be meaningful to the learner and should support the desired behavior through praise, positively worded corrections, and suggestions of alternative methods. Question 9 A home health client having difficulty keeping his medication schedule organized says ―There are so many pills and the names are all confusing to me. I don‘t even understand what they‘re for.‖ What should the nurse do? 1. Help the client remember color and size in relationship to dosing time. 2. Write out the generic and trade name of all the pills for the client. 3. Fill a pill bar and tell the client not to worry, and just take the pills according to that system. 4. Have the physician talk to the client about his medications. Rationale 1: Learning is facilitated by material that is logically organized and proceeds from the simple to the complex. This helps the learner comprehend new information, apply it to previous learning, and form new understandings. Naming the pills by color and size and dosing time helps the client move from that level to learning what each medication is for and why he is taking it—simple to complex. Question 10 At the end of a busy clinical day a staff nurse asks the instructor if a student would like to administer a Z-track injected medication. This is a skill that the students have not yet been exposed to yet. What should the instructor respond to the staff nurse that supports timing and learning environment? 1. ―It will take me a moment to explain the procedure to the students because we‘ve not practiced this, but I‘ll find somebody to administer it.‖ 2. ―Would it be OK if the students observed today? Then, we‘ll do it next time we‘re here.‖ 3. ―We‘re leaving now, but thanks for asking.‖ 4. ―I‘ll check with the students and see if one of them would like to volunteer.‖Chapters 26, 27, 28, 34, 47, 48, 49 15 Rationale 2: Allowing them to observe the staff nurse, then coming back when they are more refreshed would allow a better learning experience for the students. Question 11 A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching? 1. ―It‘s going to take time for me to understand this whole thing.‖ 2. ―Let‘s make sure my spouse is around before you start explaining.‖ 3. ―I wish my doctor would have explained this more in depth.‖ 4. ―I‘m feeling nauseous, but go ahead and start anyway.‖ Rationale 4: Learning can be inhibited by physiologic events such as illness, pain, or sensory deficits. The client must be able to concentrate and apply adequate energy to the learning or the learning itself will be impaired. If the client is experiencing nausea, the nurse should first try to reduce this symptom before beginning the teaching session. Question 12 A nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should 1. provide written instructions before discharge. 2. address any healing beliefs the family has. 3. make sure the child comes back for the follow-up appointment. 4. make sure the parents can set up the treatments for their child. Rationale 2: If the prescribed treatment conflicts with the client/family‘s cultural healing beliefs, the client may not be compliant with the recommended treatments. To be effective, nurses must deal directly with any conflicts and differing values held by the client. Question 13 A client who is legally blind requires vitamin B12 injections every 2 weeks and insists on selfadministration. What is the best way for the nurse to assist this client?Chapters 26, 27, 28, 34, 47, 48, 49 16 1. Teach the spouse to draw up the medication, then the client can give the injection. 2. Make sure that the injection is scheduled during a visit, so the nurse can supervise. 3. Prefill syringes with the correct dose, so the client can use them for self-administration. 4. Schedule the client‘s clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic. Rationale 3: Clients who have visual impairment may need the assistance of a support person or creative care in order to remain compliant with their treatment. Because the client insists on selfadministration, prefilling syringes (and keeping them away from light and heat) would be a plausible solution. The client is concerned with independence, and allowing the client to maintain that would be quite important. Question 14 A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client‘s motivation to learn? 1. Demonstrating the finger stick on the nurse 2. Offering to do the procedure for the client each time it is scheduled 3. Teaching the client‘s support system how to perform the procedure 4. Encouraging the client‘s participation each time the procedure is performed Rationale 4: Nurses can increase a client‘s motivation in several ways, including encouragement of self-direction and independence. Question 15 The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that 1. information given to this group is written at a third-grade level. 2. teaching includes a variety of approaches. 3. information includes pictures. 4. there is ample time for teaching.Chapters 26, 27, 28, 34, 47, 48, 49 17 Rationale 4: When working with the older population, the nurse must realize that increased time for teaching is necessary because processing of information is slower. Health literacy skills are often limited in older adults. Question 16 A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: ―I‘m never going to understand what to do, when to do it, and why I should be doing all these things.‖ Which nursing diagnosis should the nurse formulate for this client? 1. Health-Seeking Behavior related to desire to prevent heart problems 2. Deficient Knowledge (diet and medication regimen) related to inexperience 3. Noncompliance related to situational factors 4. Risk for Myocardial Infarction related to deficient knowledge Rationale 2: The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis. Question 17 The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client? 1. Client will understand the importance of eating healthy. 2. Client will be able to lose weight. 3. Client will list foods that are nutritionally sound, low fat, and high fiber. 4. Client will appreciate the value of using the Food Guide Pyramid. Rationale 3: Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Question 18 A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority?Chapters 26, 27, 28, 34, 47, 48, 49 18 1. Client will be able to set up and administer a nebulizer treatment by the end of the day. 2. Client will have increased activity level by the end of the week. 3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days. 4. Client will have a positive attitude about the diagnosis by the end of the month. Rationale 1: Learning outcomes state the client behavior and are ranked according to priority. Nurses can use theoretical frameworks such as Maslow‘s hierarchy of needs to establish priorities. In this case, the physiological need of learning how to administer medication takes priority over activity and attitudinal needs. Question 19 A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group? Standard Text: Select all that apply. 1. Based on learning outcomes 2. Current 3. Adjusted to the adolescent client 4. Based on sources available within the school system 5. Consistent with the teaching topics Rationale 1: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be based on learning outcomes. Rationale 2: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be current. Rationale 3: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be adjusted to the learner‘s age. Rationale 5: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be consistent with the information that the nurse is teaching.Chapters 26, 27, 28, 34, 47, 48, 49 19 Question 20 The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. When organizing the teaching/learning experience, the nurse should 1. start from the beginning and proceed through all material. 2. break up sessions into shortened time periods. 3. discover what the learner knows before proceeding with further teaching. 4. make sure the client‘s spouse is present before the teaching session begins. Rationale 3: Nurses should save time in constructing their own teaching sessions and should follow basic guidelines when sequencing the learning experience. The nurse should find out what the learner knows, and then proceed to the unknown. This gives the learner confidence. This information can be elicited either by asking questions or by having the client take a pretest or fill out a form. Question 21 A client needs discharge teaching regarding the use of a walker before going home. The client‘s room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do? 1. Wait until just prior to discharge, then do the teaching in the hospital lobby. 2. Close the door to the client‘s room and make sure there is no clutter on the floor before the teaching session begins. 3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the client‘s room. 4. Make sure a physical therapist is available to do the teaching and can see the client before discharge. Rationale 3: Going to a larger area and then evaluating the learning by watching the client ambulate back to the room would be the best way to implement teaching in this particular situation. Question 22 A community health nurse runs a clinic that provides health screening to mainly Mexican American and Native American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. In order to adjust to their time orientation, what is the best action of the nurse? 1. Make sure that the classes are held at specific times.Chapters 26, 27, 28, 34, 47, 48, 49 20 2. Begin classes when a group of clients are gathered. 3. Mail letters ahead of time to make sure clients are informed about the upcoming class. 4. Make posters and place them in areas of the community frequented by these groups. Rationale 2: The nurse must be quite flexible, treat the culture‘s beliefs with respect, and not expect that cultural practices will change to reflect the nurse‘s needs. Question 23 At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation? 1. Shared by the nurse and client 2. A return demonstration by the client 3. When the nurse is satisfied that the client can complete the technique 4. If the wound heals Rationale 1: Both the client and the nurse should evaluate the learning experience. The client can tell the nurse what was helpful and provide a demonstration that shows mastery of the skill. The nurse needs to evaluate whether the client has an understanding of the rationale behind the technique. Question 24 The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information? Standard Text: Select all that apply. 1. Diagnosed learning needs 2. Supplies required 3. Client outcomes 4. Need for additional teaching 5. Topics taughtChapters 26, 27, 28, 34, 47, 48, 49 21 Rationale 1: The parts of the teaching process that should be documented in the client‘s chart include diagnosed learning needs. Rationale 3: The parts of the teaching process that should be documented in the client‘s chart include client outcomes. Rationale 4: The parts of the teaching process that should be documented in the client‘s chart include need for additional teaching. Rationale 5: The parts of the teaching process that should be documented in the client‘s chart include topics taught. Question 25 When making an assessment of the client‘s learning needs, the nurse will focus on which elements? Standard Text: Select all that apply. 1. Nurse‘s own knowledge 2. Client‘s age 3. Client‘s understanding of health problem 4. Sensory acuity 5. Learning style Rationale 2: The client‘s age provides information on the person‘s developmental status that might indicate health teaching content and teaching approaches. Rationale 3: The client‘s understanding of health problems might indicate deficient knowledge or misinformation. Rationale 4: Sensory acuity is part of the psychomotor ability of which the nurse must be aware when planning a teaching session. Rationale 5: Learning style identifies the client‘s best way to learn so that the nurse can adapt teaching accordingly. Question 26 A school nurse is planning a program for adolescents about positive lifestyle choices. The nurse should keep in mind that content presented to this age group must be Standard Text: Select all that apply.Chapters 26, 27, 28, 34, 47, 48, 49 22 1. based on learning outcomes. 2. current. 3. adjusted to the adolescent client. 4. based on sources available within the school system. 5. accurate. Rationale 1: Whatever sources the nurse chooses, content should be based on learning outcomes. Rationale 2: Whatever sources the nurse chooses, content should be current. Rationale 3: Whatever sources the nurse chooses, content should be adjusted to the learners‘ age. Rationale 5: Whatever sources the nurse chooses, content should be accurate. Question 27 A client is being discharged after a 23-hour stay for a surgical procedure. When preparing the instructions for this client, what does the nurse need to do? Standard Text: Select all that apply. 1. Ensure the client‘s safe transition to home. 2. Include information about what the client has been taught. 3. Include what the client still needs to learn when discharged. 4. Check the client‘s insurance for hospitalization coverage. 5. Call the client‘s prescriptions in to the client‘s local pharmacy. Rationale 1: Because of decreased lengths of stay, time constraints on client education can occur. The nurse needs to provide education that will ensure the client‘s safe transition to home. Rationale 2: Discharge plans must include information about what the client has been taught. Rationale 3: Discharge plans must include what the client still needs to learn when discharged. Question 28Chapters 26, 27, 28, 34, 47, 48, 49 23 The nurse serves as an educator of other health care personnel. In what capacity will this nurse participate in education? Standard Text: Select all that apply. 1. Preceptor of new graduate nurses 2. Instructing a part of the critical care course 3. Clinical instruction of nursing students 4. One-to-one teaching of clients 5. Teaching grandparents how to care for children Rationale 1: Nurses are involved in the instruction of professional colleagues, such as functioning as preceptors for new graduate nurses. Rationale 2: Nurses with specialized knowledge and experience may share that knowledge and experience with nurses by instructing a part of the critical care course. Rationale 3: Nurses in nursing practice settings are often involved in the clinical instruction of nursing students. Question 29 The nurse planning an educational session for adult clients should include which andragogy concepts? Standard Text: Select all that apply. 1. People move from dependence to independence with maturity. 2. Previous experiences can be used as a resource for learning. 3. Learning is related to an immediate need or problem. 4. Learning is reinforced by prompt feedback. 5. Adults are oriented to learning when the material is useful sometime in the future. Rationale 1: An andragogy concept about adult learners is that as people mature, they move from dependence to independence. Rationale 2: An andragogy concept about adult learners is that an adult‘s previous experiences can be used as a resource for learning.Chapters 26, 27, 28, 34, 47, 48, 49 24 Rationale 3: An andragogy concept about adult learners is that learning is related to an immediate need or problem. Rationale 4: An andragogy concept about adult learning is that learning is reinforced by prompt feedback. Question 30 The nurse is utilizing humanistic theory when instructing a client. What will the nurse demonstrate when utilizing this theory? Standard Text: Select all that apply. 1. Empathy 2. Encouraging the client to establish goals 3. Encouraging the client to participate in self-directed learning 4. Multisensory teaching strategies 5. Providing a physical environment conducive to learning Rationale 1: Conveying empathy is a characteristic of humanism. Rationale 2: Encouraging the client to establish goals is a characteristic of humanism. Rationale 3: Encouraging the client to participate in self-directed learning is a characteristic of humanism. Question 31 A client tells the nurse that he has no questions about his illness, as he did a search for information on the Internet. What should the nurse do? 1. Ask the client to share the information obtained from the Internet search. 2. Document that the client has received instruction. 3. Tell the client that the Internet is a form of entertainment, not instruction. 4. Document that the client refused instruction. Rationale 1: The Internet is an important source of health information for many adult clients in the United States. Nurses need to know and be able to integrate this technology into the teaching plansChapters 26, 27, 28, 34, 47, 48, 49 25 for those clients who use the Internet. The nurse should ask the client to share the information obtained from the Internet search in order to integrate the content into the client‘s teaching plan. Question 32 The nurse instructs the older client to access the Internet to complete a post-hospitalization survey and update health information. The client tells the nurse that he does not have a computer and would not know how to use one. What should the nurse do? Standard Text: Select all that apply. 1. Suggest the client learn how to use a computer through classes held at a local library. 2. Provide times for the client to attend basic computer use classes through the community learning center. 3. Document that the client is resistant to instruction. 4. Notify the physician that the client will not be adhering to medical instruction as planned. 5. Identify the client as being noncompliant with instruction. Rationale 1: The older client might not own a computer or have Internet access. The nurse could suggest that the client learn how to use a computer through classes held at a local learning center. Rationale 2: The nurse should provide times for the older client to attend basic computer use classes though the community learning center. Question 33 The nurse suspects a client has low literacy. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Incorrect completion of previous hospitalizations form 2. Client refusing to sign forms because eyeglasses are at home 3. Client saying he forgot to report for laboratory testing 4. Score of 6 on the Newest Vital Sign assessment tool 5. Questioning the dosage pattern on a newly prescribed medication Rationale 1: The nurse should suspect a literacy problem when a client incorrectly completes forms.Chapters 26, 27, 28, 34, 47, 48, 49 26 Rationale 2: The nurse should suspect a literacy problem when a client refuses to sign forms because of lack of eyeglasses. Rationale 3: The nurse should suspect a literacy problem when appointments are missed. Question 34 The nurse is designing a teaching plan for a client to learn a new psychomotor skill. What strategies can the nurse use to facilitate learning for this client? Standard Text: Select all that apply. 1. Demonstration 2. Practice 3. Modeling 4. Discovery 5. Role playing Rationale 1: Demonstration is used to learn a psychomotor skill. Rationale 2: Practice is used to learn a psychomotor skill. Rationale 3: Modeling is used to learn a psychomotor skill. Question 35 The nurse instructs a client on self-care for a new ostomy. Which client behaviors demonstrate that instruction has been effective? Standard Text: Select all that apply. 1. Client provides skin care and changes ostomy device. 2. Client states what items are needed to perform ostomy care. 3. Client is unable to identify changes in skin around the stoma. 4. Client tells the nurse that he does not want to do the care. 5. Client asks his wife to learn how to perform the care so he will not have to do it.Chapters 26, 27, 28, 34, 47, 48, 49 27 Rationale 1: The acquisition of psychomotor skills is best evaluated by observing how well the client carries out a procedure such as self-care for an ostomy. Rationale 2: In cognitive learning, the client demonstrates acquisition of knowledge by responding appropriately to oral questions. Question 36 The nurse is documenting the teaching plan for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Actual information to be taught 2. Teaching strategies to use 3. Skills to be taught 4. Amount of time needed to teach each topic 5. Vital signs before and after each teaching session Rationale 1: The written teaching plan that the nurse uses to guide future teaching sessions can include the actual information to be taught. Rationale 2: The written teaching plan that the nurse uses to guide future teaching sessions can include the teaching strategies to use. Rationale 3: The written teaching plan that the nurse uses to guide future teaching sessions can include the skills to be taught. Rationale 4: The written teaching plan that the nurse uses to guide future teaching sessions can include the amount of time needed to teach each topic. Question 37 The nurse has completed a teaching session for a client with a tracheostomy. What should the documentation include? Standard Text: Select all that apply. 1. Diagnosed learning needs 2. Supplies requiredChapters 26, 27, 28, 34, 47, 48, 49 28 3. Client outcomes 4. Need for additional teaching 5. Topics taught Rationale 1: The parts of the teaching process that should be documented in the client‘s chart include diagnosed learning needs. Rationale 3: The parts of the teaching process that should be documented in the client‘s chart include client outcomes. Rationale 4: The parts of the teaching process that should be documented in the client‘s chart include need for additional teaching. Rationale 5: The parts of the teaching process that should be documented in the client‘s chart include topics taught. Question 38 The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this client‘s plan? Standard Text: Select all that apply. 1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 4. The evaluation of the effectiveness of teaching 5. The amount of time needed to cover the content Rationale 1: Elements of a teaching plan include the content. Rationale 2: Elements of a teaching plan include learning outcomes. Rationale 4: Evaluation of the effectiveness of the teaching occurs after the teaching has been completed. Rationale 5: Elements of a teaching plan include the time frame needed for teaching. Question 39Chapters 26, 27, 28, 34, 47, 48, 49 29 The nurse is preparing to teach a client on skin care and application of a stoma device. What should the nurse keep in mind when teaching the client this information? Standard Text: Select all that apply. 1. Address the client‘s concerns first. 2. Assess what the client knows already. 3. Address anxiety–producing issues last. 4. Teach the basics before complicated tasks. 5. Leave time for review and answering questions. Rationale 1: The nurse should start with something that the client is concerned about. Rationale 2: The nurse should assess what the client knows and then proceed to the unknown. This gives the learner confidence. Rationale 4: The nurse should teach the basics before proceeding to variations, adjustments, or complicated steps. Rationale 5: The nurse should schedule time for the review of content and any questions the client may have to clarify information. Chapter 28 Kozier & Erb‘s Fundamentals of Nursing, 10/E Chapter 28 Question 1 According to the National Council of State Boards of Nursing (NCSBN), which ―rights‖ of delegation should the nurse follow? Standard Text: Select all that apply. 1. Supervision 2. Evaluation 3. Client 4. TimeChapters 26, 27, 28, 34, 47, 48, 49 30 5. Task Rationale 1: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Rationale 2: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Rationale 5: According to the NCSBN, the nurse delegates the right task under the right circumstances to the right person with the right direction and communication and the right supervision and evaluation. Question 2 An unlicensed assistive person (UAP) is working on a rehabilitation unit. Which task would be appropriate for this person to delegate? 1. Taking and recording vital signs 2. Assisting with bathing 3. Making a bed 4. An unlicensed assistive person may not delegate tasks. Rationale 4: The unlicensed person may not delegate tasks to another person. Delegation is part of the registered nurse‘s role. Question 3 An RN delegates the task of taking a newly admitted client‘s vital signs to a nurse‘s aide. The client‘s blood pressure was 182/98, but did not get reported to the physician for several hours. Who is responsible for the lapse in time between discovery and action? 1. Nurse manager 2. Aide 3. Client 4. RNChapters 26, 27, 28, 34, 47, 48, 49 31 Rationale 4: The RN is ultimately responsible for the action, for reporting it, and for following through on any action. Part of delegation is supervision and evaluation—ultimate responsibilities that belong to the RN. Question 4 A nurse manager has the reputation of being an autocratic leader. Which of the following statements by this manager would support that reputation? 1. ―I‘d like to hear from you (addressing the staff) what your ideas are for promoting better morale in this unit.‖ 2. ―I‘m putting a suggestion box in the break room if anyone has ideas that would be helpful to the unit.‖ 3. ―The new work schedule is posted for the next 6 weeks.‖ 4. ―I put the new procedure manual out. Please add your comments to the blank sheet of paper attached to the front.‖ Rationale 3: An autocratic leader makes decisions for the group. This style is likened to a dictator in that the autocratic leader gives orders and directions to the group, determines policies, and solves problems without input from the group. Question 5 During a particularly heated staff meeting regarding staff assignments, the nurse manager makes this comment: ―When you all can come to a decision, let me know and we‘ll move on from there.‖ This leader is best identified as which of the following? 1. Democratic leader 2. Permissive leader 3. Bureaucratic leader 4. Situational leader Rationale 2: The permissive leader recognizes the group‘s need for autonomy and self-regulation by assuming a ―hands-off‖ approach. Allowing the group to come to its own decision and then accepting that decision reflects the style of a permissive leader. Question 6Chapters 26, 27, 28, 34, 47, 48, 49 32 A nurse manager allows the staff members to make their own schedules and do their own client assignments on their shifts. However, during a code situation, the nurse manager will make decisions for the staff by instructing which nurse to assume which responsibility. This manager is exemplifying which style of leadership? 1. Permissive 2. Democratic 3. Situational 4. Bureaucratic Rationale 3: According to contingency theorists, effective leaders adapt their leadership style to the situation. Unlike the singular style of authoritarian, democratic, and permissive leaders, the situational leader adapts his or her leadership to the readiness and willingness of the group to perform the assigned task. Question 7 A group of community health nurses work together in the same office. They are each responsible for their own caseloads and scheduling of appointments. Their major leadership directives come from the state health office, several hundred miles away. This group of nurses is functioning under what type of leadership? 1. Charismatic 2. Shared 3. Transformational 4. Transactional Rationale 2: Shared leadership recognizes that a professional workforce is made up of many leaders. No one person is considered to have knowledge or ability beyond that of other members of the work group, as in this situation. Question 8 A charge nurse‘s responsibilities include the day-to-day management and coordination of therapies for the clients, client assignments, and scheduling. Which type of management is the charge nurse performing? 1. Top level 2. Middle levelChapters 26, 27, 28, 34, 47, 48, 49 33 3. First level 4. Upper level Rationale 3: First-level managers are responsible for managing the work of nonmanagerial personnel and the day-to-day activities of a specific work group (rehabilitation unit in this case). Question 9 Type: SEQ The nurse manager is implementing risk management for a client-care issue. In what order will the manager implement risk management? Standard Text: Click and drag the options below to move them up or down. Choice 1. Analyzing, classifying, and prioritizing risks Choice 2. Evaluating and modifying risk reduction programs Choice 3. Anticipating and seeking sources of risk Choice 4. Developing a plan to avoid and manage risk Choice 5. Gathering data that indicate success at avoiding or minimizing risk Correct Answer: 3, 1, 4, 5, 2 Question 10 A nurse manager is working on new job descriptions for all nursing units of the hospital. Which management function is this nurse conducting? 1. Planning 2. Organizing 3. Directing 4. Coordinating Rationale 2: Organizing is an ongoing process of management that involves determining responsibilities, communicating expectations (which job descriptions would fall under), and establishing the chain of command for authority and communication.Chapters 26, 27, 28, 34, 47, 48, 49 34 Question 11 A hospital was named in a lawsuit after a client had to undergo a second surgical procedure because an arthroscopy was performed on the wrong knee during surgery. The hospital settled out of court with the client for damages. This is an example of which principle of management? 1. Authority 2. Responsibility 3. Coordination 4. Accountability Rationale 4: Accountability is the ability and willingness to assume responsibility for one‘s actions and to accept the consequences of one‘s behavior. The hospital had a responsibility to the client for quality care and service. That was not provided; therefore, the hospital was willing to accept the consequences of the injury experienced by the client. Question 12 A nurse manager has had to handle a particularly difficult physician who is demanding as well as demeaning. Through this situation, the nurse manager has learned that accuracy and honesty are attributes of which skill necessary for managers? 1. Critical thinking 2. Communication 3. Networking 4. Responsibility Rationale 2: Good communication skills are essential to managers and include assertiveness, clear expression of ideas, accuracy, and honesty. Question 13 A nursing student would like to do an observation on one of the inpatient units at a hospital. In assisting the student to meet this desire, the educator would look for which type of nurse? 1. Mentor 2. Manager 3. Team leaderChapters 26, 27, 28, 34, 47, 48, 49 35 4. Preceptor Rationale 4: The preceptor is a person of experience who assists a ―new‖ nurse in improving clinical skills and nursing judgment. Question 14 A hospital is implementing a computerized charting system, and all nursing staff is required to be oriented to the system by a specific deadline. Which type of change is occurring with the staff? 1. Overt change 2. Covert change 3. Unplanned change 4. Drift Rationale 1: An overt change is one that is planned and that people are aware of. Implementing a new computer system is certainly a planned, purposeful event. Question 15 The nursing staff is informed that the current system of record keeping is going to be changed to make it more efficient. In which stage of change is the nursing staff? 1. Refreezing 2. Unfreezing 3. Moving 4. Drift Rationale 2: During the unfreezing stage, the need for change is recognized, driving and restraining forces are identified, alternative solutions are generated, and participants are motivated to change. Question 16 Prior to delegating a task, the nurse reviews the ―rights‖ of delegation; these include which rights? Standard Text: Select all that apply. 1. SupervisionChapters 26, 27, 28, 34, 47, 48, 49 36 2. Evaluation 3. Client 4. Time 5. Task Rationale 1: According to the National Council of State Boards of Nursing (NCSBN), right supervision is one of the ―rights‖ of delegation. Rationale 2: According to the National Council of State Boards of Nursing (NCSBN), right evaluation is one of the ―rights‖ of delegation. Rationale 5: According to the National Council of State Boards of Nursing (NCSBN), right task is one of the ―rights‖ of delegation. Question 17 The nurse has been promoted to the role of manager for a client care area. What responsibilities of the nurse will this new role include? Standard Text: Select all that apply. 1. Accomplish the goals of the organization. 2. Use the organization‘s resources efficiently. 3. Ensure effective client care. 4. Ensure compliance with regulatory standards. 5. Manage relationships. Rationale 1: The nurse manager is responsible for efficiently accomplishing the goals of the organization. Rationale 2: The nurse manager is responsible for efficiently using the organization‘s resources. Rationale 3: The nurse manager is responsible for ensuring effective client care. Rationale 4: The nurse manager is responsible for ensuring compliance with regulatory standards. Question 18Chapters 26, 27, 28, 34, 47, 48, 49 37 A nurse is identified as being an effective leader. With this designation, the nurse will most likely demonstrate which characteristics? Standard Text: Select all that apply. 1. Self-aware 2. Focus on people 3. Excellent communicator 4. Mentor to others 5. Focus on systems Rationale 1: The nurse as leader is self-aware. Rationale 2: The nurse as leader is focused on people. Rationale 3: The nurse as leader is an excellent communicator. Rationale 4: The nurse as leader mentors others. Question 19 A staff nurse has been identified by others as being an effective leader. With this designation, the nurse implements which principles? Standard Text: Select all that apply. 1. Vision 2. Influence 3. Serve as a role model 4. Planning 5. Organizing Rationale 1: Principles of effective leadership include vision, which is a mental image of a possible and desirable future state. Rationale 2: Principles of effective leadership include influence, which is an informal strategy used to gain the cooperation of others without exercising formal authority. Rationale 3: Principles of effective leadership include role modeling, an example of which is demonstrating caring toward coworkers and clients.Chapters 26, 27, 28, 34, 47, 48, 49 38 Question 20 The nurse is reviewing feedback from other staff members on leadership behaviors. Which characteristics are consistent with being an effective leader? Standard Text: Select all that apply. 1. Energetic 2. Creative 3. Optimistic 4. Open 5. Risk taking Rationale 1: Being energetic is a characteristic of an effective leader. Rationale 2: Creativity is a characteristic of an effective leader. Rationale 3: Optimism is a characteristic of an effective leader. Rationale 4: Being open is a characteristic of an effective leader. Question 21 The nurse has been promoted to a position that includes the supervision of first-level management and responsibility for activities in a specific department. This nurse will most likely have which title? Standard Text: Select all that apply. 1. Supervisor 2. Nurse manager 3. Head nurse 4. Primary care nurse 5. Vice president Rationale 1: Middle-level managers may be called supervisors. Rationale 2: Middle-level managers may be called nurse managers.Chapters 26, 27, 28, 34, 47, 48, 49 39 Rationale 3: Middle-level managers may be called head nurses. Question 22 The nurse practices responsibility when functioning in the role of manager of a care area. What will the nurse manager demonstrate as evidence of responsibility? Standard Text: Select all that apply. 1. Effective utilization of resources 2. Communication to subordinates 3. Implementation of organizational goals and objectives 4. Problem solving 5. Managing the work team Rationale 1: Managers are responsible for effective utilization of resources. Rationale 2: Managers are responsible for communication to subordinates. Rationale 3: Managers are responsible for the implementation of organizational goals and objectives. Question 23 The nurse is determining whether an activity can be delegated to a UAP. What will the nurse use to make this determination? Standard Text: Select all that apply. 1. Determine whether it is the right task. 2. Determine whether it is under the right circumstances. 3. Determine whether it is to the right person. 4. Determine the type of communication. 5. Determine whether there is enough time. Rationale 1: The right task is one of the five ―rights‖ of delegation.Chapters 26, 27, 28, 34, 47, 48, 49 40 Rationale 2: The right circumstance is one of the five ―rights‖ of delegation. Rationale 3: The right person is one of the five ―rights‖ of delegation. Rationale 4: The right communication is one of the ―five rights‖ of delegation. Question 24 The manager identifies a staff nurse to serve as a change agent for the implementation of a computerized documentation system. What attributes did the manager observe to designate the staff nurse to have this role? Standard Text: Select all that apply. 1. Self-confident 2. Skilled in teaching 3. Hesitant with decision making 4. Excellent communication skills 5. Effective utilization of resources Rationale 1: Change agents are self-confident and are able to take risks and inspire trust in themselves and others. Rationale 2: Change agents are skilled in teaching. Rationale 4: Change agents have excellent communication skills with all levels and types of individuals. Rationale 5: Change agents have knowledge of available resources and know how to use them wisely. Question 25 The manager determines that a new graduate nurse needs additional training on the principles of delegation. What delegation to unlicensed assistive personnel did the manager observe to make this decision? Standard Text: Select all that apply. 1. Bathing a patient recovering from surgery 2. Weighing a patient who is prescribed diureticsChapters 26, 27, 28, 34, 47, 48, 49 41 3. Discharge instruction teaching 4. Transferring and ambulating a client after hip replacement surgery 5. The care of an intravenous access device Rationale 3: Client education may not be delegated to unlicensed assistive personnel. Rationale 5: The care of invasive lines may not be delegated to unlicensed assistive personnel. Chapter 34 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 34 The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client. Rationale 2: Collecting the specimen comes during the intratest phase. Question 2 The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? 1. BNP 2. CBC 3. LDH 4. PKU Rationale 1: The specific blood test to detect and guide treatment for heart failure is the BNP test. B-type natriuretic peptide is secreted primarily by the left ventricle in response to increased ventricular volume and pressure.Chapters 26, 27, 28, 34, 47, 48, 49 42 Question 3 The nurse is reviewing laboratory results for a client. Which diagnostic study determines how well blood glucose levels have been controlled in the client? 1. Blood chemistry 2. Capillary blood glucose 3. Hemoglobin A1c 4. Serum electrolytes Rationale 3: The glycosylated hemoglobin or hemoglobin A1c (HbA1c) is a measurement of blood glucose that is bound to hemoglobin. Hemoglobin A1c is a reflection of how well blood glucose levels have been controlled. Question 4 Which return demonstration by a client indicates that teaching about performing a blood glucose monitoring test has been effective? 1. The client punctures the fingertip. 2. The client puts on gloves. 3. The client smears the blood on the reagent strip. 4. The client washes the hands. Rationale 4: One of the first steps the client would perform is hand washing for infection control. Question 5 A client asks the nurse, ―Why do I have to monitor my blood glucose levels?‖ What is an appropriate response from the nurse? 1. ―Because your doctor ordered it.‖ 2. ―If I were you, I would monitor the blood glucose when I didn‘t feel good.‖ 3. ―Monitoring your blood glucose better enables you to manage your diabetes.‖ 4. ―You can eat anything you want.‖Chapters 26, 27, 28, 34, 47, 48, 49 43 Rationale 3: Blood glucose monitoring improves diabetes management. By testing one‘s blood, one can change the insulin regimen to maintain a normal glycemic range. Question 6 What is the responsibility of the nurse when collecting a specimen from a client? 1. Always accompany the client to collect a specimen. 2. Handle the specimen discreetly. 3. Clean technique should be used with all specimen collection. 4. Use day-old specimens. Rationale 2: The nurse should handle the specimen discreetly to avoid embarrassing the client. Question 7 A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Analyze the stool for dietary products and digestive secretions. 2. Detect the presence of bacteria or viruses. 3. Detect the presence of ova and parasites. 4. Determine the presence of occult blood. Rationale 1: The nurse needs to collect and send the total quantity of stool expelled at one time instead of a small sample so that the specimen can be analyzed for dietary products and digestive secretions. Question 8 A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order? 1. To test for acid-fast bacillus 2. To assess the effectiveness of therapy 3. To identify origin, structure, function, and pathology of cellsChapters 26, 27, 28, 34, 47, 48, 49 44 4. To identify the specific organism Rationale 2: The reason for this doctor‘s order is to assess if the therapy ordered is effective for this client. Question 9 The nurse is collecting a sputum specimen from a client. Which action should the nurse take during the collection of this specimen? 1. Collect at least 30 mL of sputum. 2. Offer mouth care. 3. Take shallow breaths. 4. Wear a mask. Rationale 2: Offer mouth care so that the specimen will not be contaminated with microorganisms from the mouth. Question 10 Which instruction should the nurse give to the client when a stool specimen is to be collected? 1. Defecate in the toilet. 2. Follow sterile technique. 3. Send at least 60 mL of specimen. 4. Void before the specimen is collected. Rationale 4: To avoid contaminating the specimen, the client should void before the specimen is collected. Question 11 What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning.Chapters 26, 27, 28, 34, 47, 48, 49 45 3. Keep the specimen on ice. 4. Void in a sterile cup. Rationale 2: Routine urine examination is usually performed on the first voided specimen in the morning because it tends to have a higher, more uniform concentration and a more acidic pH than specimens later in the day. Question 12 The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? 1. Apply sterile gloves. 2. Clear the throat. 3. Cough to bring up secretions. 4. Rinse the mouth with mouthwash prior to the collection. Rationale 3: Clients need to cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to expectorate the specimen into a collecting container. Question 13 The nurse is preparing to collect a throat culture from a client. What client response indicates to the nurse that teaching about this test has not been effective? 1. ―I need to hyperextend my neck.‖ 2. ―I need to say ‗ah.'‖ 3. ―I will need to sit up.‖ 4. ―The nurse will use a light.‖ Rationale 1: The client should extend the tongue when a throat culture is to be taken, not hyperextend the neck. Question 14 A client is scheduled for a barium enema. What is the nursing priority for this client?Chapters 26, 27, 28, 34, 47, 48, 49 46 1. Assess bowel sounds. 2. Assess for allergies. 3. Cleanse the bowel. 4. Keep the client NPO. Rationale 3: For visualization of the colon, the bowel has to be cleansed; otherwise the test cannot be performed. Therefore, that is the first priority the nurse must keep in mind. Question 15 A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective? 1. ―I‘m told this test causes no discomfort.‖ 2. ―I will have to walk on a treadmill.‖ 3. ―I will need to remain NPO.‖ 4. ―I will need to take my pulse prior to the test.‖ Rationale 1: An echocardiogram causes no discomfort, although conductive gel is used and it may be cold. Question 16 The nurse is reviewing instructions provided to a client about an upcoming cystoscopy. Which client response indicates that no further teaching is required? 1. ―During the procedure the physician will take x-rays.‖ 2. ―I will be awake for this procedure.‖ 3. ―The doctor will be able to see my kidneys.‖ 4. ―The scope is a lighted instrument inserted through the urethra.‖ Rationale 4: The cystoscope is a lighted instrument inserted through the urethra. Question 17Chapters 26, 27, 28, 34, 47, 48, 49 47 A client with tattooed eyeliner is scheduled for an MRI. What should the nurse instruct the client about this diagnostic test? 1. Earplugs will be provided. 2. Lie very still. 3. Report any burning sensation. 4. Wear goggles. Rationale 4: Recent reports have shown that, in very few instances, people with tattoos or permanent cosmetics experience edema or burning in the tattoo during an MRI. Any potential problems can be avoided by wearing goggles to cover permanent cosmetics around the eyes. Question 18 A client is having a lumbar puncture. In which position should the nurse place the client? 1. Lateral with head bent toward the chest and knees flexed onto the abdomen 2. Lying prone, with the knees drawn up toward the abdomen 3. Sitting bent over from the waist with legs extended 4. Supine with knees pulled toward the chest Rationale 1: Lying in the lateral position with the head bent toward the chest and knees flexed onto the abdomen is the correct position for a lumbar puncture. In this position the back is arched, increasing the spaces between the vertebrae so that the spinal needle can be readily inserted. Question 19 A client is scheduled to have abdominal ascites fluid removed. What should the nurse instruct the client about this procedure? 1. A catheter will be inserted into the bladder. 2. A liver biopsy will be done. 3. An abdominal paracentesis will be done. 4. A thoracentesis will be done. Rationale 3: An abdominal paracentesis is performed to remove ascites, which relieves pressure on the abdominal organs.Chapters 26, 27, 28, 34, 47, 48, 49 48 Question 20 The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? Standard Text: Select all that apply. 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report the results to appropriate health team members. Rationale 2: During the posttest phase of diagnostic testing, the nurse will compare the previous and current test results. Rationale 4: During the posttest phase of diagnostic testing, the nurse will modify nursing interventions as necessary. Rationale 5: During the posttest phase of diagnostic testing, the nurse will report the results to appropriate health team members. Question 21 The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed assistive personnel. Rationale 3: A nursing procedure or laboratory manual is often available if the nurse is unfamiliar with the procedure. If there is any question about the procedure, the nurse should call the laboratory for directions before collecting the specimen. Question 22Chapters 26, 27, 28, 34, 47, 48, 49 49 An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client? 1. Provide a clean funnel to pour the urine into the specimen cup. 2. Document that the specimen could not be obtained. 3. Catheterize the client for the specimen. 4. Ask the physician to obtain the specimen. Rationale 1: If an older client is having difficulty with a specimen cup for a clean catch urine specimen, the nurse should provide a clean funnel to pour the urine into the container. Question 23 A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? 1. It is the use of a magnetic field to produce an image of a body part or organ. 2. A radioisotope will be injected to determine organ functioning as being either hot or cold. 3. It produces a three-dimensional image of an organ. 4. It is more sensitive than an x-ray image. Rationale 2: In nuclear imaging studies, a radioisotope is injected, and the body organ is determined as functioning as either hot or cold. Question 24 The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? Standard Text: Select all that apply. 1. Clean the perineal area using a circular motion. 2. Use all towelettes provided. 3. Use each towelette once, and discard. 4. Clean the perineal area from back to front. 5. Clean the perineal area from front to back.Chapters 26, 27, 28, 34, 47, 48, 49 50 Rationale 2: To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use all towelettes provided. Rationale 3: To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use each towelette once and discard. Rationale 5: To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to clean the perineal area from front to back. Question 25 Unlicensed assistive personnel (UAP) will be conducting a test on a client‘s urine. What should the nurse instruct the UAP about the test? Standard Text: Select all that apply. 1. Nothing, because the UAP can perform urine testing. 2. Remind the UAP to tell the client the results of the test. 3. Notify the physician with the results of the test. 4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test. Rationale 4: The nurse should instruct the UAP to report the results of the test to the nurse. Rationale 5: The nurse should instruct the UAP to save the urine in case the nurse wants to repeat the test. Question 26 A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. What should the nurse do? 1. Continue with the test, and document that one specimen is missing. 2. End the test immediately, and send what is collected to the laboratory. 3. Document that the test cannot be completed. 4. Start the test over.Chapters 26, 27, 28, 34, 47, 48, 49 51 Rationale 4: If the client or staff forgets and discards the client‘s urine during a timed collection, the procedure must be restarted from the beginning. Question 27 The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this client‘s procedure? Standard Text: Select all that apply. 1. Date and time performed 2. The physician‘s name 3. The client‘s ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The client‘s status after the procedure Rationale 1: When documenting after a lumbar procedure, the nurse should include the date and time the procedure was performed. Rationale 2: When documenting after a lumbar procedure, the nurse should include the physician‘s name. Rationale 4: When documenting after a lumbar procedure, the nurse should include the color, character, and amount of cerebrospinal fluid withdrawn. Rationale 5: When documenting after a lumbar procedure, the nurse should include the client‘s status after the procedure. Question 28 A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? Standard Text: Select all that apply. 1. Client‘s tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexesChapters 26, 27, 28, 34, 47, 48, 49 52 5. Presence of pain and any pain medication received Rationale 1: The nurse should document how well the client tolerated the procedure, as it can cause considerable discomfort. Rationale 3: The nurse should document the bone marrow biopsy site for bleeding, as this can occur. Rationale 5: The nurse should document whether the client is experiencing any pain, and whether any pain medication was provided. Question 29 A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? Standard Text: Select all that apply. 1. Tissue samples may be taken for biopsy. 2. Eating will not be permitted for 12 hours. 3. A local anesthetic is sprayed on the throat. 4. Bed rest for 8 hours is necessary after the test. 5. Informed consent is required for this procedure. Rationale 1: A bronchoscopy is a sterile procedure. Tissue samples may also be taken for biopsy. Rationale 3: A local anesthetic is sprayed on the client‘s pharynx to prevent gagging. Rationale 5: Informed consent is required for this procedure. Question 30 The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? Standard Text: Select all that apply. 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen.Chapters 26, 27, 28, 34, 47, 48, 49 53 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the specimen immediately or refrigerate it for later pickup. 5. Clamp the drainage tubing for 30 minutes if there is no urine in the catheter. Rationale 1: When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should withdraw 30 mL of urine for a routine urinalysis. Rationale 4: When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should send the specimen immediately or refrigerate it for later pickup. Rationale 5: When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should clamp the drainage tubing for 30 minutes if there is no urine in the catheter. Chapter 47 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 47 Question 1 Type: MCSA The parent of a newborn infant reports that the baby wakes up every 2 hours and only takes about 2 ounces of formula before going back to sleep. What instruction should the nurse give this parent? 1. Make the baby wait at least 3 hours between feedings. 2. Continue to feed the baby with this on-demand schedule. 3. When the baby gets sleepy during feeding, use techniques such as moving around and tickling to encourage wakefulness. 4. Offer the baby less formula to prevent waste. Rationale 2: Newborns are often fed following an on-demand schedule. This might include feedings every 2 hours at first. Question 2 What criteria should the nurse use to evaluate to determine if an infant‘s regurgitation, or spitting up, should be further investigated? 1. How often the baby spits upChapters 26, 27, 28, 34, 47, 48, 49 54 2. How much the baby spits up at a time 3. If the baby is gaining weight adequately 4. The consistency of the regurgitated matter Rationale 3: As long as the baby is gaining weight adequately, it is not abnormal for regurgitation or spitting up to occur. Question 3 The parents of a 7-month-old child have started offering solid foods to their baby. The baby has enjoyed and tolerated rice cereal, applesauce, and other fruits. Which food should the nurse recommend to be introduced next? 1. Strained beef 2. Green beans 3. Squash 4. Strained chicken Rationale 3: As the baby develops, foods are offered in the sequence in which they are generally best tolerated. Most experts recommend introducing cereals, fruits, yellow vegetables (e.g., squash), green vegetables (e.g., green beans), and then meats. Question 4 The nurse has advised the client to consume alcohol only in moderation. What guideline should the nurse provide as a ―moderate‖ alcohol intake? 1. Two drinks per week for women, three for men 2. Two drinks per day for women, three for men 3. One drink per day for women, two for men 4. One drink per week for women, two for men Rationale 3: Moderate alcohol consumption is considered one drink per day for women, two drinks per day for men. Question 5Chapters 26, 27, 28, 34, 47, 48, 49 55 The nurse completes triceps skinfold measurement on a client. In order to obtain the most meaningful data, how soon should the nurse repeat this measurement? 1. 2 days 2. 10 days to 2 weeks 3. 1 month 4. 1 year Rationale 4: Anthropometric measurements such as triceps skinfold measurement provide the most meaningful data when monitored over longer periods of time, such as several months to years. Question 6 The client‘s lab studies reveal a normal serum albumin with a prealbumin of 10. How should the nurse interpret the significance of these readings? 1. The client has had recent protein malnutrition. 2. The client is now relatively well nourished with malnutrition 6 to 8 months ago. 3. The client is at risk for development of malabsorption syndromes. 4. Carbohydrate malnutrition has occurred over the last 6 months. Rationale 1: Prealbumin is the most responsive serum protein to rapid changes in nutritional status. A level below 11 indicates that aggressive nutritional intervention is necessary. Question 7 A client reports following the ―food pyramid‖ to guide nutritional intake. How should the nurse evaluate this information? 1. Because this food pyramid is produced by the U.S. Department of Agriculture, the client is likely consuming necessary levels of all essential nutrients. 2. The food pyramid is most useful when applied to the nutritional intake of children. 3. The food pyramid is not very useful because it does not take fluid intake and combination foods into consideration. 4. Following the appropriate food pyramid is helpful, but there are additional factors to consider in a balanced diet.Chapters 26, 27, 28, 34, 47, 48, 49 56 Rationale 4: Because there are numerous food pyramids, the client should be following the appropriate one, and other factors such as fluid intake and activity level should be considered in planning a balanced diet. Question 8 The nurse has instructed an overweight client to follow a 2,000-calorie diet by substituting foods considered low in calories for those higher in calories. How should the client interpret the food label to decide if a food is low in calories? 1. The product label will state ―lighter‖ or ―reduced calories.‖ 2. The Nutrition Facts label will have the letter ―L‖ located in the lower right corner. 3. Nutritional labeling on the product will indicate less than 40 calories per serving. 4. The product will contain no more than 11% fat. Rationale 3: In order to qualify as a low-calorie food in a 2,000-calorie diet, the food must have less than 40 calories per serving. Question 9 Nitrogen balance testing is planned for a client. What instruction to the staff caring for this client is essential? 1. Remove the client‘s oxygen cannula 10 minutes prior to the test. 2. Accurate measurement of food intake is very important. 3. All urine output should be collected for 48 hours. 4. Keep the client NPO beginning at midnight before the test. Rationale 2: Nitrogen balance is determined by comparing the grams of protein taken in to the urinary nitrogen output for 24 hours. Accurate food intake is essential. Question 10 A client who has undergone a gastrointestinal surgery is permitted to have a clear liquid diet on the second postoperative day. Which fluid should the nurse order from the diet kitchen for this client? 1. Apricot nectarChapters 26, 27, 28, 34, 47, 48, 49 57 2. Cranberry juice 3. Chicken broth 4. Cherry ice pop Rationale 3: Chicken broth is the only liquid listed that is clear and not red. Question 11 Unlicensed assistive personnel are assigned the task of feeding breakfast to older clients with alterations in mobility and orientation. What instruction should the nurse include in this delegation? 1. Breakfast should be completed quickly so that baths may begin. 2. Give fluids before and after each bite of solid foods. 3. Stand to the left of right-handed clients during feeding. 4. Engage the client in conversation during the meal. Rationale 4: Of the options given, the best answer is to engage the client in conversation during the meal. This makes the mealtime pleasant and encourages socialization as well as appetite. Question 12 The nurse is preparing to insert a nasogastric tube into a client. In what order will the nurse conduct the following steps? Standard Text: Click and drag the options below to move them up or down. Choice 1. Ask the client to tilt the head forward. Choice 2. Insert the tube with its natural curve toward the client. Choice 3. Ask the client to hyperextend the neck. Choice 4. Have the client swallow a small amount of liquid. Choice 5. Employ a slight twisting motion on the tube. Correct Answer: 2, 3, 5, 1, 4 Rationale 1: At this time, have the client tilt the head forward to facilitate passage of the tube into the posterior pharynx and esophagus.Chapters 26, 27, 28, 34, 47, 48, 49 58 Rationale 2: The tube should first be inserted with its natural curve toward the client. Rationale 3: At this time, having the client hyperextend the neck will reduce the curvature of the nasopharyngeal junction. Rationale 4: The client should then be asked to swallow to move the epiglottis over the opening of the larynx, directing the tube toward the esophagus. Rationale 5: A slight twisting motion may help pass the tube into the nasopharynx. Question 13 The nurse has delegated administration of tube feeding to a specially trained UAP. What action should be taken by the nurse in regard to this delegation? 1. Order the equipment to give the feeding. 2. Check the tube for placement. 3. Set up the equipment and mix the feeding. 4. Regulate the rate of the feeding. Rationale 2: The nurse is responsible to assess tube placement and to determine that the tube is patent. Question 14 The nurse notices that the client‘s continuous open system tube-feeding set is almost empty. What action should the nurse take? 1. Add tube feeding to the set. 2. Discontinue the feeding and hang a closed system bag. 3. Wash out the set and add new feeding. 4. Flush the set with clear carbonated soda and discontinue. Rationale 3: The open set should be taken down, washed well, and rehung with new feeding. Question 15Chapters 26, 27, 28, 34, 47, 48, 49 59 As the nasogastric tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action? 1. Remove the tube and attempt reinsertion. 2. Give the client a few sips of water. 3. Use firm pressure to pass the tube through the glottis. 4. Have the client tilt the head back to open the passage. Rationale 2: Swallowing ice or water may help calm the gag reflex and also facilitate the ―swallowing‖ of the tube. Question 16 The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What should the nurse do first? 1. Place the client in high Fowler‘s position. 2. Turn off the tube feeding. 3. Assess the client‘s lung sounds. 4. Assess the client‘s bowel sounds. Rationale 2: These findings indicate possible aspiration of the feeding. The priority action is to discontinue the feeding to eliminate the amount of material going into the client‘s lungs. This should be done before any further assessment or client position change is attempted. If it is discovered that there is no aspiration, the tube feeding can be restarted. Question 17 The client has a body mass index (BMI) of 18. How should the nurse interpret this finding? 1. The client is malnourished. 2. The client is underweight. 3. The client is normal. 4. The client is overweight. Rationale 2: A BMI of 18 falls within the category of being underweight (16–19).Chapters 26, 27, 28, 34, 47, 48, 49 60 Question 18 On admission, the client weighs 165 lb (75 kg). The client reports that this is a weight loss from 180 lb (82 kg). What is this client‘s percent weight loss? 1. 4.5% 2. 6.25% 3. 8.3% 4. 10.0% Rationale 3: To calculate the percent weight loss, subtract the current weight (165 lb) from the usual weight (180 lb). Divide the result by the usual weight and multiply that result by 100. In this case, the loss is 8.3%. Question 19 The client is weighed each month while residing in the long-term care facility. This month the client weighs 110 lb (50 kg). The nurse compares this weight to the last 3 months‘ results and discovers the client has lost 22 lb (10 kg). There has been no attempt to lose this weight. How should the nurse interpret this weight loss? 1. No malnutrition 2. Mild malnutrition 3. Moderate malnutrition 4. Severe malnutrition Rationale 2: To calculate the level of nutritional deficit, the nurse first figures the current percentage of usual body weight and then compares that result to nutritional standards. To calculate the percent of usual body weight, divide the current weight by the usual body weight and multiply by 100. In this case, the client is at 91% of usual body weight. Mild malnutrition is 85% to 90%, moderate malnutrition is 75% to 84%, and severe malnutrition is less than 74%. This calculation is particularly important in an unintentional weight loss. Question 20 The nurse is reviewing laboratory data for a client who is receiving total parenteral nutrition. Which laboratory value should be immediately brought to the physician‘s attention?Chapters 26, 27, 28, 34, 47, 48, 49 61 1. BUN of 60 2. Prealbumin of 15 3. Serum glucose of 328 4. Potassium of 3.5 Rationale 3: The most important concern in this set of laboratory data is the increased serum glucose. Question 21 What nursing diagnosis is the most important for the nurse to include in the care plan of a client who has just been started on total parenteral nutrition (TPN) therapy? 1. Risk for Infection 2. Imbalanced Nutrition: Less Than Body Requirements 3. Activity Intolerance 4. Fluid Volume Deficit Rationale 1: TPN is delivered via a venous catheter and is very high in glucose. There is a very high risk for infection. Question 22 A client reports that an adolescent family member has started a vegan diet. Which additions to meals should the nurse recommend to help ensure that the adolescent does not become deficient in calcium? Standard Text: Select all that apply. 1. Tofu 2. Soybeans 3. Brewer‘s yeast 4. Raisins 5. OkraChapters 26, 27, 28, 34, 47, 48, 49 62 Rationale 1: Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet tofu (soybean curd) fortified with calcium. Rationale 2: Calcium deficiency is a concern for strict vegetarians. It can be prevented by including in the diet soybean milk. Rationale 4: Raisins are a good source of iron. Question 23 During diet teaching with a client diagnosed with diabetes, the nurse should instruct that the most prevalent monosaccharide is 1. fructose. 2. galactose. 3. corn syrup. 4. glucose. Rationale 4: Of the three monosaccharides—glucose, fructose, and galactose—glucose is by far the most abundant simple sugar. Question 24 The nurse is instructing a client on foods that are considered complete proteins. What will the nurse include in these instructions? Standard Text: Select all that apply.Chapters 26, 27, 28, 34, 47, 48, 49 63 1. Meat 2. Gelatin 3. Eggs 4. Chicken 5. Fish Correct Answer: 1, 3, 4, 5 Rationale 1: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including meats, are complete proteins. Rationale 3: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including eggs, are complete proteins. Rationale 4: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including poultry, are complete proteins. Rationale 5: Complete proteins contain all of the essential amino acids plus many nonessential ones. Most animal proteins, including fish, are complete proteins. Question 25 A client is diagnosed with an elevated cholesterol level. What should the nurse instruct the client regarding foods to avoid? Standard Text: Select all that apply. 1. Fish 2. Milk 3. Liver 4. Chicken 5. Egg yolk Rationale 2: Cholesterol is found in milk. Rationale 3: Cholesterol is found in organ meats, such as liver. Rationale 5: Cholesterol is found in egg yolks.Chapters 26, 27, 28, 34, 47, 48, 49 64 Question 26 The nurse is planning an educational program for community members on ways to improve nutritional intake. What information should the nurse include about carbohydrate digestion and metabolism? Standard Text: Select all that apply. 1. Enzymes are needed to digest carbohydrates. 2. The breakdown of carbohydrates results in simple sugars. 3. Carbohydrates are a major source of body energy. 4. The simple sugar glucose provides a readily available source of energy. 5. Pancreatic amylase enhances the use of glucose by the body cells. Correct Answer: 1, 2, 3, 4 Rationale 1: Major enzymes of carbohydrate digestion speed up chemical reactions. Rationale 2: The desired end products of carbohydrate digestion are monosaccharides. Some simple sugars are already monosaccharides, and require no digestion. Rationale 3: Carbohydrate metabolism is a major source of body energy. Rationale 4: After the body breaks carbohydrates down into glucose, some glucose continues to circulate in the blood to maintain blood levels and to provide a readily available source of energy. Question 27 A client is diagnosed as having a negative nitrogen balance. What should the nurse instruct the client about this finding? 1. Discuss ways to reduce protein in the diet. 2. Review how to limit carbohydrates in the diet. 3. Discuss ways to increase protein in the diet. 4. Analyze reasons why fats should be limited in the diet. Rationale 3: Nitrogen balance means the amounts of protein anabolism and protein catabolism are equal. In negative nitrogen balance, there is an excessive amount of protein catabolism or a decrease in the amount of protein ingested in the diet.Chapters 26, 27, 28, 34, 47, 48, 49 65 Question 28 A client diagnosed with negative nitrogen balance tells the nurse about participating in ritualistic fasts as a part of his culture. The client abstains from all food for several days at a time. What should the nurse discuss with the client regarding this practice? 1. The amount of weight the client will lose during the fasts 2. The need to ingest some carbohydrates for body functions 3. The amount of calories the client will need to ingest after fasting for several days 4. The importance of the practice to the client Rationale 2: A person who fasts will obtain most of his or her calories from fat metabolism, but some of the body‘s carbohydrate and protein stores must be used to support brain, nerve, and red blood cell function. The nurse should discuss with the client reasons to ingest carbohydrates to preserve the client‘s protein stores during the ritualistic fasts. Question 29 A client asks the nurse for help in selecting foods, as some are ―good‖ and others are ―bad.‖ How should the nurse respond to the client? Standard Text: Select all that apply. 1. ―Eat a wide variety of foods to furnish adequate nutrients.‖ 2. ―Avoid starchy foods.‖ 3. ―Limit foods with high-fructose corn syrup.‖ 4. ―Eat three meals a day to reduce calories.‖ 5. ―Eat moderately to maintain correct body weight.‖ Rationale 1: Nurses should not use a ―good food, bad food‖ approach, but rather should realize that variations of intake are acceptable under different circumstances. The only ―universally‖ accepted guidelines are to eat a wide variety of foods to furnish adequate nutrients. Rationale 5: Nurses should not use a ―good food, bad food‖ approach, but rather should realize that variations of intake are acceptable under different circumstances. The only ―universally‖ accepted guidelines are to eat moderately to maintain correct body weight. Question 30Chapters 26, 27, 28, 34, 47, 48, 49 66 A client tells the nurse that fresh fruit should be eaten only on an empty stomach, as it will cause other foods to ferment in the stomach. The nurse realizes this client‘s nutritional status is influenced by 1. lifestyle. 2. culture. 3. beliefs about food. 4. religious practices. Rationale 3: Beliefs about the effects of foods on health and well-being can affect food choices. Many people acquire their beliefs about food from television, magazines, and other media. Food fads that involve nontraditional food practices are relatively common. Question 31 The nurse is planning instruction for a client who is underweight. What should be included in this teaching? Standard Text: Select all that apply. 1. Discuss factors contributing to inadequate nutrition and weight loss. 2. Discuss ways to manage, minimize, or alter the factors contributing to malnourishment. 3. Discuss principles of a well-balanced diet and high- and low-calorie foods. 4. Provide information about community agencies that can assist in providing food. 5. Provide information about ways to increase calorie intake. Rationale 1: Client teaching for underweight clients should include a discussion of the factors contributing to inadequate nutrition and weight loss. Rationale 2: Client teaching for underweight clients should include a discussion of ways to manage, minimize, or alter the factors contributing to malnourishment. Rationale 4: Client teaching for underweight clients should include information about community agencies that can assist in providing food. Rationale 5: Client teaching for underweight clients should include information about ways to increase caloric intake. Question 32Chapters 26, 27, 28, 34, 47, 48, 49 67 The nurse is planning interventions for a client to improve the appetite. What actions would be appropriate for this client? Standard Text: Select all that apply. 1. Select small portions. 2. Avoid unpleasant treatments immediately before or after a meal. 3. Ensure a clean environment free of unpleasant sights and odors. 4. Encourage oral hygiene before a meal. 5. Provide medication for pain or other symptoms after a meal. Correct Answer: 1, 2, 3, 4 Rationale 1: Interventions to improve a client‘s appetite include selecting small portions. Rationale 2: Interventions to improve a client‘s appetite include avoiding unpleasant treatments immediately before or after a meal. Rationale 3: Interventions to improve a client‘s appetite include ensuring a clean environment that is free of unpleasant sights and odors. Rationale 4: Interventions to improve a client‘s appetite include encouraging oral hygiene before a meal. Question 33 A client‘s nasogastric tube has been discontinued and needs to be removed. Place in order the steps the nurse will perform to remove this tube. Standard Text: Click and drag the options below to move them up or down. Choice 1. Place the tube in a plastic bag. Choice 2. Ask the client to take a deep breath and to hold it. Choice 3. Smoothly withdraw the tube. Choice 4. Pinch the tube with the gloved hand. Choice 5. Observe the intactness of the tube. Choice 6. Apply clean gloves. Correct Answer: 6, 2, 4, 3, 1, 5Chapters 26, 27, 28, 34, 47, 48, 49 68 Rationale 1: When removing a nasogastric tube, the nurse should: (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube. Rationale 2: When removing a nasogastric tube, the nurse should: (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube. Rationale 3: When removing a nasogastric tube, the nurse should: (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube. Rationale 4: When removing a nasogastric tube, the nurse should: (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube. Rationale 5: When removing a nasogastric tube, the nurse should: (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube. Rationale 6: When removing a nasogastric tube, the nurse should: (1) apply clean gloves; (2) ask the client to take a deep breath and to hold it; (3) pinch the tube with the gloved hand; (4) smoothly withdraw the tube; (5) place the tube in a plastic bag; and (6) observe the intactness of the tube. Question 34 The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding? 1. Assess tube placement. 2. Measure vital signs. 3. Assist the client to a prone position. 4. Lower the head of the bed. Rationale 1: Prior to administering a feeding through a gastrostomy tube, the nurse should assess for tube placement. Question 35 The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? Standard Text: Select all that apply.Chapters 26, 27, 28, 34, 47, 48, 49 69 1. Name of physician prescribing the feedings 2. Solution provided 3. Amount of fluid 4. Duration of the feeding 5. Client tolerance of the feeding Rationale 2: When documenting after a tube feeding, the nurse should document the solution provided. Rationale 3: When documenting after a tube feeding, the nurse should document the amount of fluid provided. Rationale 4: When documenting after a tube feeding, the nurse should document the duration of the feeding. Rationale 5: When documenting after a tube feeding, the nurse should document the client‘s tolerance of the feeding. Question 36 A client receives several tube feedings each day. After documenting the client‘s tolerance of the feedings and assessments in the medical record, the nurse should also document the amount of feeding provided on the 1. graphic sheet. 2. dietary consultation notes. 3. vital signs record. 4. intake and output record. Rationale 4: The amount of fluid as feeding provided to the client should be recorded on the intake and output record. Question 37 A client is prescribed a 1600-calorie diet. Of this diet, 30% of the intake should be protein, 20% fat, and 50% carbohydrates. How many grams of carbohydrates should the client ingest every day? Standard Text: Calculate to the nearest whole number.Chapters 26, 27, 28, 34, 47, 48, 49 70 Correct Answer: 200 grams Rationale: First determine the number of calories for carbohydrates by multiplying the total number of calories by the percentage; 1600 calories × 50% = 800 calories. Then divide the total calories by calories/gram. For carbohydrates, this would be 800 calories/4 = 200 grams. The client should eat 200 grams of carbohydrates each day. Question 38 The nurse is concerned that an older client is at risk for aspiration. What feeding techniques should the nurse instruct the family to use once the client is discharged? Standard Text: Select all that apply. 1. Thicken all fluids. 2. Use the chin-tuck method. 3. Place the client in a seated position 4. Focus on food preferences. 5. Keep the head of the bed at a 30-degree angle. Correct Answer: 1, 2, 3, 4 Rationale 1: Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include thickening fluids. Many older adults can swallow foods with thicker consistency more easily than thin liquids. Rationale 2: Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include using the chin-tuck method. Flexing the head toward the chest when swallowing decreases the risk of aspiration into the lungs. Rationale 3: Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include eating in a seated position. Rationale 4: Safety should always be a priority concern, with attention paid to preventing aspiration. Techniques to reduce this risk include focusing on food preferences. Chapter 48 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 48Chapters 26, 27, 28, 34, 47, 48, 49 71 Question 1 The nurse is assessing a client‘s urinary elimination. Which factor should the nurse keep in mind as influencing this elimination? 1. Age 2. Body image 3. Knowledge 4. Socioeconomic status Rationale 1: Development factors such as how old the client is influence urinary elimination. Question 2 The nurse realizes that which client is at risk for difficulty in urinary elimination? 1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure Rationale 3: The client who is 80 years old with frequent urination at night is having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination. Question 3 A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output Rationale 1: Nocturia is voiding frequently at night. An increased intake of fluid causes some increase in the frequency of voiding. Conditions such as urinary tract infection (UTI), stress, andChapters 26, 27, 28, 34, 47, 48, 49 72 pregnancy can cause frequent voiding of small quantities of urine. Total fluid intake and output may be normal. Question 4 Which intervention would the nurse plan to help a client prevent a urinary tract infection? 1. Encourage the use of bubble baths. 2. Have the client increase sugar in the diet. 3. Instruct the client to empty the bladder completely. 4. Wipe from back to front. Rationale 3: Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection. Question 5 The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? 1. Change the appliance several times a day. 2. Increase fluid intake. 3. Notify the physician if the stoma is deep pink and shiny. 4. Strands of blood may appear in the urine. Rationale 2: Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma. Question 6 Which nursing intervention is appropriate when caring for a client with a retention catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag.Chapters 26, 27, 28, 34, 47, 48, 49 73 4. Retape the catheter to the thigh. Rationale 4: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling. Question 7 Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction Rationale 2: The floor is the dirtiest place, so the drainage device should never be placed on the floor. Question 8 The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence? 1. The client will empty her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 5 to 10 seconds. 4. The client will stop the flow of urine when voiding. Rationale 3: Performing four to five squeezes for 5 to 10 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence. Question 9 Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention.Chapters 26, 27, 28, 34, 47, 48, 49 74 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort. Rationale 1: Avoiding bladder distention will help eliminate stasis of urine in the bladder, which contributes to urinary tract infections, a possible complication of urine flow being obstructed from an enlarged prostate. Question 10 The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this client‘s urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and observation Rationale 4: The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient. Question 11 A client has been admitted with incontinence. What should the nurse expect to assess in this client? 1. Client is wearing cotton undergarments. 2. Leakage of urine occurs when client laughs. 3. Leakage of urine occurs when talking with the client. 4. The skin of the client is clear without discoloration. Rationale 2: Incontinence involves a small leakage of urine when a client laughs. Question 12Chapters 26, 27, 28, 34, 47, 48, 49 75 A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion? 1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma Rationale 1: Black color to the stoma and sloughing are signs of necrosis of the stoma. Question 13 A client‘s results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 10–15, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection Rationale 4: The pH, glucose, specific gravity, and protein are all within normal limits. Urine is usually clear to slightly cloudy, and WBC count can be from 0 to 4. Therefore, the gross cloudiness and WBC count of 10–15 are not normal, indicating a urinary tract infection. Question 14 A client‘s urinalysis is reported as being normal. What were the client‘s results? 1. Blood present and no ketones 2. Dark amber color and output less than 500 cc in 24 hours 3. pH 6 and no glucose present 4. Specific gravity 1.035 and faint aromatic odor Rationale 3: Normal pH is 4.5 to 8, so a pH of 6 and no glucose present are two normal characteristics of urine.Chapters 26, 27, 28, 34, 47, 48, 49 76 Question 15 A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication? 1. The medication should be discontinued abruptly. 2. Notify the physician if you experience urinary retention. 3. Take a laxative every day. 4. Take the medication on an empty stomach. Rationale 2: A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be of the utmost importance to notify the physician. Question 16 A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination? 1. Don‘t interrupt your day by going to the bathroom; wait until you‘re at a good stopping place. 2. Drink 8 to 10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day. Rationale 2: Drinking 8 to 10 glasses of water daily will encourage the need for bladder emptying, keeping the system flushed. Question 17 A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day.Chapters 26, 27, 28, 34, 47, 48, 49 77 Rationale 4: The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract. Question 18 A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen. Rationale 2: Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem. Question 19 The nurse is reviewing kidney function with a client experiencing renal failure. Identify the area in the nephron where solutes such as glucose are reabsorbed. Standard Text: Click on the correct area on the image. Correct Answer: Rationale: Solutes such as glucose are reabsorbed in the loop of Henle. Question 20 The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client? 1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy Rationale 1: This is an incontinent urinary diversion (ileal conduit).Chapters 26, 27, 28, 34, 47, 48, 49 78 Question 21 A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention Rationale 3: When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output. Question 22 A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client? 1. Elimination of urine from the bladder 2. Ability of the kidneys to absorb solutes 3. Ureteral function 4. Urethra function Rationale 1: The bladder contains the detrusor muscle, which is responsible for expulsion of urine from the bladder. If the client has a cervical spine injury, muscle function will be affected below the level of the injury, resulting in an impaired ability to eliminate urine from the bladder. Question 23 A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? Standard Text: Select all that apply. 1. Urethral stricture 2. Renal failureChapters 26, 27, 28, 34, 47, 48, 49 79 3. Urethral injury 4. Bladder injury 5. Urinary infection Rationale 1: Dysuria means voiding that is either painful or difficult. It can occur with a urethral stricture. Rationale 3: Dysuria means voiding that is either painful or difficult. It can occur with a urethral injury. Rationale 4: Dysuria means voiding that is either painful or difficult. It can occur with a bladder injury. Rationale 5: Dysuria means voiding that is either painful or difficult. It can occur with a urinary infection. Question 24 A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Standard Text: Select all that apply. 1. To evaluate the glomerular filtration rate 2. To determine the extent of renal failure 3. To determine the amount of retained urine after voiding 4. To determine the need for medications 5. To evaluate fluid volume status Rationale 3: Residual urine is measured to assess the amount of retained urine after voiding. Rationale 4: Residual urine is measured to determine the need for interventions such as medications. Rationale 5: Residual urine is not measured to evaluate fluid volume status. Question 25 A client‘s urine pH is 8.0. What further assessments would be indicated for this client?Chapters 26, 27, 28, 34, 47, 48, 49 80 Standard Text: Select all that apply. 1. Intake of fruits and vegetables 2. Intake of cranberries 3. Intake of high-protein foods 4. Symptoms of diarrhea 5. Symptoms of a urinary tract infection Rationale 1: Alkaline urine might indicate a diet high in fruits and vegetables. Rationale 5: Alkaline urine might indicate a urinary tract infection. Question 26 The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this client‘s teaching? Standard Text: Select all that apply. 1. Limit intake of caffeine. 2. Limit intake of alcohol. 3. Increase intake of citrus juices. 4. Limit evening fluid intake. 5. Increase intake of beverages with artificial sweeteners. Rationale 1: Clients with stress incontinence should be instructed to limit the intake of caffeine. Rationale 2: Clients with stress incontinence should be instructed to limit the intake of alcohol. Rationale 4: Clients with stress incontinence should be instructed to limit evening fluid intake. Question 27 The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion? 1. The client is wearing tight clothing.Chapters 26, 27, 28, 34, 47, 48, 49 81 2. The client is employed as a computer operator. 3. The client drinks 8–10 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 30–60 minutes most days of the week. Rationale 1: Tight-fitting pants or other clothing can cause irritation to the urethra and prevent ventilation of the perineal area, leading to an infection. Question 28 The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain Rationale 3: In the older client, confusion can be an early sign of urinary tract infection. Question 29 The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash his or her hands. 2. Document the client‘s tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted. Rationale 4: The nurse should make sure that the tip of the penis is not touching the condom and that the condom is not twisted, because a twisted condom could obstruct the flow of urine. Question 30 The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the client‘s labia for cleansing, the nurse will maintain this hand as beingChapters 26, 27, 28, 34, 47, 48, 49 82 1. sterile. 2. contaminated. 3. able to evaluate the effectiveness of the catheter balloon. 4. clean. Rationale 2: When performing urinary catheterization, the nondominant hand is considered contaminated once it touches the client‘s skin. Question 31 The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the client‘s intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the client‘s mobility status. Rationale 1: Applying a condom catheter may be delegated to UAP. However, the nurse must determine whether the specific client has unique needs, such as impaired circulation or latex allergy, that would require special training of the UAP in the use of the condom catheter. Question 32 The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client Rationale 4: Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to UAP.Chapters 26, 27, 28, 34, 47, 48, 49 83 Question 33 The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure Rationale 1: The nurse should document the catheterization procedure, including the catheter size. Rationale 3: The nurse should document the amount of urine that drained after insertion. Rationale 5: The nurse should document the client‘s tolerance of the procedure. Question 34 A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Standard Text: Select all that apply. 1. Number of ml of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis Rationale 4: The nurse should document the application of the condom, including the time. Rationale 5: The nurse should document any pertinent observations, such as the integrity of the penis.Chapters 26, 27, 28, 34, 47, 48, 49 84 Question 35 The nurse has completed closed irrigation of a client‘s retention catheter. What specific information should the nurse document about this procedure? 1. Number of ml of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation Rationale 2: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds. Question 36 A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the client‘s output as being 1425 mL. What is the client‘s urine output for the 8-hour shift? Standard Text: Calculate to the nearest whole number. Correct Answer: 625 mL Rationale: The client is to receive 800 mL of bladder irrigant for the 8-hour shift. The nurse needs to subtract the bladder irrigant total from the total output, or 1425 – 800 = 625 mL. This is the client‘s urine output for the 8-hour shift. Question 37 An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this client‘s risk of developing an infection because of the catheter? Standard Text: Select all that apply. 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter.Chapters 26, 27, 28, 34, 47, 48, 49 85 5. Keep the collection bag below the level of the bladder. Rationale 1: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain a sterile closed drainage system. Rationale 3: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain unobstructed urine flow by making sure the catheter and tubing are not kinked. Rationale 4: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should wash his or her hands before any manipulation of the catheter or collection system. Rationale 5: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should keep the collection bag below the level of the bladder at all times. Chapter 49 Kozier & Erb’s Fundamentals of Nursing, 10/E Chapter 49 Question 1 A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which would be the nurse‘s best response? 1. The sitting position decreases the contractions of the muscles of the pelvic floor. 2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool. 3. The sitting position increases the pressure within the abdomen. 4. The sitting position inhibits the urge to urinate, allowing one to defecate. Rationale 2: Normal defecation is facilitated by thigh flexion, which increases the pressure within the abdomen, and a sitting position, which increases the downward pressure on the rectum. Question 2 A client asks the nurse why expelled flatus is foul-smelling. What should the nurse respond? 1. The actions of microorganisms within the gastrointestinal tract are responsible for the odor. 2. The client‘s emotions are causing the gas formation.Chapters 26, 27, 28, 34, 47, 48, 49 86 3. The sensory nerves in the rectum are being stimulated. 4. The client has swallowed too much air while eating. Rationale 1: The actions of the microorganisms are responsible for the odor produced and also the color of the feces. Question 3 The home care nurse is reviewing a list of clients prior to making visits. For which client should the nurse plan interventions to decrease the risk of developing constipation? 1. An adult who is on bed rest 2. An infant who is breast-fed 3. A school-age child at recess 4. A toddler who is now walking Rationale 1: Adults who are on bed rest are at greatest risk for developing constipation. Question 4 The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which response should the nurse make to explain why this practice should be changed? 1. ―If you continue to ignore the urge to defecate, the urge is ultimately lost.‖ 2. ―It is best to suppress the urge rather than suffer embarrassment at work.‖ 3. ―This is a common practice, and it will strengthen the reflex later.‖ 4. ―You will get the urge later; don‘t worry.‖ Rationale 1: When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause the urge to be lost. Question 5 The nurse is preparing to assess a client‘s fecal elimination status. Which activity will the nurse complete during this assessment?Chapters 26, 27, 28, 34, 47, 48, 49 87 1. Obtain a nursing history. 2. Interpret results of diagnostic tests. 3. Perform a physical examination. 4. Set goals with the client. Rationale 1: Assessment of fecal elimination includes a nursing history and also a review of any data from the client‘s records. Question 6 The nurse determines that an adult client‘s feces are normal. What did the nurse assess to come to this conclusion? 1. Black in color 2. Cylindrical in shape 3. Pungent in odor 4. Yellow in color Rationale 2: Cylindrical in contour is a normal characteristic of feces because it takes the shape of the rectum. Question 7 The nurse is caring for a client who experiences frequent bouts of diarrhea. What should the nurse instruct the client to do? 1. Change the daily routine. 2. Decrease fluid consumption. 3. Increase fiber in the diet. 4. Note the precipitating event. Rationale 4: Psychological stress such as anxiety, medications, food allergies, and certain diseases can cause diarrhea. Noting the event can help identify and stop the cause. Question 8Chapters 26, 27, 28, 34, 47, 48, 49 88 The nurse is caring for a client who is experiencing constipation. Which client behavior indicates that teaching was effective? 1. The client continues to ask for his pain medication. 2. The client decreases his fluid consumption. 3. The client refuses to eat the bran flakes on his tray. 4. The client walks around the unit several times a day. Rationale 4: Increased activity such as walking promotes gastric motility, which increases bowel function. Question 9 A client has a bowel movement of hard, dry, but formed stool. The nurse associates these characteristics with 1. bowel incontinence. 2. constipation. 3. diarrhea. 4. fecal impaction. Rationale 2: Hard, dry, formed stool is characteristic of constipation. Question 10 What nursing diagnosis should the nurse select as appropriate to address bowel evacuation for a client who is on bed rest? 1. Bowel Incontinence 2. Constipation 3. Diarrhea 4. Disturbed Body Image Rationale 2: Lack of activity, as in bed rest, is a major contributor to constipation. Lack of movement slows bowel movements.Chapters 26, 27, 28, 34, 47, 48, 49 89 Question 11 The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client? 1. Client will defecate regularly. 2. Client will increase the amount of sugar in the diet. 3. Client will limit fluid intake. 4. Client will regain normal stool consistency. Rationale 4: Because this client is experiencing diarrhea, the goal would be to regain normal stool consistency, which would be less water in the stool and a more formed consistency. Question 12 The nurse is instructing a client on ostomy care. What should be included in this teaching? 1. Change the drainage pouch daily. 2. Clothing of a special style will be needed now that a pouch is worn. 3. Stick a pin into the drainage pouch to relieve any gas buildup. 4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed. Rationale 4: The skin around a stoma is very susceptible to irritation and breakdown. To avoid skin irritation, the faceplate to the drainage pouch needs to fit close enough to the stoma so as not to expose any other skin. Question 13 Which assessment technique will the nurse use first when examining a client with a fecal elimination problem? 1. Auscultation 2. Inspection 3. Palpation 4. Percussion Rationale 2: The nurse will first inspect the client‘s abdominal region.Chapters 26, 27, 28, 34, 47, 48, 49 90 Question 14 The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision? 1. Bowel sounds active in all four quadrants 2. Clay-colored stool 3. Increased appetite 4. Semisolid and moist stool Rationale 2: Clay-colored stools would be an indication of a problem in the GI tract. Clay color is a sign of the absence of bile pigment (bile obstruction). Question 15 A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem? 1. Drink two to four glasses of water daily. 2. Include more spicy foods and sugar in the diet. 3. Include more whole grains in the diet. 4. Use enemas as desired. Rationale 3: Eating more whole grains will increase fiber in the diet, which increases bulk and volume. Question 16 The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate? 1. Apply pressure over the stoma. 2. Clean the stoma and pat dry. 3. Dilate the stoma. 4. Scrub the stoma.Chapters 26, 27, 28, 34, 47, 48, 49 91 Rationale 2: Stoma care includes cleaning the area and patting dry. Question 17 A client is prescribed to receive a cleansing enema. What should the nurse instruct the client prior to administering this enema? 1. Hold the solution for a short time. 2. Lie in the left lateral position. 3. Lie in the right lateral position. 4. Take fast breaths through the nose. Rationale 2: The client lies in the left lateral position in order to clean the rectum and sigmoid. Question 18 A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action? 1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon 2. Exerts a lower osmotic pressure than the surrounding interstitial fluid 3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon 4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon Rationale 1: A hypertonic solution exerts osmotic pressure and draws fluid from the interstitial space into the colon. Question 19 After eating dinner, a client asks for help to get to the bathroom because of an extreme urge to defecate. The nurse realizes that the client has experienced which physiological function of the colon? 1. Flatus 2. Mass peristalsis 3. Haustral churningChapters 26, 27, 28, 34, 47, 48, 49 92 4. Peristalsis Rationale 2: Mass peristalsis involves a wave of powerful muscular contraction that moves over large areas of the colon. Mass peristalsis most commonly occurs after eating, stimulated by the presence of food in the stomach and small intestine. In adults, mass peristaltic waves occur only a few times a day. Question 20 The nurse determines that a client‘s fecal elimination is pale in color. This finding supports which client behavior obtained during the health history? 1. The client rarely eats animal protein, and ingests milk and cheese at several meals each day. 2. The client rarely eats fruits or vegetables. 3. The client uses laxatives routinely. 4. The client drinks 8 to 10 8-ounce glasses of water each day. Rationale 1: Stool that is pale in color is seen in those who ingest a diet high in milk and milk products and low in meat. Question 21 An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client? Standard Text: Select all that apply. 1. Normal patterns of elimination are different for everyone. 2. Increase fiber intake to 20–35 grams a day. 3. Engage in enjoyable exercise. 4. Ignore the urge to have a bowel movement. 5. Drink six to eight glasses of fluid daily. Rationale 1: Older adults should be advised that normal patterns of bowel elimination vary considerably. For some, a normal pattern might be every other day; for others, twice a day. Rationale 2: Constipation can be relieved by increasing the fiber intake to 20–35 grams per day. Rationale 3: Adequate exercise is a preventative measure for constipation.Chapters 26, 27, 28, 34, 47, 48, 49 93 Rationale 5: Daily fluid intake of six to eight glasses is an essential preventive measure for constipation. Question 22 A client recovering from abdominal surgery is demonstrating abdominal distention from trapped flatus. What can the nurse do to help this client? 1. Assist the client to move in bed. 2. Restrict fluids. 3. Obtain an order for a rectal tube. 4. Provide a diet rich in foods that create flatulence. Rationale 3: If excessive gas cannot be expelled through the anus, it might be necessary to insert a rectal tube to remove it. Question 23 A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is experiencing 1. constipation. 2. diarrhea. 3. trapped flatus. 4. fecal impaction. Rationale 4: A client who has a fecal impaction will experience the passage of liquid fecal seepage and no normal stool. The liquid portion of the feces seeps out around the impacted mass. Symptoms include anorexia, abdominal distention, nausea, and vomiting. Question 24 A client has occasional bouts of constipation, and asks the nurse what can be done to prevent these episodes in the future. What should the nurse instruct the client to do? Standard Text: Select all that apply. 1. Establish a regular exercise regimen.Chapters 26, 27, 28, 34, 47, 48, 49 94 2. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. 3. Maintain fluid intake of 2000 to 3000 mL a day. 4. Do not ignore the urge to defecate. 5. Use over-the-counter medications to treat constipation. Rationale 1: Measures to promote healthy defecation include establishing a regular exercise regimen. Rationale 2: Measures to promote healthy defecation include the intake of high-fiber foods such as vegetables, fruits, and whole grains. Rationale 3: Measures to promote healthy defecation include maintaining a fluid intake of 2000 to 3000 mL per day. Rationale 4: Measures to promote healthy defecation include not ignoring the urge to defecate. Question 25 A hospitalized client tells the nurse of the inability to have a bowel movement because ―too many people are around.‖ What should the nurse do to promote normal fecal elimination for this client? 1. Provide a laxative. 2. Assist the client to the bathroom to ensure privacy. 3. Restrict fluids. 4. Assist the client with ambulation. Rationale 2: Privacy during defecation is extremely important to many people. The nurse should therefore provide as much privacy as possible for such clients, but might need to stay with those who are too weak to be left alone. Question 26 A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within 1. 1 to 3 hours. 2. 10 to 20 minutes. 3. 5 to 10 minutes.Chapters 26, 27, 28, 34, 47, 48, 49 95 4. 10 to 15 minutes. Rationale 1: Oil retention enemas take effect within 1 to 3 hours. Question 27 A client experiencing hard, dry feces is scheduled for an enema. The nurse recognizes that what type of solution would be best for the client? Standard Text: Select all that apply. 1. Hypertonic 2. Hypotonic 3. Soapsuds 4. Oil retention 5. Isotonic Rationale 2: Hypotonic enema solutions soften the feces. Rationale 5: Isotonic enema solutions soften the feces. Question 28 The nurse is discussing different types of ostomy appliances with a client with a new ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance should Standard Text: Select all that apply. 1. be changed daily. 2. protect the skin. 3. collect stool. 4. control odor. 5. be open, so the client can empty it sporadically throughout the day. Rationale 2: An ostomy appliance should protect the skin. Rationale 3: An ostomy appliance should collect stool.Chapters 26, 27, 28, 34, 47, 48, 49 96 Rationale 4: An ostomy appliance should control odor. Question 29 The nurse is delegating activities regarding fecal elimination to unlicensed assistive personnel (UAP). Which activity can UAP safely perform to meet a client‘s fecal elimination needs? 1. Provide a fracture pan to a client on bed rest. 2. Provide a client who has a fecal impaction and prolapsed rectum with a cleansing enema. 3. Change a client‘s ostomy device. 4. Irrigate a client‘s ostomy. Rationale 1: Providing a client who is on bed rest with a fracture pan is within the skill level of UAP. Question 30 During morning care, a UAP notes that thick green drainage is seeping around the appliance of a client‘s new ostomy. What should the UAP have been instructed to do? 1. Clean around the drainage. 2. Remove the ostomy appliance and cover the stoma with toilet tissue. 3. Perform complete ostomy care. 4. Report the drainage to the nurse. Rationale 4: Care of a new ostomy is not delegated to UAP. However, aspects of ostomy function are observed during usual care, and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse. Question 31 Type: SEQ The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care. Standard Text: Click and drag the options below to move them up or down. Choice 1. Clean and dry the peristomal skin and stoma.Chapters 26, 27, 28, 34, 47, 48, 49 97 Choice 2. Prepare and apply the skin barrier. Choice 3. Empty the pouch and remove the ostomy barrier. Choice 4. Assess the stoma and peristomal skin. Choice 5. Apply the pouch. Choice 6. Place a piece of tissue or gauze over the stoma and change it as needed. Correct Answer: 3, 1, 4, 6, 2, 5 Rationale 1: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch. Rationale 2: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch. Rationale 3: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch. Rationale 4: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch. Rationale 5: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch. Rationale 6: When caring for a client with an ostomy, the nurse should: (1) empty the pouch and remove the ostomy barrier; (2) clean and dry the peristomal skin and stoma; (3) assess the stoma and peristomal skin; (4) place a piece of tissue or gauze over the stoma and change it as needed; (5) prepare and apply the skin barrier; and (6) apply the pouch. Question 32 While administering an enema, the client complains of abdominal cramping. What should the nurse do? 1. Raise the height of the solution container.Chapters 26, 27, 28, 34, 47, 48, 49 98 2. Clamp the flow for 30 seconds, and restart at a slower rate. 3. Discontinue the enema infusion. 4. Assist the client to a supine position. Rationale 2: If the client complains of fullness or pain, lower the container or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower rate. Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution. Question 33 A client has received a return-flow enema. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Number of times the solution was changed. 2. Type of solution. 3. Length of time the solution was retained. 4. The amount, color, and consistency of the return. 5. Client relief of flatus and abdominal distention. Rationale 2: For a return-flow enema, the nurse should document the type of solution used. Rationale 3: For a return-flow enema, the nurse should document the length of time the solution was retained. Rationale 4: For a return-flow enema, the nurse should document the amount, color, and consistency of the return. Rationale 5: For a return-flow enema, the nurse should document the client‘s relief of flatus and abdominal distention. Question 34 The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided? Standard Text: Select all that apply. 1. Any change in stoma sizeChapters 26, 27, 28, 34, 47, 48, 49 99 2. Condition of the skin around the stoma 3. Amount and type of drainage 4. Client‘s response to the procedure 5. Degree of bowel sounds after care provided Rationale 1: After ostomy care, the nurse should document any changes in stoma size. Rationale 2: After ostomy care, the nurse should document the condition of the skin around the stoma. Rationale 3: After ostomy care, the nurse should document the amount and type of drainage. Rationale 4: After ostomy care, the nurse should document the client‘s response to the procedure. Question 35 During an assessment, the nurse notes that a client‘s stool is black. Which medication should the nurse consider as causing this client‘s change in stool color? Standard Text: Select all that apply. 1. Iron 2. Aspirin 3. Antacids 4. Antibiotics 5. Pepto-Bismol Rationale 1: Iron salts lead to black stool because of the oxidation of the iron. Rationale 2: Any drug that causes gastrointestinal bleeding, such as aspirin, can cause the stool to be black. Rationale 5: Pepto-Bismol causes stools to be black. Question 36 Type: MCMA The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client?Chapters 26, 27, 28, 34, 47, 48, 49 100 Standard Text: Select all that apply. 1. Assess perianal skin. 2. Irrigate the pouch every shift. 3. Maintain the drainage system. 4. Change the bag every 72 hours. 5. Explain the purpose of the system to the client. Rationale 1: For the client with a fecal incontinence pouch, the nurse should regularly assess the perianal skin area. Rationale 3: For the client with a fecal incontinence pouch, the nurse should maintain the drainage system. Rationale 4: For the client with a fecal incontinence pouch, the nurse should change the bag every 72 hours or sooner if there is leakage. Rationale 5: For the client with a fecal incontinence pouch, the nurse should explain the purpose of the pouch to the client. [Show More]

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