NSG 100 Exam 4: Nutrition, Elimination, and Comfort

Question 1

An elderly, tense patient is having trouble relaxing enough to sleep. Which measures should be implemented by the nurse to help promote sleep? (Select all that apply.)

a. Give the patient a back rub.
b. Take the patient for a brisk walk right before bedtime.
c. Provide a warm, quiet environment.
d. Encourage the patient to eat a large meal in the evening.
e. Give the patient a diet cola.
f. Play soft music 30 minutes before bedtime.

Answer 1

a. Give the patient a back rub.
c. Provide a warm, quiet environment.
f. Play soft music 30 minutes before bedtime.

Rationale: Giving a back rub, providing a warm and quiet environment, and playing soft music enhance relaxation, which will lead to easier transition into sleep. Brisk exercise, caffeine drinks, and large meals all are contraindicated in the evening because they induce changes that will interfere with sleep.

Question 2

A nurse who was hired to work in a sleep lab understands that the most common type of sleep apnea is caused by which factor?

a. Airway collapse
b. Lack of exercise
c. Dietary factors
d. Medication use

Answer 2

a. Airway collapse

Rationale: Airway collapse of the soft structures of the upper airway is the most common cause of sleep apnea.
Lack of exercise and certain dietary factors may adversely affect sleep patterns, especially the initiation of sleep.
Medications in the proper dose seldom cause sleep apnea unless improperly combined with other medications or taken with alcohol.

Question 3

A patient has been referred for polysomnography to confirm a diagnosis of narcolepsy. What behavior would the nurse expect the patient to be exhibiting?

a. Excessive use of sleeping medications
b. A lack of dreaming during sleep
c. Consistent use of relaxation techniques
d. Unexpected daytime sleeping episodes

Answer 3

d. Unexpected daytime sleeping episodes

Rationale: Narcolepsy is characterized by uncontrolled and unexpected episodes of falling asleep during the day.
Because of sleeping too much, sleep medications and relaxation techniques are not needed.
The patient goes almost directly to rapid eye movement (REM) sleep upon falling asleep, so vivid dreaming would be expected.

Question 4

A mother brings her toddler for a well-child checkup and mentions that she is having a lot of trouble getting the child to go to bed. Which intervention can the nurse teach the mother to help her toddler establish good sleep habits?

a. Establish and maintain a consistent bedtime routine.
b. Put the child to bed immediately after the evening meal.
c. Allow the child to stay up as long as desired to increase sleepiness.
d. Allow the child to sleep with the parents until the child is older.

Answer 4

a. Establish and maintain a consistent bedtime routine.

Rationale: Toddlers and preschoolers benefit from a consistent routine to help their sleep patterns.
Putting the child to bed too early (right after a meal) will not help sleep; any bedtime snacks should be light snacks containing carbohydrates.
The child will become too tired if allowed to stay up as long as desired, with consequent sleep disruption the next day.
The American Academy of Pediatrics does not recommend that children sleep with their parents.

Question 5

An elderly patient complains of difficulty sleeping after the death of his spouse of 56 years. What would be an appropriate nursing assessment for this patient?

a. Assess the patient for possible use of sedatives.
b. Obtain a health history regarding sleep hygiene.
c. Assess the patient’s weight over the past year.
d. Request a sleep study to rule out sleep apnea.

Answer 5

b. Obtain a health history regarding sleep hygiene.

Rationale: Obtaining a health history of the patient’s sleep hygiene will help determine interventions that might promote relaxation and sleep.
Sedatives are prescribed for only some patients with chronic, ongoing sleep disturbances that interfere with daily life after nonpharmacologic methods have been tried. Although assessing the patient’s weight is an important part of a physical exam, weight is not related to the type of sleep problem described.
No symptoms of sleep apnea have been reported, so the nurse would not request a sleep study.

Question 6

The nurse is completing a sleep assessment for a newly admitted patient. Which data reported by the patient would cause the nurse to suspect obstructive sleep apnea? (Select all that apply.)

a. Morning headaches
b. Sudden weight loss
c. Loud snoring during sleep
d. Daytime sleepiness
e. Deep sleep during the night
f. Increased blood pressure problems

Answer 6

a. Morning headaches
c. Loud snoring during sleep
d. Daytime sleepiness
f. Increased blood pressure problems

Rationale: Signs of obstructive sleep apnea include headaches from hypoxemia on first awakening, loud snoring related to airway collapse, daytime sleepiness from nonrestorative sleep at night, and increased hypertension. Sudden weight loss is not associated with obstructive sleep apnea, although it can be related to other medical disorders such as cancer. Deep sleep is not obtained with obstructive sleep apnea, because the affected person experiences many awakenings during the night.

Question 7

A patient complains of not being able to sleep while in the hospital. What action would be a priority for the nurse to implement?

a. Administer a sleeping medication with the evening meal.
b. Restrict visitors for the patient in the evening.
c. Decrease noise around the patient during the night.
d. Offer a hot drink of regular tea at bedtime.

Answer 7

c. Decrease noise around the patient during the night.

Rationale: Noise is a primary cause of disturbed sleep in the hospital. Administering sleeping medications with the evening meal is too early to help the patient sleep throughout the night.
Restricting visitors may be helpful if the patient requests it, but visitors often provide emotional support and reassurance to the patient, which helps with relaxation. Regular tea contains caffeine, which is not helpful in sleep promotion.

Question 8

A patient reports that the prescribed sleeping medication is no longer effective. What information would be appropriate for the nurse to recommend to the patient? (Select all that apply.)

a. Take the medication with an alcoholic drink.
b. Use relaxation techniques before sleep.
c. Do not study in the bedroom before bedtime.
d. Adjust sleep temperature for comfort.
e. Sleep in a different room of the home.

Answer 8

b. Use relaxation techniques before sleep.
c. Do not study in the bedroom before bedtime.
d. Adjust sleep temperature for comfort.

Rationale: Tolerance frequently develops to sleeping medications, especially with long-term use, and additional sleep hygiene practices such as mindful relaxation, only sleeping in the bedroom, and creating a comfortable environment can be effective adjunctive measures. Alcohol plus a sleeping medication is a dangerous combination. Sleeping in an alternate room removes the patient from the familiar setting and is more likely to disrupt sleep.

Question 9

A nurse is working a night shift after several months of working day shift. What action does the nurse take to protect patient safety?

a. Take a meal break at midnight.
b. Plan critical tasks for early in the shift.
c. Ask another nurse to administer all medications.
d. Turn up lights on the unit to maintain alertness.

Answer 9

b. Plan critical tasks for early in the shift.

Rationale: The 4 A.M. window is when most people become the sleepiest during the night, so it is important that noncritical tasks be planned for this time and that extra care be taken with patient care tasks.
A meal break at midnight may be too early to prevent hunger for the entire shift and is not directly related to patient safety. It is not necessary to have another nurse administer all medications if the nurse is aware of the high-risk time for care tasks. Increasing the amount of light is likely to impair the sleep of all patients on the unit.

Question 10

At a routine clinic visit, an athlete training for a major sports event reports difficulty sleeping that is affecting the training schedule. What would be the best recommendation by the nurse for this patient?

a. Increase the use of electrolyte-enriched drinks to increase stamina.
b. Obtain a short-term prescription for sleeping medications.
c. Plan to arise later in the morning to accommodate sleep changes.
d. Avoid vigorous exercise for at least 2 hours before bedtime.

Answer 10

d. Avoid vigorous exercise for at least 2 hours before bedtime.

Rationale: Vigorous exercise in the hours before bedtime will cause stimulation that prevents sleep.
Adjusting the training schedule to account for this effect is the preferred first step for improving the athlete’s sleep, rather than starting medications that may affect alertness during the day.
A regular sleep schedule is preferred to maintain sleep promotion, including getting up at the same time each day no matter when bedtime occurred.

Question 11

Which lifestyle changes should the nurse recommend to a patient with recent onset of insomnia related to a job change?

a. Obtain a prescription for sleep medication.
b. Increase evening alcohol intake to induce relaxation.
c. Arise each day at the same time.
d. Increase evening exercise to promote sleepiness.

Answer 11

c. Arise each day at the same time.

Rationale: Arising at the same time each day is an important measure to help regulate circadian sleep patterns.
Non-pharmacologic measures should be tried before medication due to the potential side effects of medications.
While alcohol may initially relax some people, it interferes with later sleep patterns. Exercise should not be done for at least 2 hours before bedtime as it inhibits relaxation.

Question 12

A patient reports using a combination of prescription sleeping medication and alcohol every night for the past 8 months after the loss of her job. She tells the nurse that she now wants to stop taking the sleeping medications. What teaching would be appropriate for the nurse to provide?

a. The same sleep routine should be followed until the patient finds another job.
b. An additional prescription medication will be needed.
c. The medication should not be stopped suddenly.
d. Diet changes will be needed before stopping the medication.

Answer 12

c. The medication should not be stopped suddenly.

Rationale: Sleeping medications should not be stopped abruptly to minimize withdrawal symptoms.
Sleep medications are best used short-term, so continuing for an unknown length of time is not advisable.
It is not recommended to add additional medications as medication effects will be much increased.
Diet changes are not necessary when stopping sleep medications, although decreasing alcohol, caffeine, and tobacco use are recommended when starting sleep medications.

Question 13

A patient returns to the clinic requesting an increase in prescribed sleeping medication. What teaching should the nurse provide regarding the long-term use of sleeping medications?

a. “Long-term use of sleeping medications is an appropriate treatment.”
b. “Adding diet changes will increase the effects of the medication.”
c. “More medication will cause hallucinations.”
d. “Long-term use of sleeping medications can increase sleep disorders.”

Answer 13

d. “Long-term use of sleeping medications can increase sleep disorders.”

Rationale: The long-term use of sleeping medications actually is detrimental to sleep promotion and is not recommended, even with any diet changes. Sleep deprivation can ultimately cause hallucinations.

Question 14

A nurse is completing discharge planning for a new mother and newborn infant. Which statement by the mother indicates an understanding of infant care?

a. “Sleep patterns of a newborn are irregular.”
b. “I will put a small pillow and bumpers in the crib.”
c. “My baby should sleep through the night within a week.”
d. “Babies sleep best when placed on their stomachs.”

Answer 14

a. “Sleep patterns of a newborn are irregular.”

Rationale: It is correct that the sleep of the newborn is irregular.
A caregiver who plans to place an infant on his or her stomach to sleep needs further teaching that the recommended position to decrease the risk for SIDS is supine, or on his or her back.
Pillows and other soft objects should not be used in the crib to decrease the risk of suffocation, and babies do not sleep through the night until approximately 4 months of age.

Question 15

A patient who is trying to lose weight requests information from the nurse to improve sleep patterns. What recommendation would be appropriate for this patient?

a. Do not drink diet colas for at least 4 hours prior to bed.
b. Increasing evening exercise will increase sleepiness.
c. High protein bedtime snacks are appropriate.
d. Using diet pills will improve sleep patterns.

Answer 15

a. Do not drink diet colas for at least 4 hours prior to bed.

Rationale: Caffeine is commonly in cola drinks and interferes with sleep when ingested within 4 hours of bedtime.
Exercise should not be done in the hours prior to sleep.
A bedtime snack containing carbohydrates is preferred as protein helps the brain stay alert. Diet pills may contain stimulants that prevent good sleep.

Question 16

A patient has been diagnosed with obstructive sleep apnea. What teaching regarding a common intervention for this disorder is the nurse likely to initiate?

a. The proper use of devices to support the patency of the airway
b. The correct administration of sleeping medications
c. The use of a supine position for sleeping
d. The use of caffeine to maintain alertness

Answer 16

a. The proper use of devices to support the patency of the airway

Rationale: Obstructive sleep apnea is caused by airway collapse, so the use of an oral airway, continuous positive airway pressure, or other devices that keep the airway open are commonly prescribed.
Sleep medications may further relax airway structures, increasing the problem.
Sleeping in a supine position increases the risk of the tongue falling to the back of the throat and blocking the airway.
Caffeine does maintain alertness and does not promote sleep.

Question 17

The nurse knows that the desired outcome for a sleep-deprived patient has been met when the patient makes which comment?

a. “I have less of a headache every morning.”
b. “I have enough energy to do my housework every day.”
c. “I only get up three times during the night to go to the bathroom.”
d. “I only smoke one pack of cigarettes per day now.”

Answer 17

b. “I have enough energy to do my housework every day.”

Rationale: A common result of sleep deprivation is fatigue during the day that prevents a person from completing required tasks, so the outcome of being able to do his or her work is a desirable outcome.
With adequate sleep and oxygenation, there should be no morning headaches.
Getting up several times during the night to void adds to sleep deprivation.
Tobacco products act as stimulants and their use will continue to disrupt sleep.

Question 18

A patient admitted to the hospital complains of sharp, tingling sensations in his lower extremities that prevent him from sleeping. The nurse suspects the patient may have which sleep disorder?

a. Obstructive sleep apnea
b. Narcolepsy
c. Restless leg syndrome
d. Insomnia

Answer 18

c. Restless leg syndrome

Rationale: Restless leg syndrome is characterized by sharp, often painful sensations in the calves and legs that are relieved with walking or movement. Obstructive sleep apnea signs include fatigue, snoring, and periods of apnea while sleeping. Narcolepsy presents with sudden episodes of falling asleep even while doing tasks during the day. Insomnia presents as difficulty falling or staying asleep.

Question 19

A parent is a primary caregiver for a child with multiple disabilities requiring constant care. The parent reports sleeping in 45-minute blocks during the night, having trouble concentrating, and being increasingly irritable. The nurse recognizes that this parent is consistently missing what stage of sleep?

a. Nonrapid eye movement (NREM) stage 2
b. Rapid eye movement (REM) stage
c. Sleep latency stage
d. Sleep arousal stage

Answer 19

b. Rapid eye movement (REM) stage

Rationale: The rapid eye movement stage of sleep is needed to complete the restorative function of sleep and is needed to prevent the cognitive effects of sleep deprivation. Nonrapid eye movement stages begin the sleep cycles and reset with stage one if sleep is interrupted. Sleep latency occurs prior to sleep occurring, and sleep arousal is prior to awakening; neither is a specific stage of sleep.

Question 20

A summer camp nurse is prescreening a school-age child who has a diagnosis of sleep enuresis. What intervention does the nurse expect the child to request while at camp?

a. Separate sleeping area to use a bed alarm
b. Separate sleeping area close to the bathroom
c. Separate sleeping area for a later bedtime
d. Separate sleep area with access to bedtime snacks

Answer 20

a. Separate sleeping area to use a bed alarm

Rationale: Use of a bed alarm is an effective intervention for enuresis; having an area where the alarm can be used in privacy will decrease any stigma associated for the child. Children do not wake up in response to the urge to void, so being close to the bathroom will not decrease the enuresis. Enuresis is not affected by a later bedtime or bedtime snacks, although caffeinated foods or drinks may increase the incidence of enuresis.

Question 21

Which sleep disorders are dyssomnias? Select all that apply.

A. Narcolepsy
B. Hypersomnia
C. Somnambulism
D. Sleep deprivation
E. Nocturnal enuresis

Answer 21

A. Narcolepsy
B. Hypersomnia
D. Sleep deprivation

Rationale: Dyssomnia is primary sleep disorder characterized by a decreased amount or quality of sleep or by irregular sleep timings. Dyssomnias include narcolepsy, hypersomnia, and sleep deprivation. Parasomnias include abnormal sleep behaviors and include somnambulism and nocturnal enuresis.

Question 22

A patient reports difficulty falling asleep. Further assessment shows that the patient consumes alcohol. What are the effects of alcohol on sleep? Select all that apply.

A. Alcohol promotes sleep.
B. Alcohol prevents the patient from falling asleep.
C. Alcohol causes the patient to remain awake.
D. Alcohol awakens the patient early and causes difficulty returning to sleep.
E. Alcohol limits rapid eye movement (REM) sleep.

Answer 22

A. Alcohol promotes sleep.
D. Alcohol awakens the patient early and causes difficulty returning to sleep.
E. Alcohol limits rapid eye movement (REM) sleep.

Rationale: Small amounts of alcohol may help some people fall asleep, but alcohol increases wakefulness in the last half of the night. Ingesting large quantities of alcohol creates difficulty falling asleep and limits REM sleep, and this may cause a restless sleep and the sensation of a “hangover” on arising.

Question 23

The nurse is learning about various stages of nonrapid eye movement (NREM) sleep. One particular stage of NREM lasts for 15 to 30 minutes. It is the deepest stage of sleep, and it is very difficult to arouse the sleeper from this stage. The vital signs are lower than normal waking hours. Which stage of NREM sleep is the nurse referring to? Record your answer using a whole number. __________

Answer 23

4

Rationale: The stage 4 of NREM sleep is the deepest stage and lasts for 15 to 30 minutes. The stage is characterized by lowering of vital signs. It may be difficult to arouse the sleeper from this stage.

Question 24

Which neurotransmitter levels are elevated during non-rapid eye movement (NREM) sleep? Select all that apply.

A. Serotonin
B. Melatonin
C. Acetylcholine
D. Norepinephrine
E. Gamma aminobutyric acid (GABA)

Answer 24

A. Serotonin
E. Gamma-aminobutyric acid (GABA)

Rationale: Sleep consists of two phases, rapid eye movement sleep (REM) and non-rapid eye movement (NREM) sleep. Serotonin and GABA are neurotransmitters that induce NREM sleep; therefore, one can find high levels of these neurotransmitters during NREM sleep. Melatonin is a hormone, not a neurotransmitter, and its levels generally increase at night. The levels of neurotransmitters such as acetylcholine and norepinephrine increase during REM sleep.

Question 25

A patient who recently immigrated to the United States tells the nurse, "I am unable to sleep and concentrate on my work." What might be the reason for this condition? 1. Sleep apnea 2. Hypersomnia 3. Sleep terror disorder 4. Circadian rhythm sleep disorder

Answer 25

4. Circadian rhythm sleep disorder Rationale: When a person travels from one time zone to another, he or she may face difficulty in adjusting to the time changes. This causes difficulty in sleeping, memory problems, depression, weight gain, and impaired concentration levels. This type of sleep disorder is termed a circadian rhythm sleep disorder. Sleep apnea is shallow or absent breathing during sleep. Hypersomnia is a sleep-wake disorder in which a person sleeps excessively during the daytime, even after a normal 8 to 12 hours of sleep at night. A patient who has sleep terror disorder wakes suddenly in a terrified state from deep sleep.

Question 26

Which substances may produce insomnia if consumed in the evening? Select all that apply. A. Alcohol B. Nicotine C. Caffeine D. Light meal E. Protein-rich diet

Answer 26

A. Alcohol B. Nicotine C. Caffeine Rationale: Consumption of alcohol, nicotine, and caffeine in the evening produces insomnia. Nicotine and caffeine act as stimulants and produce sleeplessness. Alcohol interferes with the quality of sleep. A light meal and protein-rich diet do not cause insomnia.

Question 27

Which complications does the nurse expect to find in a patient who is on beta blockers? Select all that apply. A. Insomnia B. Irritability C. Drowsiness D. Nightmares E. Restlessness

Answer 27

A. Insomnia D. Nightmares Rationale: Beta-blockers inhibit the effects of the adrenaline hormone and also inhibit the nighttime secretion of melatonin, a hormone involved in regulating both sleep and the body's circadian clock. Reduced secretions of melatonin, which induces sleep, result in insomnia and nightmares. Irritability occurs due to sleep deprivation. Drowsiness and restlessness occur due to over usage of medications such as barbiturates, amphetamines, and antidepressants.

Question 28

A patient reports difficulty falling asleep. The nurse asks questions to assess the symptoms of insomnia and analyzes the different stages of the patient's sleep cycle. What are the characteristics of stage 2 of nonrapid eye movement (NREM) sleep? Select all that apply. A. Sleepwalking may occur. B. Body functions become slow. C. Arousal remains relatively easy. D. Muscles relaxation increases. E. Vital signs are significantly lower than during waking hours.

Answer 28

B. Body functions become slow. C. Arousal remains relatively easy. D. Muscles relaxation increases. Rationale: In stage 2 of nonrapid eye movement (NREM) sleep, the body functions become slow. The sleeper can be easily aroused in this stage. The muscles continue to relax. A person may sleepwalk during stage 4 of NREM sleep. Also during stage 4, the vital signs are lower than they are during waking hours.

Question 29

Which stage of the sleep cycle is associated with snoring? 1. NREM 1 2. NREM 2 3. NREM 3 4. NREM 4

Answer 29

2. NREM 2 Rationale: Snoring is a condition characterized by noisy breathing during the second stage of non-rapid eye movement (NREM) sleep. As the physiological functions become slower in this stage, sleep becomes deeper, and snoring occurs. Snoring does not occur in the other stages of sleep. Drowsiness occurs in NREM 1 stage. Vital signs decrease and muscles relax in NREM 3 stage. Somnambulism and nocturnal enuresis may occur in NREM 4 stage.

Question 30

A nurse has a sleep disorder due to working on rotating shifts. Which physiologic symptoms are observed in the nurse? Select all that apply. A. Fatigue B. Increased reflexes C. Difficulty concentrating D. Decreased neuromuscular coordination E. Increased visual alertness

Answer 30

A. Fatigue C. Difficulty concentrating D. Decreased neuromuscular coordination Rationale: Sleep deprivation can occur due to rotating shifts, as the human biologic clock becomes maladjusted. It can lead to symptoms of fatigue, headache, nausea, increased sensitivity to pain, decreased neuromuscular coordination, irritability, and difficulty concentrating.

Question 31

What complications does the nurse expect to find in a patient who has circadian rhythm sleep disorders? Select all that apply. A. Tremors B. Cataplexy C. Depression D. Hypertension E. Sexual dysfunction

Answer 31

C. Depression D. Hypertension E. Sexual dysfunction Rationale: Improper sleep due to circadian rhythm sleep disorders decreases dopamine levels, which causes depression. Increases in stress hormones due to insufficient sleep cause hypertension. The metabolic rate decreases due to improper sleep; this causes an imbalance in sex hormones and results in sexual dysfunction. Tremors occur due to the withdrawal of barbiturate-sedative hypnotics. Cataplexy is the loss of muscle tone that occurs in a patient who has narcolepsy.

Question 32

What are the withdrawal symptoms of barbiturate sedative-hypnotics? Select all that apply. A. Tremors B. Restlessness C. Skin irritation D. Increased pulse rate E. Claustrophobia sensations

Answer 32

A. Tremors B. Restlessness D. Increased pulse rate Rationale: Withdrawal symptoms occur upon the abrupt cessation of drugs after prolonged use. Barbiturate sedative-hypnotics that are used to reduce anxiety can cause physical and psychological dependence and result in withdrawal symptoms. Barbiturates bind to the gamma-aminobutyric acid (GABA) receptor site and show indirect agonist action on these receptors. This may be responsible for the occurrence of tremors upon withdrawal. Barbiturate sedative-hypnotics may also cause central nervous system stimulation and hyperadrenergic activity upon withdrawal. Thus, it may cause restlessness and increase the patient's pulse rate. Skin irritation and claustrophobia sensations are side effects of continuous positive airway pressure, which is used to treat obstructive sleep apnea.

Question 33

When assessing the patient for pain, which factors should the nurse consider? (Select all that apply.) a. Previous medical history b. Physical appearance c. Age, gender, and culture d. Lifestyle and loss of appetite e. Hair color and style

Answer 33

a. Previous medical history b. Physical appearance c. Age, gender, and culture d. Lifestyle and loss of appetite Rationale: Medical history, physical appearance, age, gender, culture, lifestyle, and loss of appetite should be considered when conducting a pain assessment. Hair color and style are not necessary components of a pain assessment.

Question 34

Which statement best describes the dosage of pain medication that a nurse should administer given pharmacologic treatment considerations? a. The smallest dose possible to avoid opioid addiction b. The smallest dose possible to decrease adverse effects c. A dose that best manages pain with the fewest side effects d. A large dose initially decreases the initial level of pain.

Answer 34

c. A dose that best manages pain with the fewest side effects Rationale: Based on the patient's report of pain, the nurse administers the dose of medication that is effective in relieving pain without causing adverse side effects. Administering too small of a dose does not relieve pain. Administering a large dose may result in unwanted side effects. Addiction to narcotics is rare.

Question 35

Which method is the most accurate way to determine the pain level of a patient who is alert and oriented? a. Evaluate whether the patient is crying or grimacing. b. Assess the patient's heart rate and blood pressure. c. Consider the seriousness of the patient's condition. d. Use a pain assessment tool and ask the patient to rate the pain level.

Answer 35

d. Use a pain assessment tool and ask the patient to rate the pain level. Rationale: Because pain is defined as what a patient says it is, a patient's report based on the pain scale is currently the most accurate way to determine the pain level of a cognitively alert patient. Crying or grimacing may be considered on a noncognitive scale for a nonverbal patient. Vital signs and the patient's condition contribute to a pain assessment, but they may not be the most accurate determinants.

Question 36

A patient who has a serious back injury received intravenous medication for pain approximately 1 hour earlier. The patient practices relaxation techniques but still is reporting pain at a level of 9 of 10. What intervention should the nurse implement next? a. Report the lack of pain relief to the primary care provider. b. Tell the patient to give the medication more time. c. Reposition the patient, and try diversion activities. d. Document in the nurse's notes that the patient has a low pain tolerance.

Answer 36

a. Report the lack of pain relief to the primary care provider. Rationale: If the patient with a serious injury is not obtaining pain relief from pharmacologic and nonpharmacologic interventions, the primary care provider should be notified. Waiting longer and using more nonpharmacologic interventions are not likely to relieve pain in this situation.

Question 37

Which symptom does the nurse recognize as a physiologic response to acute pain? a. Increased blood pressure b. Decreased pulse c. Increased temperature d. Restlessness

Answer 37

a. Increased blood pressure Rationale: Acute pain can increase blood pressure and pulse rate but may not affect temperature. Restlessness is a psychological response, not physiologic.

Question 38

When administering medications to elderly patients, what information does the nurse need to understand? a. Start with a low dosage, and increase the dosage as needed for pain relief. b. Start with a high dosage, and decrease the dosage as pain is relieved. c. Start with a mid-range dosage, and increase or decrease the dosage as needed for pain. d. Start with a low dosage, and decrease the dosage as indicated for pain

Answer 38

a. Start with a low dosage, and increase the dosage as needed for pain relief. Rationale: Due to decreased metabolism and clearance of medications, start with a lower dose and increase as indicated for pain relief. A high dose may result in drug toxicity. Too low of a dose will not relieve pain.

Question 39

The nurse administered intravenous morphine at 0830. At what time will the nurse ask the patient if pain relief was obtained? a. 1000 b. 1030 c. 0900 d. 0930

Answer 39

c. 0900 Rationale: After administering intravenous medication, check the patient in 15 to 30 minutes for relief from pain. Intravenous medication is injected directly into the bloodstream and bypasses the gastric system metabolism.

Question 40

The patient who had a below-the-knee amputation 3 days ago complains of pain from the amputated extremity. Which statement by the nurse best explains what the patient is experiencing? a. "The phantom pain will subside when the brain realizes the lower extremity is no longer there." b. "The radiating pain will continue for months because the lower extremity is no longer there." c. "You are suffering from referred pain, which you will always have, but it will lessen with time." d. "You are experiencing psychogenic pain because loss of an extremity is an emotional loss."

Answer 40

a. "The phantom pain will subside when the brain realizes the lower extremity is no longer there." Rationale: Feeling an extremity after amputation is phantom pain. This type of pain decreases over time as the brain adjusts to the missing extremity. Radiating, referred, and psychogenic types of pain are not the source of this patient's discomfort.

Question 41

The endocrine system releases excessive hormones during episodes of acute pain. The nurse should monitor patients experiencing acute pain for which potential problem? a. Hyperglycemia b. Migraine headache c. Hyperkalemia d. Diarrhea

Answer 41

a. Hyperglycemia Rationale: The release of hormones causes the blood glucose level to increase, causing hyperglycemia. Hypokalemia may result from the metabolic effects of the genitourinary injury. Constipation results from decreased intestinal motility. Migraine headaches are not a result of hormone release during acute pain.

Question 42

A patient with a fractured femur thinks about vacationing on the beach to relieve pain. What nonpharmacologic pain relief technique should the nurse document the patient is using? a. Distraction b. Imagery c. Relaxation d. Biofeedback

Answer 42

b. Imagery Rationale: Imagery is the use of visual concentration to change the perception of pain. Distraction is the use of music or television to occupy the mind to decrease concentration on pain. Relaxation is muscle relaxation to decrease anxiety created by pain. Biofeedback enables voluntary control over the body to decrease pain

Question 43

The patient who had surgery to remove part of the intestines is complaining of pain. What type of pain is the patient experiencing? a. Somatic pain b. Visceral pain c. Referred pain d. Radiating pain

Answer 43

b. Visceral pain Rationale: Visceral pain is pain originating from a body organ. Somatic pain is bone, muscle, etc. originating pain. Referred pain is pain in a different area from where pain originated. Radiating pain extends into another area of the body.

Question 44

A patient complains of shoulder pain during a gallbladder attack. How does the nurse document this pain? a. Referred pain b. Phantom pain c. Chronic pain d. Psychogenic pain

Answer 44

a. Referred pain Rationale: Referred pain is pain in another area of the body from where the pain originated. Phantom pain is pain from an amputated extremity that is no longer present. Chronic pain is pain that lasts more than 6 months. Psychogenic pain is pain without a physical cause.

Question 45

The patient has been experiencing chronic pain from fibromyalgia for the past six months. What change will the nurse note in the patient's vital signs? a. Increase in blood pressure and pulse b. Decrease in blood pressure and pulse c. Increase in temperature and respirations d. Decrease in temperature and respirations

Answer 45

b. Decrease in blood pressure and pulse Rationale: Chronic pain stimulates the parasympathetic system resulting in a decrease in blood pressure and pulse. Acute pain causes an increase in blood pressure and pulse. Temperature and respirations are not affected.

Question 46

What are the signs of opioid withdrawal? Select all that apply. A. Itching B. Anxiety C. Vomiting D. Drowsiness E. Hypertension

Answer 46

B. Anxiety C. Vomiting E. Hypertension Rationale: Opioid drugs are categorized as narcotic analgesics that have addictive properties. Sudden withdrawal might be lethal, so opioid doses should be gradually tapered off. They may cause withdrawal symptoms that are very uncomfortable to the patient, including anxiety, restlessness, fear, and nervousness. The patient may also experience vomiting and hypertension. Itching is a histaminic reaction, not a withdrawal symptom, observed in patients who take opioid analgesics. Drowsiness is also a side effect of opioid analgesics, but it is not evident upon withdrawal.

Question 47

The nurse is caring for a patient who reports mild headache and fever. Which medication does the nurse expect the primary health care provider to recommend for this patient? 1. Docusate (Colace) 2. Naloxone (Narcan) 3. Atenolol (Tenormin) 4. Acetaminophen (Tylenol)

Answer 47

4. Acetaminophen (Tylenol) Rationale: Acetaminophen (Tylenol) is an analgesic drug that helps in relieving pain at various locations of the body; therefore, it can also help in relieving a headache. Acetaminophen (Tylenol) also acts as an antipyretic and is used to reduce fever. Docusate (Colace) is useful in treating constipation. Naloxone (Narcan) is useful in treating respiratory depression caused by an overdose of opioid analgesics. Atenolol (Tenormin) is a drug that is useful in treating hypertension.

Question 48

Which conditions does the nurse identify as causes of visceral pain? Select all that apply. A. Arthritis B. Appendicitis C. Fibromyalgia D. Pancreatitis E. Pyelonephritis

Answer 48

B. Appendicitis D. Pancreatitis E. Pyelonephritis Rationale: Viscera generally refers to the soft internal organs of the body such as the appendix, pancreas, and kidneys. Appendicitis refers to inflammation of the appendix, which causes pain in the abdomen. Pancreatitis refers to inflammation of the pancreas, which causes severe upper abdominal pain radiating to the back. Pyelonephritis refers to kidney infection, which causes pain in the back and on the side of the abdomen. Arthritis refers to joint pain, which is not considered visceral pain because it is not related to the soft internal organs. Fibromyalgia refers to chronic muscle pain at tender points and limbs, which are somatic organs.

Question 49

The nurse is assessing touch, pain, and temperature sensation of a patient who is diagnosed with diabetic neuropathy. Arrange the parts of the central nervous system through which pain sensation is carried in ascending order. 1. Cerebrum 2. Thalamus 3. Medulla, pons, midbrain 4. Spinal cord

Answer 49

1. Cerebrum 2. Thalamus 3. Medulla, pons, midbrain 4. Spinal cord Rationale: Pain sensation is transmitted from afferent fibers to the spinal cord. From the spinal cord, the pain sensation is carried to medulla, pons, and midbrain. From here it continues through the spinothalamic tract to the thalamus and then to cerebrum.

Question 50

A patient with bronchial carcinoma reports constipation for the past 2 months. The patient is on meperidine (Demerol) and ibuprofen (Advil) for pain relief for the past 6 months. The patient is also taking metformin and captopril (Capoten) for the past 10 years. What could be the most probable reason for constipation in the patient? 1. Side effect of opioid 2. Side effect of captopril 3. Interaction of metformin and captopril 4. Metastasis of cancer to other organs

Answer 50

1. Side effect of opioid Rationale: Constipation is a common side effect of opioids that are used for pain relief. Captopril is an ACE-inhibitor drug that is used to treat hypertension. Cough is the common side effect of captopril. Metformin is an oral hypoglycemic drug. Interaction between metformin and captopril does not cause constipation. It is unlikely that metastasis of cancer caused constipation.

Question 51

Which type of pain does a patient experience after undergoing minor surgery? 1. Chronic pain 2. Referred pain 3. Nociceptive pain 4. Psychogenic pain

Answer 51

3. Nociceptive pain Rationale: Nociceptors are present on the sensory neurons on the skin and internally in the tissues and organs. These receptors carry sensory stimuli, including pain stimuli, from the site of injury to the cerebral cortex. Surgery involves cutting the patient's skin and the tissues that contain nociceptors, so a patient who has undergone surgery experiences nociceptive pain. Chronic pain refers to pain that lasts for a long period of time, approximately 3 to 6 months. This type of pain is observed in conditions such as arthritis, fibromyalgia, and neuropathy. The patient would not likely experience chronic pain after minor surgery. Referred pain is observed in a patient who has pain at one particular site, but the perception of pain is felt at another site. It is observed in cases of appendicitis and myocardial infarction. Pain after surgery would be perceived at the site of the operation. Psychogenic pain occurs due to persistent mental and emotional factors, and there is no physical cause for the pain.

Question 52

Which drug does the nurse expect the primary health care provider to prescribe a patient who is recovering from a myocardial infarction? 1. Aspirin 2. Naloxone (Narcan) 3. Oxycodone (Dazidox) 4. Acetaminophen (Tylenol)

Answer 52

1. Aspirin Rationale: A myocardial infarction occurs due to the aggregation of platelets in the arteries. Aspirin is a nonsteroidal antiinflammatory drug that acts against blood clots formed due to platelet aggregation. Naloxone (Narcan) is useful in treating respiratory depression caused by overdose of opioid analgesics. Oxycodone (Dazidox) is an agonist analgesic that is useful in treating severe pain. Acetaminophen (Tylenol) is useful in treating mild headaches and fever.

Question 53

The nurse is assessing a patient with acute pain. Which statements are true about acute pain? Select all that apply. A. Patients with acute pain are more likely to suffer from depression and fatigue. B. Acute pain has an identifiable cause. C. Acute pain lasts less than 6 months. D. Anxiety increases the severity of acute pain. E. Patients with acute pain seek numerous healthcare providers.

Answer 53

B. Acute pain has an identifiable cause. C. Acute pain lasts less than 6 months. D. Anxiety increases the severity of acute pain. Rationale: Acute pain has an identifiable cause. The duration of acute pain is less than 6 months, and that of chronic pain is longer than 6 months. In acute pain, the presence of anxiety increases the severity of the pain experienced, reduces the individual's tolerance to pain, and decreases the ability to cope with pain. Individuals with chronic pain are more likely to suffer from depression and fatigue and are more likely to attempt suicide. A patient with chronic pain may seek numerous healthcare providers if the pain has an unknown cause.

Question 54

The nurse is caring for a young patient with cancer who is intubated and conscious. How does the nurse best assess pain in this patient? 1. By using the Wong-Baker Facial Grimace Scale 2. By monitoring the patient's blood pressure and pulse rate 3, By asking the patient to point out his or her pain score on a pain assessment tool 4. By asking the patient to verbally report the pain score on a pain assessment tool

Answer 54

3, By asking the patient to point out his or her pain score on a pain assessment tool Rationale: The patient is conscious and is intubated. In this case, the nurse explains the pain assessment tool to the patient and then asks the patient to point out the pain score on the tool. The patient is young and not cognitively impaired; therefore, the nurse need not assess pain with the Wong-Baker Facial Grimace Scale. The patient is conscious; therefore, the nurse need not monitor the patient's blood pressure and pulse rate to assess pain as would be done for an intubated patient who is sedated. The patient is intubated and therefore would not be able to verbally communicate a score on a pain assessment tool.

Question 55

The nurse is caring for a patient who underwent surgery and has a diagnosis of acute pain. Which clinical manifestations does the nurse expect to find in this patient? Select all that apply. A. Tachycardia B. Bradycardia C. Hypertension D. Hypotension E. Constipation

Answer 55

A. Tachycardia C. Hypertension E. Constipation Rationale: Surgery may cause acute pain (pain that lasts for less than 6 months). Acute pain causes an increase in sympathetic nerve activity; thus, it causes an increase in heart rate (tachycardia) and an increase in blood pressure (hypertension). Pain normally affects the gastrointestinal tract by decreasing gastric motility and thereby causing constipation. Chronic pain causes a decreased heartbeat (bradycardia) and a decrease in blood pressure (hypotension).

Question 56

A patient is under preoperative care for an elective surgery. After understanding the explanation given by the nurse about spinal anesthesia, the patient expresses fear of becoming paralyzed due to spinal anesthesia. How should the nurse respond in this situation? 1. Send the patient home as it is not a surgical emergency. 2. Ask the healthcare provider to postpone the surgery without patient's permission. 3. Arrange an appointment with a surgical counselor as soon as possible. 4. Reassure the patient and explain that numbness, tingling, and coldness are common symptoms.

Answer 56

4. Reassure the patient and explain that numbness, tingling, and coldness are common symptoms. Rationale: 4. Reassure the patient and explain that numbness, tingling, and coldness are common symptoms. The nurse should be aware that many patients fear paralysis when they learn about spinal or epidural anesthesia. This is because epidural and spinal injections come close to the spinal cord. Therefore, the nurse should reassure the patient and explain that numbness, tingling, and coldness are common following spinal anesthesia. Sending the patient home or asking the healthcare provider to postpone the surgery may not help to relieve the patient's fears. An appointment with the surgical counselor may be arranged if the nurse is unable to reassure the patient.

Question 57

The nurse explains patient-controlled analgesia to a patient. If the patient has understood this information, what would be the patient's most appropriate statement? 1. The device reduces the risk of an overdose of medication. 2. The caregivers can operate the device if the patient is unable to do so. 3. The patient will be lying down in a prone lying position during the procedure. 4. The patient will decide about the loading dose of the analgesic drug.

Answer 57

1. The device reduces the risk of an overdose of medication. Rationale: A nurse should teach about the use of patient-controlled analgesia to a patient before any procedure. It is important to tell the patient that PCA reduces any risk of overdose. It should be emphasized to the patient that the patient-controlled analgesia device (PCA device) should not be operated by caregivers. The caregivers are not able to perceive the patient's pain and thus cannot decide the amount of drug required. The patient would be placed in a comfortable position in which the IV line is accessible. This prone position is not likely to be a comfortable position for the patient. The patient does not decide the loading dose of the drug; the loading dose is already prescribed.

Question 58

An elderly patient complains of severe pain in both lower extremities. The patient becomes tearful when describing the pain and states that it is intolerable. How should the nurse develop a healing relationship with the patient? Select all that apply. A. By inquiring how the pain is affecting the patient's daily routine. B. By telling the patient about various pain-relieving interventions. C. By encouraging the patient to be strong and deal with the pain positively. D. By asking the family to help the patient cope with pain and anxiety. E. By administering pain medications and encouraging the patient to exercise.

Answer 58

A. By inquiring how the pain is affecting the patient's daily routine. B. By telling the patient about various pain-relieving interventions. D. By asking the family to help the patient cope with pain and anxiety. Rationale: To establish a healing relationship and a helping role, the nurse should not just look at the patient's leg pain as a medical problem. The nurse should also try to understand how it affects patient's daily life and spirituality, and work to improve the patient's overall well-being. By informing the patient about various methods to alleviate pain, the nurse mobilizes hope in the patient. The nurse should also help the patient use social resources, such as friends and family, who can help the patient deal with her health condition. Asking the patient to be strong and deal with the pain may decrease spirituality and increase stress and anxiety. The nurse should focus on more than just medications and exercise to develop a healing relationship.

Question 59

A patient is admitted to the hospital for multiple injuries and is put on an intravenous analgesia. After a couple of hours, the patient is still in severe pain. The nurse finds that the skin around the intravenous catheter is red and swollen. The nurse finds no other changes in the patient's condition. What should be the immediate response of the nurse? 1. Notify the primary healthcare provider. 2. Change the pain medication. 3. Change the intravenous access line. 4. Increase the dose of pain medication.

Answer 59

3. Change the intravenous access line. Rationale: The nurse should continuously monitor the intravenous access line to check its patency. Pain medication or analgesics are effective only if the intravenous (IV) access is patent. The swelling around the intravenous catheter indicates that the IV line is blocked. Therefore, the nurse should first change the intravenous access line. If there is no improvement in the patient's condition after changing the IV line, then the nurse should notify the primary healthcare provider. The primary healthcare provider would change the analgesic or increase the dose of the analgesic drug if necessary.

Question 60

A nurse is assessing a hospitalized patient with acute pain. Which questions should the nurse ask the patient for an appropriate assessment? Select all that apply. A. "How bad is your pain now?" B. "What makes your pain worse?" C. "Describe your pain." D. "What is the worst pain you have had in the past 24 hours?" E. "Show me where you hurt. Does it stay there or does it spread?"

Answer 60

B. "What makes your pain worse?" C. "Describe your pain." E. "Show me where you hurt. Does it stay there or does it spread?" Rationale: When assessing a patient with acute pain, the questions should be specific. The questions should aim to determine intensity, location, and quality of pain. Ask for provocative factors like what makes the pain worse. Ask about the region of the pain and the radiation of pain. Asking how bad the pain is may not yield specific details. Instead the patient should be asked to rate the pain on a scale of 0 to 10. Other details can be asked once the patient is comfortable.

Question 61

Which patients would be appropriate for application of acupuncture therapy? Select all that apply. A. A patient with back pain B. A patient with a skin infection C. A patient with myofascial pain D. A patient with a bleeding disorder E. A patient with a migraine headache

Answer 61

A. A patient with back pain C. A patient with myofascial pain E. A patient with a migraine headache Rationale: Acupuncture therapy regulates the vital energy, which flows like a river through the body in channels that form a system of pathways. Back pain, myofascial pain, and migraine headaches are chronic conditions believed to be caused by a disruption to flow of energy in the body. Acupuncture helps to realign the flow of energy and relieve symptoms of back pain, myofascial pain, and migraine headaches. Acupuncture therapy is contraindicated for clients who have a skin infection or bleeding disorder.

Question 62

The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern? a. The patient’s son uses a marked pillbox to set up the patient’s medications weekly. b. The patient has lost 10 pounds (4.5 kg) during the last month. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient tells the nurse that a close friend recently died.

Answer 62

b. The patient has lost 10 pounds (4.5 kg) during the last month.

Question 63

The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient? a. “Your weight is within normal limits. Continue maintaining with current lifestyle choices.” b. “You are a little overweight. Cut down on calories and increase your activity, and you should be fine.” c. “You are morbidly obese, and we would like to schedule you an appointment to speak with a bariatric specialist about surgery.” d. “You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

Answer 63

d. “You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."

Question 64

The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient? a. Regular diet b. Low sodium diet c. Pureed diet d. Low sugar diet

Answer 64

b. Low sodium diet

Question 65

During a nutritional assessment, the nurse calculates that a female patient’s BMI is 27. The nurse would advise the patient to follow which of these recommendations? a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. b. This measurement indicates that the patient is underweight and will need to take measures to gain weight. c. This measurement indicates that the patient is morbidly obese and may be a candidate for bariatric surgery. d. This measurement indicates that the patient is of normal weight and should continue with current lifestyle.

Answer 65

a. This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight.

Question 66

During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall

Answer 66

d. 24-hour recall

Question 67

During a physical examination, the nurse notes that the patient’s skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present? a. Vitamin C b. Vitamin B c. Essential fatty acid d. Protein

Answer 67

c. Essential fatty acid

Question 68

During a physical examination, the nurse notes that the patient’s skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency? a. Hair loss and hair that is easily removed from the scalp b. Inflammation of the tongue and fissured tongue c. Inflammation of peripheral nerves and numbness and tingling in extremities d. Fissures and inflammation of the mouth

Answer 68

a. Hair loss and hair that is easily removed from the scalp

Question 69

An African American is at an increased risk for which of the following? (Select all that apply.) a. Vitamin D deficiency b. Type 1 diabetes c. Celiac disease d. Type 2 diabetes e. Hypertension f. Metabolic syndrome

Answer 69

a. Vitamin D deficiency d. Type 2 diabetes e. Hypertension f. Metabolic syndrome Rationale: Type 1 diabetes and celiac disease are more common in Northern European heritage.

Question 70

The nurse is providing education to a patient about the difference between simple and complex carbohydrates. Which statement by the patient indicates a need for further education? a. “Simple carbohydrates give me quick energy.” b. “Complex carbohydrates come from fruit.” c. “Complex carbohydrates take longer to break down.” d. “Simple carbohydrates come from milk products.”

Answer 70

b. “Complex carbohydrates come from fruit.”

Question 71

The nurse teaches the family member to provide the patient with how much dietary fiber per day? a. 25 to 35 g b. 20 to 35 g c. 25 to 40 g d. 20 to 40 g

Answer 71

b. 20 to 35 g

Question 72

The nurse is providing education to an older adult around a healthy diet to support the challenges related to aging. Which statement indicates a need for further education? a. “I should choose foods that are nutrient dense.” b. “High-fiber foods minimize the risk of constipation.” c. “I should eat more calories to avoid malnutrition.” d. “I can add spices to enhance the taste of food.”

Answer 72

c. “I should eat more calories to avoid malnutrition.”

Question 73

When caring for an adolescent patient with anorexia nervosa, the nurse knows what would be the best treatment option for this patient? a. Hospitalization with skill nursing care b. Compulsory tube feedings c. Individually determined by a collaborative team d. Outpatient treatment

Answer 73

c. Individually determined by a collaborative team

Question 74

A new UAP is measuring a patient’s height. Which step of the procedure indicates a need for the registered nurse to provide further education on this skill? a. The UAP instructs the patient to remove shoes. b. The UAP measures from the top of the patient’s head to the bottom of the patient’s foot arch. c. The UAP positions the head against the headboard or measuring device. d. The UAP makes sure the patient is standing erect.

Answer 74

b. The UAP measures from the top of the patient’s head to the bottom of the patient’s foot arch.

Question 75

The nurse is performing an oral examination on a patient and notices a beefy-red tongue. The nurse identifies this as a characteristic finding for what condition? a. Anorexia nervosa b. Malnutrition c. Bulimia d. Pernicious anemia

Answer 75

d. Pernicious anemia

Question 76

The nurse has delegated the feeding of a patient who has recently had a stroke to the UAP. Which procedure that the UAP performs would demonstrate a need for further education? a. Uses thickened liquids. b. Puts the bed at 25 degrees. c. Encourages slow eating. d. Has the patient alternate between food and sips of fluid.

Answer 76

b. Puts the bed at 25 degrees.

Question 77

The nurse recognizes which outcome statement to be appropriate for the nursing diagnosis Impaired swallowing? a. Patient will consume 50% of each meal. b. Patient will gain 2 lb a week. c. Patient will not show any signs of aspiration during meals. d. Patient will demonstrate using an assistive device to feed self.

Answer 77

c. Patient will not show any signs of aspiration during meals.

Question 78

The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation? a. “I can give the patient orange juice.” b. “I can give the patient yogurt.” c. “I can give the patient oatmeal.” d. “I can give the patient milk.”

Answer 78

c. “I can give the patient oatmeal.”

Question 79

The nurse is educating a patient about a renal diet. Which statement by the patient indicates a need for further education? a. “I need to eat a low-sodium diet.” b. “I can have limited amounts of meat.” c. “I can drink unlimited cola if it is diet.” d. “I should avoid or limit bananas.”

Answer 79

c. “I can drink unlimited cola if it is diet.”

Question 80

The nurse knows that initial verification of a nasogastric placement is important. Which method is considered the only reliable method to determine enteral tube placement? a. Auscultation of air bolus b. Measurement of pH of the aspirate c. Radiographic image d. Aspirate contents to visually inspect appearance

Answer 80

c. Radiographic image

Question 81

The nurse is attempting to open an occluded PEG tube. Which intervention by the nurse requires re-education? a. Flushes the tube with a small amount of air. b. Flushes the tube using a 50- to 60-mL syringe and warm water. c. Reinserts the stylet to break up the clot. d. Flushes the tube with a special enzyme solution.

Answer 81

c. Reinserts the stylet to break up the clot.

Question 82

When the nurse is caring for a patient who is receiving total parenteral nutrition (TPN), the nurse will change the tubing at which interval? a. Every 72 hours b. Every 48 hours c. Every 24 hours d. Every 12 hours

Answer 82

c. Every 24 hours

Question 83

The nurse is preparing to insert a nasogastric (NG) tube in a patient. Which step in the process indicates a need for further education? a. The nurse lubricates 4 inches of the tube prior to insertion. b. The nurse marks the length of the tube with a marker for insertion. c. The nurse measures the length of tube needed using the nose-earlobe-xiphoid process. d. The nurse applies clean gloves for the procedure.

Answer 83

b. The nurse marks the length of the tube with a marker for insertion.

Question 84

The nurse has received an order from the health care provider to discontinue the nasogastric tube. Which action by the nurse indicates a need for further education? a. The nurse clears the tube with air prior to discontinuing. b. The nurse stops the tube feeding. c. The nurse instructs the patient to cough while pulling out the tube. d. The nurse clamps the tube while pulling it out.

Answer 84

c. The nurse instructs the patient to cough while pulling out the tube.

Question 85

Based on research on aging, the nurse knows that improper nutrition may result in the onset of which specific diseases? (Select all that apply.) a. Type 2 diabetes b. Atherosclerosis c. Osteoporosis d. Rheumatoid arthritis e. Chronic asthma

Answer 85

a. Type 2 diabetes b. Atherosclerosis c. Osteoporosis

Question 86

The nurse is helping a patient understand the difference between macronutrients and vitamins and minerals. The nurse identifies which items that should be included in the list of macronutrients? (Select all that apply.) a. Water b. Potassium c. Starches d. Fiber e. Riboflavin

Answer 86

a. Water c. Starches d. Fiber

Question 87

The nurse is providing dietary education to the patient to assist with inclusion of more complex carbohydrates in the diet. The nurse knows which foods would be beneficial to include? (Select all that apply.) a. Green peas b. Bananas c. Beans d. Potatoes e. Apples

Answer 87

a. Green peas c. Beans d. Potatoes

Question 88

The nurse is educating a patient about including more omega-3 fatty acids in the diet and knows which food sources should be included. (Select all that apply.) a. Salmon b. Flaxseed c. Mackerel d. Steak e. Crayfish

Answer 88

a. Salmon b. Flaxseed c. Mackerel

Question 89

The nurse is planning dietary education for the patient. What food labeling considerations should the nurse be aware of when planning that education? (Select all that apply.) a. Ask patient if food labels are read routinely. b. Assess patient’s level of understanding of food labels. c. Encourage patient to read the food labels. d. Explain to patient all food labels are different. e. Assess patient’s understanding of recommended daily allowance

Answer 89

a. Ask patient if food labels are read routinely. b. Assess patient’s level of understanding of food labels. c. Encourage patient to read the food labels. e. Assess patient’s understanding of recommended daily allowance

Question 90

The nurse knows that a deficiency in vitamin C can result in which conditions? (Select all that apply.) a. Stiff joints b. Osteopenia c. Petechiae d. Loose teeth e. Bleeding gums

Answer 90

a. Stiff joints c. Petechiae d. Loose teeth e. Bleeding gums

Question 91

The nurse is teaching a patient about the impact of obesity and a high body mass index (BMI). The nurse identifies that as the BMI increases, so does the risk for which conditions? (Select all that apply.) a. Increase in blood pressure b. Increase in HDL c. Increase in total cholesterol d. Development of atherosclerosis e. Decrease in triglycerides

Answer 91

a. Increase in blood pressure c. Increase in total cholesterol d. Development of atherosclerosis

Question 92

The nurse is completing a nutrition assessment on a patient. What are some important considerations? (Select all that apply.) a. The nurse should include the patient’s cultural influences in the assessment. b. The food diary accuracy is better for a 24-hour recall than a 3 to 5 day food journal. c. The nurse should be nonjudgmental in the nutritional review. d. A consultation with a registered dietitian may be indicated. e. A gathering of anthropometric measurements may be necessary.

Answer 92

a. The nurse should include the patient’s cultural influences in the assessment. c. The nurse should be nonjudgmental in the nutritional review. d. A consultation with a registered dietitian may be indicated. e. A gathering of anthropometric measurements may be necessary.

Question 93

The nurse is educating the patient about the risk of heart disease from metabolic syndrome and describes a cluster of which symptoms? (Select all that apply.) a. Elevated blood glucose b. High waist circumference c. History of smoking d. Hypertension e. Elevation serum cholesterol

Answer 93

a. Elevated blood glucose b. High waist circumference d. Hypertension e. Elevation serum cholesterol

Question 94

The nurse is completing documentation after feeding a patient with aspiration precautions. Which items should the nurse document? (Select all that apply.) a. Episodes of coughing or gagging b. Hesitation or fear of eating c. Amount eaten d. Aspiration protocol used e. Respiratory status

Answer 94

a. Episodes of coughing or gagging b. Hesitation or fear of eating c. Amount eaten d. Aspiration protocol used e. Respiratory status

Question 95

When the nurse is caring for a patient receiving enteral feedings, which tasks can that nurse delegate to the UAP? (Select all that apply.) a. Verify tube placement b. Perform oral care c. Administer tube feeding d. Obtain vital signs and report results e. Measure oxygen saturation

Answer 95

b. Perform oral care c. Administer tube feeding d. Obtain vital signs and report results e. Measure oxygen saturation

Question 96

The nurse is assessing an undernourished client. Which manifestation of the integumentary system should the nurse consider an expected​ finding? (Select all that​ apply.) A. Muscle wasting B. Petechiae C. Spoon-shaped nails D. Constipation E. Dry brittle hair

Answer 96

B. Petechiae C. Spoon-shaped nails E. Dry brittle hair

Question 97

During a home​ visit, the nurse is concerned that the family is experiencing food insecurity. Which observation made by the nurse caused this​ concern? (Select all that​ apply.) A. The oldest daughter experiences abdominal cramps when ingesting milk products. B. The mother prepares a meal for the​ children, but she claims a lack of appetite to avoid eating. C. The mother is recovering from a second episode of pneumonia within 6 months. D. The children are visibly thin and argue over the food remaining on the serving plate. E. The kitchen cabinets contain a limited amount of food for a family of five.

Answer 97

B. The mother prepares a meal for the​ children, but she claims a lack of appetite to avoid eating. C. The mother is recovering from a second episode of pneumonia within 6 months. D. The children are visibly thin and argue over the food remaining on the serving plate. E. The kitchen cabinets contain a limited amount of food for a family of five.

Question 98

The nurse is demonstrating how to prepare a dinner menu using the MyPlate plan. Which food item should the nurse​ include? (Select all that​ apply.) A. Steamed broccoli B. One cupcake C. Sliced peaches D. Slices of roast beef E. One glass of milk

Answer 98

A. Steamed broccoli C. Sliced peaches D. Slices of roast beef E. One glass of milk

Question 99

The nurse is planning to teach a class regarding factors that influence food choices. Which factor should the nurse​ include? (Select all that​ apply.) A. Level of hunger B. Availability C. Convenience D. Cost E. Emotion

Answer 99

B. Availability C. Convenience D. Cost E. Emotion

Question 100

The nurse is caring for a patient newly diagnosed with celiac disease. When developing a teaching​ plan, which food should the nurse include as one to avoid​? ​(Select all that​ apply.) A. Rye B. Eggs C. Fruit D. Wheat E. Peanuts

Answer 100

A. Rye D. Wheat

Question 101

The nurse concludes that the client is demonstrating cardiovascular manifestations of undernutrition. Which assessment finding supports this​ conclusion? (Select all that​ apply.) A. Low blood pressure B. Lethargy C. Amenorrhea D. Slow respiratory rate E. Irregular heartbeat

Answer 101

A. Low blood pressure E. Irregular heartbeat

Question 102

The nurse is planning to collect anthropometric data from a client who is being evaluated for undernutrition. Which information should the nurse​ include? (Select all that​ apply.) A. Skinfold thickness B. Capillary blood glucose level C. Weight D. Food allergies E. Height

Answer 102

A. Skinfold thickness C. Weight E. Height

Question 103

Which laboratory test measures protein​ levels? (Select all that​ apply.) A. Serum prealbumin B. Serum electrolytes C. Lipid levels D. Complete blood count E. Serum albumin

Answer 103

A. Serum prealbumin E. Serum albumin

Question 104

The nurse is assessing a client for physical problems that affect food intake. Which factor should the nurse​ consider? (Select all that​ apply.) A. Problems with dentition B. Lactose intolerance C. Use of supplements D. Financial resources E. Trouble swallowing

Answer 104

A. Problems with dentition E. Trouble swallowing

Question 105

A pregnant client tells the nurse that she has no idea how she is going to provide food for her two​ preschool-age children in addition to the new baby. Which nursing intervention should the nurse​ implement? (Select all that​ apply.) A. Encourage the client to obtain additional employment. B. Provide information about the Supplemental Nutrition Assistance Program​ (SNAP). C. Discuss the financial support provided by the​ children's father. D. Recommend the​ Women, Infants, and Children​ (WIC) program. E. Review the importance of adequate nutrition during pregnancy.

Answer 105

B. Provide information about the Supplemental Nutrition Assistance Program​ (SNAP). D. Recommend the​ Women, Infants, and Children​ (WIC) program.

Question 106

The nurse learns that a client follows a vegan diet. Which suggestion should the nurse give the client to ensure an adequate intake of vitamins and​ minerals? (Select all that​ apply.) A. Put eggs into a salad every week. B. Add tofu and lentils into the diet. C. Include soft cheeses. D. Increase the intake of citrus fruits. E. Drink soy milk fortified with vitamin B12.

Answer 106

B. Add tofu and lentils into the diet. D. Increase the intake of citrus fruits. E. Drink soy milk fortified with vitamin B12.

Question 107

The nurse notices that a client recently lost 10 pounds. Which question or statement should the nurse use to learn more about the weight​ loss? (Select all that​ apply) A. "Do you eat​ enough?" B. "I noticed that you have lost​ weight." C. "Tell me about how you do your food​ shopping." D. "Share with me what your daily eating habits look​ like." E. "You need to eat more​ dessert."

Answer 107

B. "I noticed that you have lost​ weight." C. "Tell me about how you do your food​ shopping." D. "Share with me what your daily eating habits look​ like."

Question 108

Which tool is available to the nurse to assess a​ client's eating​ habits? (Select all that​ apply.) A. Waist-to-height ratio B. Body mass index C. Six-item Mini-Nutritional Assessment D. Food frequency questionnaire E. Food diary

Answer 108

C. Six-item Mini-Nutritional Assessment D. Food frequency questionnaire E. Food diary

Question 109

Which statement accurately reflects that the client understands how to use the MyPlate​ plan? A. "This seems too hard to remember.​ Can't I just eat​ less?" B. "You will send me a plate to use for my​ meals." C. "I will eat foods from each of the five food groups at every​ meal." D. "I will use the MyPlate handout to increase my portion​ size."

Answer 109

C. "I will eat foods from each of the five food groups at every​ meal."

Question 110

The nurse is teaching a client about a newly prescribed iron supplement. Which information should the nurse​ include? (Select all that​ apply.) A. Expect the stool to turn black. B. Explain the need to increase fiber in the diet. C. Explain how the supplement can cause constipation. D. Suggest that the client avoid ingesting citrus fruits with the supplement. E. Remind the client to ingest adequate amounts of fluid each day.

Answer 110

A. Expect the stool to turn black. B. Explain the need to increase fiber in the diet. C. Explain how the supplement can cause constipation. E. Remind the client to ingest adequate amounts of fluid each day.

Question 111

Which nursing intervention should be implemented for a client at risk of nutritional​ imbalances? (Select all that​ apply.) A. Using nutritional supplements B. Reducing body mass index C. Promoting healthy eating habits D. Providing nutritional education E. Calculating caloric needs

Answer 111

C. Promoting healthy eating habits D. Providing nutritional education

Question 112

Which is the purpose of parenteral​ nutrition? (Select all that​ apply.) A. To deliver calories during recovery from lap band or other bariatric surgical procedures B. To supply nutrients when needs cannot be met through oral intake C. To promote reducing the intake of fats and carbohydrates D. To provide nutrients when foods cannot be consumed by mouth E. To facilitate adherence to​ reduced-calorie eating plans

Answer 112

B. To supply nutrients when needs cannot be met through oral intake C. To promote reducing the intake of fats and carbohydrates

Question 113

While teaching the client about​ niacin, the client asks the​ nurse: "What brand of niacin is​ best?" Which is the​ nurse's correct​ response? A. "The brand is not important. Buy the one that costs the​ least." B. "I will ask the doctor which is the best​ brand." C. "Let me tell you about the side effects of the various​ brands." D. "Get the store​ brand."

Answer 113

C. "Let me tell you about the side effects of the various​ brands."

Question 114

A client asks the​ nurse: "Is drinking a protein drink sufficient as a​ meal?" Which is the​ nurse's most appropriate​ response? A. "No, you should never drink protein​ drinks." B. "Tell me more about the protein drink you are​ using." C. "Add a piece of fruit to your breakfast and lunch​ routine." D ​"Yes. That is​ fine."

Answer 114

B. "Tell me more about the protein drink you are​ using."

Question 115

The nurse provides information about digestion to a group of older community members. Which statement should the nurse include in this​ teaching? (Select all that​ apply.) A. Saliva production can increase. B. Risk for gallstones can increase. C. Taste can become less acute. D. Tooth enamel can become more brittle. E. Pepsin production can increase.

Answer 115

B. Risk for gallstones can increase. C. Taste can become less acute. D. Tooth enamel can become more brittle.

Question 116

The nurse prepares educational material about digestion for a group of new nursing employees. Which information should the nurse include about digestion that affects all​ ages? (Select all that​ apply.) A. Growth and development depend largely on healthy nutrition and digestion. B. Diarrhea is a primary disorder that is found in all age groups. C. Nausea, vomiting, and diarrhea are common expressions of digestion disorders in all age groups. D. Pyloric stenosis typically develops insidiously at all ages. E. Celiac disease has a familial tendency.

Answer 116

A. Growth and development depend largely on healthy nutrition and digestion. C. Nausea, vomiting, and diarrhea are common expressions of digestion disorders in all age groups. E. Celiac disease has a familial tendency.

Question 117

A client with prolonged diarrhea is concerned that the problem persists despite receiving treatment. Which response should the nurse make to address this​ client's concern? A. "Diarrhea is not life-threatening and you should not​ worry." B. "Diarrhea is a symptom of an underlying​ illness, not an illness​ itself." C. "Your diarrhea is most likely caused by a food​ allergy." D. "The healthcare provider is an expert in gastrointestinal​ disorders."

Answer 117

B. "Diarrhea is a symptom of an underlying​ illness, not an illness​ itself."

Question 118

The nurse is caring for a patient who periodically has small streaks of fresh red blood in the stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be the most likely cause of this patient’s bleeding? a. Hemorrhoids b. Bleeding gastric ulcer c. Colon polyps d. Perforated colon

Answer 118

a. Hemorrhoids

Question 119

The nurse is caring for a patient who has diarrhea and identifies which priority nursing diagnosis for this patient? a. Lack of knowledge related to prescribed diet modifications b. Impaired nutritional intake related to poor appetite c. Diarrhea related to excessive loss of fluid through stool d. Anxiety related to incontinence with loose stools and need for clothing change

Answer 119

c. Diarrhea related to excessive loss of fluid through stool

Question 120

The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse indicates a need to contact the prescriber and question the order? a. The patient has skin breakdown from loose stools. b. The patient is constipated with last BM 3 days ago. c. The patient is on a low-fiber, gluten-free diet. d. The patient has painful bleeding hemorrhoids.

Answer 120

b. The patient is constipated with last BM 3 days ago.

Question 121

The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority? a. Provide oral care after each episode of emesis. b. Apply a skin barrier to the patient’s perineal area. c. Check the patient for fecal impaction. d. Administer antiemetic medication with a sip of water.

Answer 121

c. Check the patient for fecal impaction.

Question 122

The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon? a. The patient has bowel sounds x 4 quadrants and is passing gas. b. The patient has no nausea, and abdominal pain is minimal. c. The patient feels hungry for chicken soup and hot tea. d. The patient’s nasogastric tube was discontinued the previous day.

Answer 122

a. The patient has bowel sounds x 4 quadrants and is passing gas.

Question 123

The nurse is caring for a patient who has an ileostomy. Which Nursing diagnosis has the highest priority for the patient? a. Impaired skin integrity r/t localized skin irritation from liquid stool b. Social isolation r/t potential leakage of stool from ostomy appliance c. Lack of knowledge r/t care and maintenance of ostomy appliance d. Disturbed body image r/t presence of stoma and altered elimination

Answer 123

a. Impaired skin integrity r/t localized skin irritation from liquid stool

Question 124

The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function? a. Raisin bran with skim milk, fresh fruit, and wheat toast b. Pancakes with maple syrup, bacon, and coffee with cream c. Omelet with cheddar cheese, green pepper, and onions d. Bagel with cream cheese, and strawberry nonfat yogurt

Answer 124

a. Raisin bran with skim milk, fresh fruit, and wheat toast

Question 125

The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient? a. Obtain an order to administer a soap suds cleansing enema. b. Teach the patient how to use the Valsalva maneuver. c. Discontinue medications that can cause constipation. d. Assess the patient’s usual pattern of bowel movements.

Answer 125

d. Assess the patient’s usual pattern of bowel movements.

Question 126

The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam? a. “The back of your throat will be sprayed with numbing medicine.” b. “You will need to have a clear liquid diet and take a laxative tonight.” c. “You will be given a milky liquid to drink shortly before the test starts.” d. “You should not take your dose of warfarin (Coumadin) tonight.”

Answer 126

c. “You will be given a milky liquid to drink shortly before the test starts.”

Question 127

The nurse is caring for a patient who will undergo colonoscopy testing. Which intervention will the nurse include in the patient’s plan of care for the day before the test? a. Provide the patient with zinc oxide skin barrier cream for the perineal area. b. Obtain an order for a gentle laxative to be given once the test is completed. c. Carefully assess the patient’s ability to swallow liquids through a straw. d. Check the patient for allergies to shellfish and iodine-based contrast dyes.

Answer 127

a. Provide the patient with zinc oxide skin barrier cream for the perineal area.

Question 128

The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing? a. Keep the patient on a clear liquid diet for 72 hours. b. Send the samples to the laboratory while they are still warm. c. Inform the patient that several stool samples will be needed. d. Use a sterile container when collecting the stool samples.

Answer 128

c. Inform the patient that several stool samples will be needed.

Question 129

The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding b the nurse indicates a need to contact the prescriber and question the order? a. The patient is recovering from a traumatic brain injury. b. The patient has not had a bowel movement for 3 days. c. The patient is to have a lower GI series the following morning. d. The patient had an upper GI series performed the previous day.

Answer 129

a. The patient is recovering from a traumatic brain injury.

Question 130

The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient’s abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse? a. Keep the patient NPO and document the findings in the chart. b. Administer a laxative suppository to stimulate peristalsis. c. Insert a Salem sump nasogastric tube to low continuous suction. d. Notify the surgeon and prepare the patient to return to surgery.

Answer 130

a. Keep the patient NPO and document the findings in the chart.

Question 131

The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement? a. Glass of warmed prune juice b. Loperamide (Imodium) c. Oral fiber supplement d. An oil retention enema

Answer 131

d. An oil retention enema

Question 132

The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient’s new symptoms? a. Clostridium difficile infection b. Paralytic ileus c. Fecal impaction d. Salmonella food poisoning

Answer 132

a. Clostridium difficile infection

Question 133

The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse? a. Assist the patient to ambulate in the hall. b. Insert a rectal tube to remove retained flatus. c. Administer an enema to stimulate peristalsis. d. Encourage oral intake of fluids and high-fiber foods.

Answer 133

a. Assist the patient to ambulate in the hall.

Question 134

The nurse is caring for a patient with a history of dementia who is incontinent of a stool because of the inability to communicate the need to defecate. What is the priority action of the nurse? a. Administer a daily laxative and take the patient to the toilet afterward. b. Digitally remove stool from the patient’s rectum every other day. c. Insert a rectal tube to facilitate drainage of soft or liquid stool. d. Begin a prompted toileting program to facilitate bowel continence.

Answer 134

d. Begin a prompted toileting program to facilitate bowel continence.

Question 135

The nurse is caring for a patient who is recovering after a hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis of Impaired self-toileting? a. The patient will demonstrate a safe transfer technique between the wheelchair and the toilet. b. The call light will be answered promptly when the patient needs to use the toilet. c. Toileting will be scheduled in the morning when the patient needs to defecate. d. Toilet paper and handwashing items will be kept within easy reach of the patient.

Answer 135

a. The patient will demonstrate a safe transfer technique between the wheelchair and the toilet.

Question 136

The nurse is caring for a patient who is recovering from gastroenteritis. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed? a. Applesauce b. Orange Popsicle c. White toast d. Coffee with cream

Answer 136

d. Coffee with cream

Question 137

The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient? a. The patient will remain continent with no perineal skin breakdown. b. The patient will state satisfaction with use of gait belt for toilet transfers. c. The patient will regain ability to pull up clothing after using the toilet. d. The patient will have privacy once properly positioned on the toilet.

Answer 137

a. The patient will remain continent with no perineal skin breakdown.

Question 138

A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor? a. Water-soluble lubricant is applied to the end of the enema tubing. b. The enema tubing is primed with solution that has been warmed. c. The patient is positioned comfortably in the right side-lying Sims position. d. The patient’s bedpan is put at the bedside in preparation for use.

Answer 138

c. The patient is positioned comfortably in the right side-lying Sims position.

Question 139

The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions can the nurse delegate to the nursing assistant? (Select all that apply.) a. Gently cleaning the stoma with warm water and a washcloth b. Assessing the stoma and incision for signs of infection or ischemia c. Obtaining needed supplies from the clean utility room d. Teaching the patient how to care for the ostomy after discharge e. Determining which type of ostomy appliance to use f. Application of skin protectant to the area surrounding the stoma

Answer 139

a. Gently cleaning the stoma with warm water and a washcloth c. Obtaining needed supplies from the clean utility room f. Application of skin protectant to the area surrounding the stoma

Question 140

The nurse is caring for a patient who will be having a colonoscopy the following morning. Which items must be removed from the patient’s dinner tray since they are not allowed prior to the test? (Select all that apply.) a. Cherry-flavored gelatin b. Cream of chicken soup c. Glass of apple juice d. Coffee with cream and sugar e. Lemon-flavored Italian ice f. Can of ginger ale

Answer 140

a. Cherry-flavored gelatin b. Cream of chicken soup d. Coffee with cream and sugar

Question 141

Which foods may alter the results of a patient's fecal occult blood test? Select all that apply. A. Carrots B. Cereals C. Red meat D. Grapefruit E. Milk products

Answer 141

A. Carrots C. Red meat D. Grapefruit

Question 142

A nurse is caring for a patient admitted with diarrhea. What could be the possible causes of diarrhea in the patient? Select all that apply. A. Use of opioid drugs B. Use of antibiotics C. Food allergies D. Psychological stress E. Hypothyroidism

Answer 142

B. Use of antibiotics C. Food allergies D. Psychological stress

Question 143

A nurse suspects a patient has a fecal impaction. Which findings would be consistent for a fecal impaction? Select all that apply. A. Fatigue B. Malaise C. Cramping D. Rectal pain E. Loss of appetite

Answer 143

C. Cramping D. Rectal pain E. Loss of appetite

Question 144

A stool culture is used to: Select all that apply. A. Detect parasites. B. Help determine the cause of diarrhea. C. Verify that a previous pathogenic bacterial infection has been resolved. D. Detect blood in the stool.

Answer 144

A. Detect parasites. B. Help determine the cause of diarrhea. C. Verify that a previous pathogenic bacterial infection has been resolved.

Question 145

A nurse is teaching a group of people regarding colon cancer. Which factors should the nurse list as warning signs of colon cancer? Select all that apply. A. Rectal bleeding B. Obesity and inactivity C. Change in bowel habits D. Older than 50 years of age E. Having a family history of colon cancer

Answer 145

A. Rectal bleeding C. Change in bowel habits

Question 146

A patient is scheduled for a plain film x-ray of the kidney, ureter, and bladder. What preliminary preparations should this patient take? 1. No preparation is required in plain film. 2. Bowel preparation is done with magnesium citrate. 3. Light sedatives are provided the previous night. 4. Fasting is required before examination.

Answer 146

1. No preparation is required in plain film.

Question 147

A patient with abdominal discomfort has presence of bowel sounds that are loud, high-pitched, and rushing. What pattern of the bowel sounds should the nurse record? 1. Normal 2. Hypoactive 3. Hyperactive 4. Tympanic note

Answer 147

3. Hyperactive

Question 148

Which complication does the nurse monitor for in a pregnant patient who is taking prenatal vitamin tablets with iron? 1. Diarrhea 2. Flatulence 3. Constipation 4. Incontinence

Answer 148

3. Constipation

Question 149

A nurse is caring for a patient who has a colostomy. When assessing the color of the stoma, which color indicates the stoma is healthy? 1. Reddish pink 2. Purple 3. Blue 4. Brown 5. Black

Answer 149

1. Reddish pink

Question 150

A primary healthcare provider prescribes a normal saline enema for a patient. What does the nurse understand about the effects of this enema? Select all that apply. A. It can aid in the removal of impacted feces. B. It will distend the colon. C. It will stimulate peristalsis. D. It will irritate the colonic mucosa. E. It will lubricate the colonic mucosa.

Answer 150

A. It can aid in the removal of impacted feces. B. It will distend the colon. C. It will stimulate peristalsis.

Question 151

Which foods does the nurse teach the patient to refrain from eating to prevent flatulence? Select all that apply. A. Beans B. Spicy foods C. Fresh fruit D. Cauliflower E. Whole grains

Answer 151

A. Beans B. Spicy foods D. Cauliflower

Question 152

A nurse is teaching a patient about healthy bowel habits. What information should be included in the teaching? Select all that apply. A. Laxatives should be used regularly. B. Dietary fibers should be an essential component of the diet. C. Fluid intake should be at least 6 to 8 glasses of water per day. D. Physical exercise should be avoided to prevent constipation. E. Stress management techniques should be practiced.

Answer 152

B. Dietary fibers should be an essential component of the diet. C. Fluid intake should be at least 6 to 8 glasses of water per day. E. Stress management techniques should be practiced.

Question 153

The nurse is educating a group of women about measures to reduce the risk of urinary infections. What should the nurse include in the teaching? 1. Decrease fluid intake. 2. Wash hands frequently. 3. Urinate every 8 hours. 4. Wipe from back to front after defecation.

Answer 153

2. Wash hands frequently.

Question 154

A patient has stress incontinence. What is a characteristic of stress incontinence? 1. A sudden urge to void 2. Loss of urine when coughing 3. Constant dribbling of urine 4. Inability to reach the toilet

Answer 154

2. Loss of urine when coughing

Question 155

A 70-year-old woman complains of involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when she coughs. What should the nurse teach the patient about her disorder? Select all that apply. A. It occurs due to local irritation. B. It occurs due to nervous system disorders. C. It occurs due to weakness of muscles around the urethra. D. It is called stress incontinence. E. It occurs when the intraabdominal pressure exceeds urethral resistance.

Answer 155

C. It occurs due to weakness of muscles around the urethra. D. It is called stress incontinence. E. It occurs when the intraabdominal pressure exceeds urethral resistance.

Question 156

A patient with a bladder disorder is advised to get a urinary diversion. The patient wishes to have the type of urinary diversion that allows normal voiding. Which type of urinary diversion suits the patient's requirement? 1. Ileal conduit 2. Indiana pouch 3. Orthotopic neobladder 4. Mainz pouch

Answer 156

3. Orthotopic neobladder

Question 157

To minimize the patient's episodes of nocturia, the nurse would teach him or her to: 1. Perform perineal hygiene after urinating. 2. Set up a toileting schedule. 3. Double void. 4. Limit fluids before bedtime.

Answer 157

4. Limit fluids before bedtime.

Question 158

The nurse is teaching a group of staff members about abnormal urination patterns. Which statement made by a staff member indicates effective learning? 1. "Anuria is painful urination." 2. "Anuria is reduced volume of urine." 3. "Anuria is the failure to excrete urine." 4. "Anuria is excessive urination at night."

Answer 158

3. "Anuria is the failure to excrete urine."

Question 159

A nurse is preparing to administer a continuous bladder irrigation. Which type of catheter is useful for this type of bladder irrigation? 1. Foley catheter 2. Coudé catheter 3. Straight catheter 4. Triple-lumen catheter

Answer 159

4. Triple-lumen catheter

Question 160

The nurse is preparing to administer erythropoietin to a patient who presents with a deficiency. The nurse knows that the patient needs this medication because of dysfunction in which organ? 1. Liver 2. Bone 3. Kidney 4. Spleen

Answer 160

3. Kidney

Question 161

What are the reasons for the presence of ketones in a patient's urine? Select all that apply. A. Vomiting B. Prolonged fasting C. A diet high in sugars D. A diet adequate in proteins E. A diet low in carbohydrates

Answer 161

A. Vomiting

Question 162

The nurse is reviewing the urinalysis report for a patient. Which finding indicates possible glomerular injury? 1. White blood cells 2. Casts 3. Large proteins 4. Glucose

Answer 162

3. Large proteins

Question 163

A nurse, along with unlicensed assistive personnel (UAP), is catheterizing a patient with neurogenic bladder. What are the responsibilities of the UAP? Select all that apply. A. Focus lighting. B. Provide comfort measures. C. Assist in positioning the patient. D. Insert catheter into the urethral meatus. E. Inflate the balloon fully as per the manufacturer's direction.

Answer 163

A. Focus lighting. B. Provide comfort measures. C. Assist in positioning the patient.

Question 164

A patient has constipation. What are the signs and symptoms of constipation? Select all that apply. A. Abdominal pressure B. Abdominal distention C. Stoma "budding" D. Loose feces E. Abdominal cramping

Answer 164

A. Abdominal pressure B. Abdominal distention E. Abdominal cramping

Question 165

A nurse is preparing an enema. Which enema helps to treat local infections? 1. Isotonic enema 2. Medication enema 3. Carminative enema 4. Oil-retention enema

Answer 165

2. Medication enema

Question 166

Which diagnostic examination is the safest way to assess the urinary system in pregnant women? 1. Cystoscopy 2. An ultrasound examination 3. An intravenous pyelogram 4. A computed tomographic scan

Answer 166

2. An ultrasound examination

Question 167

The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema? a. The proper way to position the patient b. Signs and symptoms of intolerance to the procedure c. Vital signs before the procedure d. History of surgery of the anus or rectum

Answer 167

d. History of surgery of the anus or rectum

Question 168

3. To prevent constipation in an inactive patient, which early interventions should the nurse implement? (Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake

Answer 168

a. Stool softener administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake

Question 169

The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal

Answer 169

a. Drinking at least eight glasses of fluid each day

Question 170

The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice?

Answer 170

d. Spinach salad with dressing

Question 171

A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Altered Skin Integrity b. Risk for Imbalanced Fluid Volume c. Acute Pain d. Self-Care Deficit: Toileting

Answer 171

b. Risk for Imbalanced Fluid Volume

Question 172

A patient is scheduled for a colonoscopy. After preprocedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. "I can have coffee the morning of the procedure." b. "I should drink a red sports drink the day before to stay hydrated." c. "I should drink clear liquids for 2 days before the procedure." d. "I will be able to drive home immediately after the procedure."

Answer 172

c. "I should drink clear liquids for 2 days before the procedure."

Question 173

Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise

Answer 173

c. Increasing fiber in the diet

Question 174

2. A patient with a history of diarrhea is seen in the clinic. Which nursing intervention is most essential to include in this patient's plan of care? a. Weighing the patient daily b. Encouraging a diet high in fiber c. Decreasing the patient's fluid intake d. Instructing the patient to increase protein in the diet

Answer 174

a. Weighing the patient daily

Question 175

3. A patient is scheduled for an upper GI series. Which information is most important to obtain from him before the procedure? a. Allergy to lasix b. Last bowel movement c. Time the enema was administered d. Any difficulty swallowing

Answer 175

d. Any difficulty swallowing

Question 176

5. Select the most appropriate goal for a patient experiencing diarrhea related to antibiotic use: a. The patient will return to previous elimination pattern. b. The patient will increase intake of grains, rice, and cereals. c. The patient will discontinue antibiotic use and contact the health care provider. d. The patient will increase fluid intake.

Answer 176

d. The patient will increase fluid intake.

Question 177

What should be included in teaching for a patient who will be discharged with a prescription for a laxative? a. Calling the health care provider if nausea, vomiting, or abdominal pain occurs b. Continuing use of laxatives to encourage bowel evacuation c. Adding regular exercise, sufficient fluids, and regular defecation habits to his or her routine d. Knowing the difference between laxatives and cathartics

Answer 177

c. Adding regular exercise, sufficient fluids, and regular defecation habits to his or her routine

Question 178

The nursing instructor is teaching information about constipation in the elderly. Which statement from the student indicates a need for further instruction on this topic? a. Patients receiving tube feedings often experience constipation. b. Poor fluid intake and inability to eat a high-fiber diet often cause constipation. c. Patients with impaired mobility may experience constipation. d. Medications commonly taken by elders often contribute to constipation.

Answer 178

a. Patients receiving tube feedings often experience constipation.

Question 179

A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. b. Reassure the patient that it is not possible to void while catheterized. c. Catheterize the patient again with a larger-gauge catheter. d. Notify the primary care provider (PCP).

Answer 179

a. Check to see if the catheter is patent.

Question 180

Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. Tell the patient to void and pour the urine into a labeled specimen container. b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container. c. Instruct the patient to discard the first void and collect the next void for the specimen. d. Have the patient keep all voided urine for 24 hours in a chilled, opaque collection container.

Answer 180

b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container.

Question 181

A female patient has had frequent urinary tract infections. Which statement by the patient indicates that the nurse's teaching on prevention has been effective? a. "I will limit my fluid intake to 40 ounces per day." b. "I will use bubble bath when bathing." c. "I will wait to wear my tight jeans until after my urine is clear." d. "I will wipe from the front to back after voiding."

Answer 181

d. "I will wipe from the front to back after voiding."

Question 182

A patient is scheduled for an intravenous pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out? a. Urinalysis showing negative results on testing for sugar and acetone b. History of allergies c. History of a recent thyroid scan d. Frequency of urination

Answer 182

b. History of allergies

Question 183

When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? (Select all that apply.) a. Taking the urinary tract analgesic phenazopyridine (Pyridium) b. A diet that includes a large amount of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake

Answer 183

a. Taking the urinary tract analgesic phenazopyridine (Pyridium) b. A diet that includes a large amount of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease

Question 184

An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the primary concern of the nurse performing the procedure? a. Teaching deep-breathing techniques b. Maintaining strict aseptic technique c. Medicating the patient for pain before the procedure d. Positioning the patient for comfort during the procedure

Answer 184

b. Maintaining strict aseptic technique

Question 185

The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining and the patient's bladder is distended. What action should the nurse take next? a. Notify the primary care provider (PCP). b. Assess the tubing for kinks and ensure downward flow. c. Change the catheter as soon as possible. d. Aspirate the stagnant urine in the catheter for culture.

Answer 185

b. Assess the tubing for kinks and ensure downward flow.

Question 186

The nurse is placing an indwelling catheter in a female patient. She inserts the catheter into the vagina. What is the next action for the nurse to implement? a. Collect a urine specimen and notify the PCP. b. Leave the catheter in place and insert a new catheter into the urethra. c. Remove the catheter from the vagina and place it into the urethra. d. Ask another nurse to attempt the catheterization of the patient.

Answer 186

b. Leave the catheter in place and insert a new catheter into the urethra.

Question 187

What symptom is most likely to be exhibited by the patient who complains of voiding small amounts of urine in relation to his fluid intake? a. Nocturia b. Polyuria c. Anuria d. Oliguria

Answer 187

d. Oliguria

Question 188

Which organism is responsible for the majority of urinary tract infections in female patients? a. Escherichia coli b. Nesseria gonorrhea c. Candida albicans d. Haemophilus influenza

Answer 188

a. Escherichia coli

Question 189

2. A patient is experiencing acute renal failure. What is the most common cause of this critical illness? a. Hypovolemia b. Cardiogenic shock c. Nephrotoxic substances d. Urethral obstruction

Answer 189

d. Urethral obstruction

Question 190

The patient is ordered an ultrasound to determine the size, shape, and location of the kidneys. The nurse knows that prior to the test the patient will a. be required to have a bowel cleansing enema. b. be checked for any allergies to shellfish. c. be required to drink a large amount of fluids before the test. d. have no pretest requirements.

Answer 190

d. have no pretest requirements.

Question 191

Nursing interventions for the patient who suffers from stress incontinence include a. kegel exercises. b. surgical interventions. c. bowel retraining. d. intermittent catheterization.

Answer 191

a. kegel exercises.

Question 192

The nurse is inserting an indwelling catheter into a male patient. While initially passing the catheter through the urethra, resistance is met. What action should the nurse take next? a. Notify the primary care provider to place a coudé catheter. b. Straighten the penis and attempt to progress the catheter again. c. Remove the catheter and insert one with a smaller lumen. d. Inflate the balloon and wait for urine passage.

Answer 192

a. Notify the primary care provider to place a coudé catheter.

Question 193

The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. The nurse recognizes which type of renal failure the patient most likely developed? a. Prerenal b. Renal c. Postrenal d. Mixed

Answer 193

a. Prerenal

Question 194

The nurse is caring for a patient with a neurological condition that causes constant severe thirst, drinking fluids continuously, and voiding 3 to 4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this patient’s urinary output? a. Anuria b. Oliguria c. Polyuria d. Enuresis

Answer 194

c. Polyuria

Question 195

The nurse is caring for a patient who is experiencing stress incontinence. The nurse identifies which goal to be the most important for this patient? a. The patient will carefully complete a voiding diary for the duration of 2 weeks. b. The patient will not experience involuntary urination during coughing or sneezing. c. The patient will be able to recognize and effectively manage perineal dermatitis. d. The patient will demonstrate how to appropriately use urinary incontinence products.

Answer 195

b. The patient will not experience involuntary urination during coughing or sneezing.

Question 196

The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse? a. Encourage oral fluid intake and administer a diuretic. b. Obtain a urine sample to test for culture and sensitivity. c. Calculate the patient’s daily intake and output. d. Obtain an order to straight-catheterize the patient.

Answer 196

d. Obtain an order to straight-catheterize the patient.

Question 197

The nurse is caring for a patient who recently underwent ileal conduit surgery. Which nursing diagnosis is the highest priority for this patient? a. Impaired sexual function related to changed body structure b. Social isolation related to potential for accidental leakage of urine c. Lack of knowledge related to care and maintenance of ostomy appliance d. Disturbed body image related to presence of stoma and appliance

Answer 197

c. Lack of knowledge related to care and maintenance of ostomy appliance

Question 198

The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine in the toilet. Which is the priority assessment to be performed by the nurse? a. Bladder scan to determine the amount of urine in the bladder b. Auscultation to assess circulation through the right and left renal arteries c. Bimanual palpation to assess for possible enlargement of the kidneys d. Calculate the patient’s intake and output to check for fluid volume deficit

Answer 198

a. Bladder scan to determine the amount of urine in the bladder

Question 199

The nurse is caring for a patient who will undergo ultrasound testing of the bladder and kidneys the next morning. Which instruction will the nurse provide to the patient about the test? a. “A small IV will be inserted into your arm to inject the contrast dye.” b. “You will need to drink lots of water but not use the toilet.” c. “You should not have anything to eat or drink after midnight.” d. “You will receive a cleansing enema before you have the test."

Answer 199

b. “You will need to drink lots of water but not use the toilet.”

Question 200

The nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder. Which action will the nurse take to facilitate this procedure? a. Obtain a Coudé catheter for insertion. b. Attach a leg bag to the catheter prior to insertion. c. Trim the pubic hair before cleaning the perineal area. d. Wait until the bladder is full to perform catheterization.

Answer 200

a. Obtain a Coudé catheter for insertion.

Question 201

The nurse is caring for an incontinent male patient who has a deep decubitus ulcer on his sacrum. Which intervention will best manage the patient’s urinary incontinence and facilitate healing of the ulcer? a. Use of disposable absorbable incontinence briefs b. Daily application of perineal barrier cream containing zinc oxide c. Careful perineal care and application of a condom catheter d. Insertion of a single-lumen straight urinary catheter

Answer 201

c. Careful perineal care and application of a condom catheter

Question 202

The nurse is caring for a patient who has urinary frequency. Which nursing diagnosis is the highest priority for this patient? a. Impaired urination r/t occasional incontinence b. Anxiety r/t living alone at home with nocturia c. Risk for infection r/t urine contact with perineal area skin d. Risk for fall-related injury r/t hurried trips to the bathroom during the day and night

Answer 202

d. Risk for fall-related injury r/t hurried trips to the bathroom during the day and night

Question 203

The nurse is caring for a patient who has just had an intravenous pyelography (IVP) completed. Which assessment is the nurse’s highest priority after the patient returns from the test? a. Calculate the patient’s intake and output. b. Monitor for discoloration of the patient’s urine. c. Assess for possible iodine or shellfish allergies. d. Inquire if the patient has burning or pain with urination.

Answer 203

a. Calculate the patient’s intake and output.

Question 204

The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient’s bladder. What is the priority nursing diagnosis for this patient? a. Anxiety r/t continual urge to urinate b. Reflex incontinence of urine r/t over-distention of the bladder c. Impaired urination r/t obstruction of urinary bladder outlet d. Impaired self-toileting r/t inability to pass urine into the toilet

Answer 204

c. Impaired urination r/t obstruction of urinary bladder outlet

Question 205

The nurse is caring for a patient who had prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake. The patient’s urine from the indwelling catheter is cherry red with occasional small clots. What is the appropriate action of the nurse? a. Remove the urinary catheter and replace it with a new one. b. Gently irrigate the catheter using warmed sterile normal saline. c. Send a sample of the patient’s urine to the laboratory for analysis. d. Call the provider and obtain an order for kidney and bladder ultrasound.

Answer 205

b. Gently irrigate the catheter using warmed sterile normal saline.

Question 206

The nurse is caring for a patient with the nursing diagnosis of Urge incontinence of urine related to urinary tract infection. Which statement is appropriate for the “as evidenced by” portion of the patient’s diagnosis? a. Sudden leakage of urine when patient is unable to get to the toilet in time b. Continuous urine flow from the bladder regardless of attempts to use the toilet c. Leakage of urine from the bladder when the patient coughs, sneezes, or laughs d. Leakage of urine because the patient is unable to indicate need to use the toilet

Answer 206

a. Sudden leakage of urine when patient is unable to get to the toilet in time

Question 207

The nurse is caring for a patient with an indwelling urinary catheter caused by severe prostate enlargement. Which is the priority nursing diagnosis for this patient? a. Risk for infection r/t indwelling urinary catheter b. Disturbed body image r/t presence of catheter c. Risk for contamination r/t potential leakage of urine on clothing d. Impaired urination r/t blockage of bladder outlet

Answer 207

a. Risk for infection r/t indwelling urinary catheter

Question 208

The preceptor is watching a nursing student care for a male patient who requires a condom catheter. Which action by the nursing student indicates that the procedure is performed correctly? a. Sterile gloves are donned before touching the catheter. b. Adhesive tape is applied securely around the base of the penis. c. Water-soluble lubricant is applied to the end of the catheter. d. The foreskin is returned to its natural position before the catheter is applied.

Answer 208

d. The foreskin is returned to its natural position before the catheter is applied.

Question 209

The nurse is caring for a patient with a history of type 1 diabetes. Which assessment finding indicates to the nurse that the patient may not be compliant with the diabetic treatment regimen? a. The patient is always thirsty and frequently voids very large amounts of urine. b. The patient’s urine is very concentrated with a dark amber color. c. The patient complains of throbbing flank pain and burning with urination. d. The patient has urinary hesitancy and difficulty initiating a stream of urine.

Answer 209

a. The patient is always thirsty and frequently voids very large amounts of urine.

Question 210

The nurse is caring for a patient who is to undergo computed tomography (CT) of the kidneys and ureters. Which assessment finding by the nurse must be reported to the provider and radiologist before the patient has the procedure? a. The patient is allergic to bananas and latex. b. The patient thinks that she might be pregnant. c. The patient has a family history of bladder cancer. d. The patient currently has a urinary tract infection.

Answer 210

b. The patient thinks that she might be pregnant.

Question 211

The nurse is caring for an elderly patient with a history of arthritis, urinary incontinence and poor perineal hygiene practices. The patient has had four urinary tract infections in the past year. Which is the priority goal for the nursing diagnosis of Impaired health maintenance for this patient? a. The patient will be provided with educational materials about risks of urosepsis. b. The patient will allow family members to assist with daily bathing and perineal care. c. The patient will discuss the possible consequences of frequent UTIs. d. Regular home care nursing visits and follow-up telephone contact will be arranged.

Answer 211

b. The patient will allow family members to assist with daily bathing and perineal care.

Question 212

The nurse is caring for an elderly patient whose dementia has become worse over the last 24 hours. The nurse suspects that the patient may have developed a urinary tract infection and obtains a urine sample. Which assessment findings prompt the nurse to contact the provider to obtain an order for urine culture and sensitivity testing? (Select all that apply.) a. Urinary dipstick testing is positive for nitrates. b. The urine appears cloudy with a foul odor. c. The urine is concentrated and dark amber in color. d. The urine smells faintly like sweet fruit. e. The patient is urinating more frequently than usual. f. The patient is normally continent but has been incontinent twice.

Answer 212

a. Urinary dipstick testing is positive for nitrates. b. The urine appears cloudy with a foul odor. e. The patient is urinating more frequently than usual. f. The patient is normally continent but has been incontinent twice.

Question 213

The nurse is caring for a male patient who will be performing intermittent self-catheterization at home. Which actions by the patient indicate the need for additional teaching about this procedure? (Select all that apply.) a. Patency of the balloon is tested prior to insertion of the catheter. b. The catheter is inserted another 2 inches after urine is seen in the tubing. c. The catheter is carefully secured to the leg to prevent accidental removal. d. The foreskin is returned to its natural position after the catheter is removed. e. Catheterization is performed regularly before the bladder becomes distended. f. Water-soluble lubricant is generously applied along the length of the catheter.

Answer 213

a. Patency of the balloon is tested prior to insertion of the catheter. c. The catheter is carefully secured to the leg to prevent accidental removal. f. Water-soluble lubricant is generously applied along the length of the catheter.

Question 214

The nurse is working with a new nursing assistant who is providing care to patients with urinary difficulties. Which actions by the nursing assistant indicates that additional teaching is required? (Select all that apply.) a. The length of the urinary catheter is cleaned up to the patient’s perineum. b. A urine sample is obtained from the drainage bag immediately after catheter insertion. c. A fresh condom catheter is applied every other day following careful perineal care. d. Zinc oxide barrier cream is applied liberally to the perineal area for incontinent patients. e. The catheter drainage bag is disconnected in order to put pants on the patient. f. Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter.

Answer 214

a. The length of the urinary catheter is cleaned up to the patient’s perineum. c. A fresh condom catheter is applied every other day following careful perineal care. e. The catheter drainage bag is disconnected in order to put pants on the patient. f. Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter.

Question 215

The nurse is caring for a patient who is to complete a 24-hour urine collection to measure creatinine clearance. Which tasks related to this test may be delegated to the nursing assistant? (Select all that apply.) a. Teaching the patient about sterile specimen collection b. Keeping the urine collection container cool on ice c. Dumping the urine from the patient’s first void d. Restricting the patient’s oral fluid intake during the test e. Transporting the specimen to the laboratory for testing f. Reminding the patient not to put toilet paper in the urine

Answer 215

b. Keeping the urine collection container cool on ice c. Dumping the urine from the patient’s first void e. Transporting the specimen to the laboratory for testing f. Reminding the patient not to put toilet paper in the urine

Question 216

After teaching a client who has stress incontinence, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching? a. “I will limit my total intake of fluids.” b. “I must avoid drinking alcoholic beverages.” c. “I must avoid drinking caffeinated beverages.” d. “I shall try to lose about 10% of my body weight.”

Answer 216

a. “I will limit my total intake of fluids.”

Question 217

The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? a. What type of incontinence pads to use? b. What types of liquids to drink and when? c. Need to perform intermittent catheterizations. d. How to do Kegel exercises to strengthen muscles?

Answer 217

d. How to do Kegel exercises to strengthen muscles?

Question 218

After delegating care to assistive personnel (AP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the AP’s understanding. Which action indicates that the AP needs additional teaching? a. Toileting the client after breakfast b. Changing the client’s incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the client’s incontinence episodes

Answer 218

b. Changing the client’s incontinence brief when wet

Question 219

The nurse is giving oral mineral oil as an ordered laxative dose. The nurse will take measures to prevent which potential problem that may occur with mineral oil? a. Fecal impaction b. Electrolyte imbalances c. Lipid pneumonia d. Esophageal blockage

Answer 219

c. Lipid pneumonia

Question 220

When administering a bulk-forming laxative, the nurse instructs the patient to drink the medication mixed in a full 8-ounce glass of water. Which statement best explains the rationale for this instruction? a. The water acts to stimulate bowel movements. b. The water will help to reduce the bulk of the intestinal contents. c. These laxatives may cause esophageal obstruction if taken with insufficient water. d. The water acts as a lubricant to produce bowel movements.

Answer 220

c. These laxatives may cause esophageal obstruction if taken with insufficient water.

Question 221

A patient will be taking bismuth subsalicylate (Pepto-Bismol) to control diarrhea. When reviewing the patient’s other ordered medications, the nurse recognizes that which medication or medication class will interact significantly with the Pepto-Bismol? a. Hypoglycemic drugs b. Antibiotics c. Acetaminophen (Tylenol) d. Antidepressants.

Answer 221

a. Hypoglycemic drugs

Question 222

While recovering from surgery, an elderly woman started taking a stimulant laxative, senna (Senokot), to relieve constipation caused by the pain medications. Two weeks later, at her follow-up appointment, she tells the nurse that she likes how “regular” her bowel movements are now that she is taking the laxative. Which teaching principle is appropriate for this patient? a. She needs to be sure to take this medication with plenty of fluids. b. It is important to have a daily bowel movement to promote bowel health. c. Long-term use of laxatives often results in decreased bowel tone and may lead to dependency. d. She needs to switch to glycerin suppositories to continue having daily bowel movements.

Answer 222

c. Long-term use of laxatives often results in decreased bowel tone and may lead to dependency.

Question 223

A patient asks the nurse about the difference between diphenoxylate with atropine (Lomotil) and the over-the-counter drug loperamide (Imodium). Which response by the nurse is correct? a. “Lomotil acts faster than Imodium.” b. “Imodium does not cause physical dependence.” c. “Lomotil is available in suppository form.” d. “Imodium is a natural antidiarrheal drug.”

Answer 223

b. “Imodium does not cause physical dependence.”

Question 224

A patient wants to prevent problems with constipation and asks the nurse for advice about which type of laxative is safe to use for this purpose. Which class of laxative is considered safe to use on a long-term basis? a. Emollient laxatives b. Bulk-forming laxatives c. Hyperosmotic laxatives d. Stimulant laxatives

Answer 224

b. Bulk-forming laxatives

Question 225

When administering mineral oil, the nurse recognizes that it can interfere with the absorption of which substance? a. Fat-soluble vitamins b. Water-soluble vitamins c. Minerals d. Electrolytes

Answer 225

a. Fat-soluble vitamins

Question 226

The nurse is reviewing the mechanism of action of antidiarrheal drugs. Which type of antidiarrheal medication works by decreasing the intestinal muscle tone and peristalsis of the intestines? a. Adsorbents such as Pepto-Bismol b. Anticholinergics such as belladonna alkaloids c. Probiotics such as Lactinex d. Lubricants such as mineral oil

Answer 226

b. Anticholinergics such as belladonna alkaloids

Question 227

The nurse is discussing the use of adsorbents such as bismuth subsalicylate (Pepto-Bismol) with a patient who has diarrhea. The nurse will warn the patient about which possible adverse effects? a. Dark stools and blue gums b. Urinary hesitancy c. Drowsiness and dizziness d. Blurred vision and headache

Answer 227

a. Dark stools and blue gums

Question 228

A patient who has been on antibiotic therapy for 2 weeks has developed persistent diarrhea. The nurse expects which medication class to be ordered to treat this diarrhea? a. Lubricants b. Adsorbents c. Anticholinergics d. Probiotics

Answer 228

d. Probiotics

Question 229

A laxative has been ordered for a patient. The nurse checks the patient’s medical history and would be concerned if which condition is present? a. High ammonia levels due to liver failure b. Diverticulosis c. Abdominal pain of unknown origin d. Chronic constipation

Answer 229

c. Abdominal pain of unknown origin

Question 230

A patient is severely constipated and needs immediate relief. The nurse knows that which class of laxative will provide the most rapid results? a. Bulk-forming laxative, such as psyllium (Metamucil) b. Stool softener, such as docusate salts (Colace) c. Magnesium hydroxide (MOM) d. Magnesium oxide tablets

Answer 230

c. Magnesium hydroxide (MOM)

Question 231

A patient is receiving lactulose (Enulose) three times a day. The nurse knows that the patient is not constipated and is receiving this drug for which reason? a. High ammonia levels due to liver failure b. Prevention of constipation c. Chronic renal failure d. Chronic diarrhea

Answer 231

a. High ammonia levels due to liver failure

Question 232

A patient is taking linaclotide (Linzess) to treat irritable bowel syndrome (IBS). The nurse will monitor this patient for which adverse effect? a. Chest pain b. Chronic constipation c. Abdominal pain d. Elevated blood glucose levels

Answer 232

c. Abdominal pain

Question 233

The nurse is preparing to administer methylnaltrexone (Relistor). This drug is appropriate for which patient? a. A patient with diarrhea b. A terminally ill patient who has opioid-induced constipation c. A patient who is scheduled for a colonoscopy d. A patient who will be having colon surgery in the morning

Answer 233

b. A terminally ill patient who has opioid-induced constipation

Question 234

A patient has been treated with alosetron (Lotronex) for severe irritable bowel syndrome (IBS) for 2 weeks. She calls the clinic and tells the nurse that she has been experiencing constipation for 3 days. The nurse will take which action? a. Advise the patient to increase intake of fluids and fiber. b. Advise the patient to hold the drug for 2 days. c. Instruct the patient to stop taking the drug and to come to the clinic right away to be evaluated. d. Instruct the patient to continue the alosetron and to take milk of magnesia for the constipation.

Answer 234

c. Instruct the patient to stop taking the drug and to come to the clinic right away to be evaluated.

Question 235

A patient has been treated with alosetron (Lotronex) for severe irritable bowel syndrome (IBS) for 2 weeks. She calls the clinic and tells the nurse that she has been experiencing constipation for 3 days. The nurse will take which action? a. Advise the patient to increase intake of fluids and fiber. b. Advise the patient to hold the drug for 2 days. c. Instruct the patient to stop taking the drug and to come to the clinic right away to be evaluated. d. Instruct the patient to continue the alosetron and to take milk of magnesia for constipation.

Answer 235

c. Instruct the patient to stop taking the drug and to come to the clinic right away to be evaluated.

Question 236

The nurse identifies what physiological response occurs with the onset of darkness and in preparation for sleep? a. Cortisol levels peak b. Cortisol levels increase c. Core body temperature increases d. Melatonin levels increase

Answer 236

d. Melatonin levels increase

Question 237

The nurse recognizes what function of the reticular activating system (RAS)? a. Records brain waves and other variables. b. Relays motor impulse to the hypothalamus. c. Influences patterns of biological functioning. d. Is affected by the light-dark cycle.

Answer 237

b. Relays motor impulse to the hypothalamus.

Question 238

The nurse is educating a patient about taking measures to help avoid disruption to the circadian rhythm. Which statement by the patient indicates a need for further education? a. “I know the circadian rhythm influences biological functions.” b. “I know the circadian rhythm exists only in humans.” c. “I know the sleep-wake circadian rhythm is impacted by the light-dark cycle.” d. “The most familiar circadian rhythm is the day-night 24-hour cycle.”

Answer 238

b. “I know the circadian rhythm exists only in humans.”

Question 239

The nurse teaches the patient what information about polysomnography? a. This is the recording of brain waves and other variables. b. This is the relay of motor impulse to the hypothalamus. c. This is the patterns of biological functioning. d. This is the recording of seizure activity in the brain.

Answer 239

a. This is the recording of brain waves and other variables.

Question 240

The nurse identifies which sequence to be the usual progression of sleep? a. NREM 1-3 then REM, then back through NREM 1 and 2 b. REM then NREM 1-4, then back through NREM 2 and 3 c. NREM 1-3 then back through NREM 3 and 2 then REM d. REM then NREM 1-4 then back through NREM 3

Answer 240

c. NREM 1-3 then back through NREM 3 and 2 then REM

Question 241

The nurse is providing discharge instructions to the parents of a toddler about sleeping habits. Which statement indicates further education is needed? a. “Sleep needs may change during growth spurts.” b. “Children sleep 12 hours a day.” c. “Toddlers will often resist going to bed.” d. “The bedtime routine can vary.”

Answer 241

d. “The bedtime routine can vary.”

Question 242

When the nurse is explaining cataplexy to the patient, which description should be included? a. It is an uncontrolled desire to sleep. b. It is falling asleep for several minutes. c. It is loss of voluntary muscle tone. d. It is a sleep cycle that begins with NREM.

Answer 242

c. It is loss of voluntary muscle tone.

Question 243

The nurse is providing discharge instructions to a patient who has had sleep alterations. Which statement by the patient indicates further education is needed? a. “I should avoid drinking caffeine too close to bedtime.” b. “I should not eat anything too close to bedtime.” c. “I should exercise regularly to help with sleeping.” d. “I can gain weight if I don’t sleep enough.”

Answer 243

b. “I should not eat anything too close to bedtime.”

Question 244

The nurse is performing an assessment of the patient’s sleep patterns. Which question by the nurse will elicit the best response? a. “Do you feel rested when you awaken?” b. “What is your normal eating pattern?” c. “Do you awaken during the night?” d. “Do you drink beverages with caffeine?”

Answer 244

c. “Do you awaken during the night?”

Question 245

A patient has sleep deprivation. What finding by the nurse best indicates goal achievement? a. Remains asleep for 6 to 7 hours consistently for 1 week. b. Falls asleep within 15 minutes of going to bed. c. Reports an ability to concentrate on tasks. d. Verbalizes understanding of medication instructions.

Answer 245

a. Remains asleep for 6 to 7 hours consistently for 1 week.

Question 246

The nurse is working with a patient who has been advised to take 2 20-minute naps during the day for fatigue. After a week, the patient states the naps have not helped. What response by the nurse is best? a. “Maybe that is too much sleep for you during the day.” b. “Why don’t you try one 40-minute nap instead?” c. “Let’s explore some sleeping medications for you to try.” d. “It often takes a few weeks for napping to help.”

Answer 246

d. “It often takes a few weeks for napping to help.” Rationale: Taking 2 20-minute naps is an appropriate action for the patient with fatigue to implement. Many non-pharmacological interventions take weeks to become effective, so the nurse would explain that fact and encourage the patient to continue the napping.

Question 247

The nurse wants to help a hospitalized patient get more sleep. What intervention will be most helpful? a. Allow the patient an hour nap during the day shift. b. Administer sleeping medication if the patient can’t go to sleep after an hour. c. Place a “do not disturb” sign on the door for the duration of the night shift. d. Cluster cares so the patient gets at least 90 minutes of uninterrupted sleep at night.

Answer 247

d. Cluster cares so the patient gets at least 90 minutes of uninterrupted sleep at night.

Question 248

The nurse is providing discharge education for a patient with narcolepsy. Which statement by the patient indicates a need for further education? a. “Daytime naps are helpful.” b. “Taking the medication will cure it.” c. “High protein meals are helpful.” d. “I need to avoid alcohol.”

Answer 248

b. “Taking the medication will cure it.”

Question 249

Which task is inappropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Providing oral care b. Evaluating sleep patterns c. Providing bedtime routines d. Documenting sleep hours

Answer 249

b. Evaluating sleep patterns

Question 250

The nurse is providing discharge instructions for the patient with sleep pattern disturbances. Which statement by the patient indicates a need for further education? a. “It is a good idea to have a bedtime routine.” b. “My bedtime routine can include watching TV in bed until I fall asleep.” c. “I will keep my regular sleep pattern on the weekend.” d. “If I can’t fall asleep, I will get out of bed and do something relaxing.”

Answer 250

b. “My bedtime routine can include watching TV in bed until I fall asleep.”

Question 251

The nurse knows that during rapid eye movement (REM) sleep, which activities occur? (Select all that apply.) a. Memories are stored b. Increase in cerebral blood flow c. Slow rhythmic scanning eye movements d. Release of epinephrine e. Repair of brain cells

Answer 251

a. Memories are stored b. Increase in cerebral blood flow d. Release of epinephrine

Question 252

The student nurse learns that during non–rapid eye movement (NREM) sleep, which activities occur? (Select all that apply.) a. Brain waves slow b. Slow rhythmic scanning eye movements c. Dreaming d. Drop in blood pressure e. Conservation of energy

Answer 252

a. Brain waves slow d. Drop in blood pressure e. Conservation of energy

Question 253

The nurse recognizes which changes in sleep patterns occur in the older adult? (Select all that apply.) a. Sleep increases to approximately 8 to 10 hours a night. b. REM sleep is shorter. c. Stage 4 NREM is decreased. d. The use of medication may interfere with sleep. e. Older adults awaken more at night.

Answer 253

c. Stage 4 NREM is decreased. d. The use of medication may interfere with sleep. e. Older adults awaken more at night.

Question 254

The nurse is providing community education on sudden infant death syndrome (SIDS). What information does the nurse include? (Select all that apply.) a. SIDS is the second most common cause of death among infants (1 to 12 months). b. The etiology remains largely unknown. c. The most modifiable risk factor is sleeping supine. d. Risk factors include being exposed to cigarette smoke. e. It is defined as sudden unexpected death.

Answer 254

b. The etiology remains largely unknown. d. Risk factors include being exposed to cigarette smoke. e. It is defined as sudden unexpected death.

Question 255

The nurse recognizes which sleeping conditions are identified as dyssomnias? (Select all that apply.) a. Difficultly getting to sleep b. Nocturnal enuresis c. Inability staying asleep d. Being excessively sleepy e. Falling asleep during the day

Answer 255

a. Difficultly getting to sleep c. Inability staying asleep d. Being excessively sleepy e. Falling asleep during the day

Question 256

The nurse manager is concerned about nursing staff who are working the night shift. What interventions can the manager suggest to help the nurses overcome shift-related sleep disturbances? (Select all that apply.) a. Power nap before leaving for the first night shift. b. Get a minimum of 4 hours of sleep. c. Wear dark glasses when driving home from work. d. Seek exposure to bright light when waking. e. Maintain a regular sleeping schedule when working and on nights off.

Answer 256

a. Power nap before leaving for the first night shift. c. Wear dark glasses when driving home from work. d. Seek exposure to bright light when waking. e. Maintain a regular sleeping schedule when working and on nights off.

Question 257

The nurse conducting a sleep workshop in the community would identify which patients to be at risk for obstructive sleep apnea (OSA)? (Select all that apply.) a. Deviated septum b. Recessed chin c. Alcohol use d. Large neck e. Recent tonsillectomy

Answer 257

a. Deviated septum b. Recessed chin c. Alcohol use d. Large neck

Question 258

The nurse is admitting a patient to the general medical–surgical unit. What should the nurse assess as part of a routine sleep assessment? (Select all that apply.) a. Usual sleeping and waking times b. Bedtime routines c. Sleeping environment preferences d. Medications used for sleep e. Any current life events

Answer 258

a. Usual sleeping and waking times b. Bedtime routines c. Sleeping environment preferences d. Medications used for sleep e. Any current life events

Question 259

The nurse will include which interventions to help improve sleep quality during hospitalization on all patients’ care plans? (Select all that apply.) a. Maintaining sleep routines b. Minimizing disruptions c. Providing light snacks d. Using sleep medications e. Using relaxation measures

Answer 259

a. Maintaining sleep routines b. Minimizing disruptions c. Providing light snacks e. Using relaxation measures

Question 260

The nurse is providing discharge education for a patient with restless leg syndrome. Which statement by the patient indicates a need for further instruction? a. “I should avoid all caffeine.” b. “I can do leg massage and knee bends.” c. “Taking magnesium supplements may be helpful.” d. “Taking a walk regularly may be helpful.”

Answer 260

a. “I should avoid all caffeine.”

Question 261

The nurse is caring for a patient recovering from knee replacement surgery. The patient complains of severe pain in the knee after receiving hydrocodone with acetaminophen (Vicodin) 2 hours previously. What is the nurse’s best action? a. Administer another dose of the medication. b. Apply ice packs to the knee. c. Apply heat packs to the knee. d. Perform gentle range of motion.

Answer 261

b. Apply ice packs to the knee.

Question 262

The nurse is checking on the patient after administering pain medication 30 minutes previously. Which assessment finding best indicates to the nurse that the pain medication was effective? a. The patient is sleeping quietly. b. The patient states a reduction of the pain. c. The patient’s respirations are slow and regular. d. The patient’s blood pressure has returned to baseline.

Answer 262

b. The patient states a reduction of the pain.

Question 263

The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. The nurse recognizes which type of pain is this patient experiencing? a. Visceral pain b. Somatic pain c. Radiating pain d. Referred pain

Answer 263

a. Visceral pain

Question 264

The nurse knows which is the best pain medication option for a patient to manage severe long-term cancer pain at home? a. Fentanyl (Duragesic) 50 mcg transdermal patch q 72 hours b. Meperidine (Demerol) 50 mg IM q 6 hours c. Hydromorphone (Dilaudid) 0.2 mg q 10 minutes IV via PCA pump d. Hydromorphone (Dilaudid) 0.08 mg/hour infusion through epidural catheter

Answer 264

a. Fentanyl (Duragesic) 50 mcg transdermal patch q 72 hours

Question 265

The nurse is caring for a patient with severe chronic pain and applied the first 50 mcg transdermal fetanyl (Duragesic) patch 2 hours ago. The patient states that the pain is presently rated at 9 on a 1 to 10 scale. What is the nurse’s best action? a. Instruct the patient that the fentanyl patch will start to work soon. b. Check the provider’s orders for a short-acting narcotic medication to administer for breakthrough pain. c. Give the patient a gentle back rub and encourage guided imagery. d. Apply a second 25-mcg transdermal fentanyl patch now.

Answer 265

b. Check the provider’s orders for a short-acting narcotic medication to administer for breakthrough pain.

Question 266

The nurse is caring for a patient who has been taking ibuprofen (Motrin) 800 mg TID for the last several months to relieve knee pain from arthritis. Which assessment finding must be reported by the nurse to the provider promptly? a. The patient has abdominal pain and pale skin. b. The patient has constipation and takes stool softeners daily. c. The patient enjoys a glass of wine every Friday and Saturday evening. d. The patient has gained 15 lb in the last 3 months.

Answer 266

a. The patient has abdominal pain and pale skin.

Question 267

The nurse is caring for a patient who just underwent laparoscopic appendectomy. The patient complains of severe postoperative pain between the shoulder blades. Which term best describes the pain that this patient is having? a. Referred pain b. Phantom pain c. Neuropathic pain d. Psychogenic pain

Answer 267

a. Referred pain

Question 268

The nurse is caring for a patient who will be using a hydromorphone (Dilaudid) PCA analgesia pump following surgery. Which intervention is the highest priority for the nurse to include in the patient’s care plan related to this pump? a. Assess the patient’s respiratory status frequently after PCA pump started. b. Review patient’s medication profile to check for interactions with hydromorphone. c. Teach the patient how to use PCA pump when the pain level is still tolerable. d. Keep naloxone (Narcan) available at the bedside in case of respiratory depression.

Answer 268

c. Teach the patient how to use PCA pump when the pain level is still tolerable.

Question 269

The nurse is caring for a patient who is recovering from thoracotomy surgery and notes that the patient’s pain is rated 9/10 and is unable to focus on anything. Which intervention by the nurse is the highest priority? a. Administer prescribed IV pain medication and evaluate impact in 30 minutes. b. Ask the patient to describe prior pain experiences and methods used to manage pain. c. Explain that comfort is a priority goal of nursing care in the postoperative period. d. Assist the patient to minimize the effects of pain on interpersonal relationships with family members.

Answer 269

a. Administer prescribed IV pain medication and evaluate impact in 30 minutes.

Question 270

The nurse is caring for a patient with rheumatoid arthritis who is in constant severe pain. Which nursing diagnosis is the highest priority for this patient? a. Impaired mobility r/t patient’s need to use a cane or walker with ambulation b. Impaired health maintenance r/t sedentary lifestyle and poor physical condition c. Anxiety r/t mistrust of health care personnel d. Chronic pain r/t ongoing inflammatory tissue damage and joint destruction

Answer 270

d. Chronic pain r/t ongoing inflammatory tissue damage and joint destruction

Question 271

The nurse is caring for a cancer patient with ongoing pain from widespread metastasis to the bones. The nurse notes that the patient’s morphine dosage had to be increased to sufficiently manage the discomfort. What is the nurse’s interpretation of this assessment finding? a. The patient became tolerant to the previous morphine dosage. b. The patient is becoming addicted to the pain medication. c. The patient has been abusing the prescribed pain medications. d. The patient may be seeking to end life with an overdose of morphine.

Answer 271

a. The patient became tolerant to the previous morphine dosage.

Question 272

The nurse identifies which patient to be best suited for PCA analgesia? a. A patient who is confused after a head injury b. A patient recovering from total hysterectomy surgery c. A patient who has severe psychogenic pain d. A patient with arthritis who is unable to push the nurse call button

Answer 272

b. A patient recovering from total hysterectomy surgery

Question 273

What is the priority nursing assessment for a patient who is receiving postoperative epidural analgesia with hydromorphone (Dilaudid)? a. Respiratory rate, depth, and pattern b. Skin underneath the epidural dressing c. Bladder scanning to check for urinary retention d. Itching on the trunk and/or extremities

Answer 273

a. Respiratory rate, depth, and pattern

Question 274

The nurse is caring for a diabetic patient who has painful foot neuropathy. The patient asks why the nurse is administering gabapentin (Neurontin) when there is no history of seizure disorder. What is the nurse’s best response? a. “Gabapentin will help you sleep at night so you can deal with the pain more effectively.” b. “Long-term diabetes can put patients at risk for certain type of seizures.” c. “This medication can help relieve your anxiety from being admitted to the hospital.” d. “Gabapentin works on the nervous system to help relieve the burning pain in your feet.”

Answer 274

d. “Gabapentin works on the nervous system to help relieve the burning pain in your feet.”

Question 275

The nurse is caring for a patient who has a PCA pump following total hysterectomy surgery. The nurse sees the visitor push the PCA button while the patient is sleeping quietly. What is the best response of the nurse? a. “Thank you for pushing the button for her to help keep her comfortable after surgery.” b. “Please do not push the button for the patient—she could receive more medication than she needs.” c. “You can push the button for her now, but please have her do it herself when she awakens.” d. “PCA pumps are great because she doesn’t have to wait for me to administer her pain medication.”

Answer 275

b. “Please do not push the button for the patient—she could receive more medication than she needs.”

Question 276

Which assessment question helps the nurse determine the character of the patient’s pain? a. “What does the pain feel like?” b. “When did the pain first start?” c. “What interventions make the pain better?” d. “Is there any pattern to when the pain occurs?”

Answer 276

a. “What does the pain feel like?”

Question 277

The nurse is caring for a patient who only speaks a foreign language. What is the best method for the nurse to assess the patient’s pain level? a. Perform a pain assessment using a translator. b. Check the patient’s vital signs and pulse oximetry. c. Check the patient’s respiratory rate, depth, and rhythm. d. Look to see if the patient appears to be resting comfortably.

Answer 277

a. Perform a pain assessment using a translator.

Question 278

The nurse is caring for a trauma patient with the Nursing diagnosis of acute pain r/t fracture and muscle spasms. Which is an appropriate goal for this Nursing diagnosis? a. The patient will experience less pain when participating in physical therapy. b. The patient will describe meditation techniques that can be used to cope with pain. c. Nursing staff will explain the ordered pain management approach to the patient. d. The patient will feel less pain each day when range-of-motion therapy is performed.

Answer 278

b. The patient will describe meditation techniques that can be used to cope with pain.

Question 279

The nurse is caring for a patient who has pain following abdominal surgery. Which actions are independent nursing interventions that can be used to make the patient more comfortable? (Select all that apply.) a. Encourage the patient to relax and imagine resting on a tropical beach. b. Provide headphones so that the patient can listen to favorite music. c. Increase pain medication dosage if prescribed regimen is ineffective to manage pain. d. Teach the patient to take pain medication before discomfort becomes severe. e. Switch the patient from IV to oral pain medication when bowel sounds return. f. Demonstrate the use of relaxation breathing before painful procedures.

Answer 279

a. Encourage the patient to relax and imagine resting on a tropical beach. b. Provide headphones so that the patient can listen to favorite music. d. Teach the patient to take pain medication before discomfort becomes severe. f. Demonstrate the use of relaxation breathing before painful procedures.

Question 280

The nurse is caring for a patient who just had knee replacement surgery. Which factors will affect how the patient experiences pain after this surgery? (Select all that apply.) a. The patient has had rheumatoid arthritis for the last 16 years. b. The patient is allergic to aspirin and strawberries. c. The patient owns a business and is self-insured. d. The patient has been a vegetarian for the last 8 years. e. The patient had the other knee replaced 2 years ago. f. The patient was a marathon runner in high school and college

Answer 280

a. The patient has had rheumatoid arthritis for the last 16 years. e. The patient had the other knee replaced 2 years ago. f. The patient was a marathon runner in high school and college

Question 281

The nurse is caring for a client who has severe osteoarthritis. What primary joint problems will the nurse expect the client to report? a. Crepitus b. Effusions c. Pain d. Deformities

Answer 281

c. Pain

Question 282

A nurse is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which drug does the nurse plan health teaching? a. Acetaminophen b. Cyclobenzaprine hydrochloride c. Hyaluronate d. Ibuprofen

Answer 282

a. Acetaminophen

Question 283

The nurse assesses a client with diabetes and osteoarthritis (OA) during a checkup. The nurse notes the client’s blood glucose readings have been elevated. What question by the nurse is most appropriate? a. “Are you following the prescribed diabetic diet?” b. “Have you been taking glucosamine supplements?” c. “How much exercise do you really get each week?” d. “You’re still taking your diabetic medication, right?”

Answer 283

b. “Have you been taking glucosamine supplements?”

Question 284

The nurse interviews an older client with moderate osteoarthritis and her husband. What psychosocial assessment question would the nurse include? a. “Do you feel like hurting yourself or others?” b. “Are you planning to retire due to your disease?” c. “Do you ask your husband for assistance?” d. “Do you experience discomfort during sex?”

Answer 284

d. “Do you experience discomfort during sex?”

Question 285

A patient was diagnosed with pancreatic cancer last month, and has complained of a dull ache in the abdomen for the past 4 months. This pain has been gradually increasing, and the pain relievers taken at home are no longer effective. What type of pain is the patient experiencing? a. Acute pain b. Chronic pain c. Somatic pain d. Neuropathic pain

Answer 285

b. Chronic pain

Question 286

A 16-year-old field hockey player fell and twisted her ankle during a game. The nurse will expect to administer which type of analgesic? a. Synthetic opioid, such as meperidine (Demerol) b. Opium alkaloid, such as morphine sulfate c. Opioid antagonist, such as naloxone HCL (Narcan) d. Nonopioid analgesics, such as indomethacin (Indocin)

Answer 286

d. Nonopioid analgesics, such as indomethacin (Indocin)

Question 287

A patient had abdominal surgery this morning. The patient is groggy but complaining of severe pain around the incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient? a. The patient’s pulse rate b. The patient’s respiratory rate c. The appearance of the incision d. The date of the patient’s last bowel movement

Answer 287

b. The patient’s respiratory rate

Question 288

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 breaths/minute. The nurse prepares for which priority action at this time? a. Assessment of the patient’s pain level b. Immediate intubation and artificial ventilation c. Administration of naloxone (Narcan) d. Close observation of signs of opioid tolerance

Answer 288

c. Administration of naloxone (Narcan)

Question 289

A patient will be discharged with a 1-week supply of an opioid analgesic for pain management after abdominal surgery. The nurse will include which information in the teaching plan? a. How to prevent dehydration due to diarrhea b. The importance of taking the drug only when the pain becomes severe c. How to prevent constipation d. The importance of taking the drug on an empty stomach

Answer 289

c. How to prevent constipation

Question 290

A patient has been treated for lung cancer for 3 years. Over the past few months, the patient has noticed that the opioid analgesic is not helping as much as it had previously and more medication is needed for the same pain relief. The nurse is aware that this patient is experiencing which of these? a. Opioid addiction b. Opioid tolerance c. Opioid toxicity d. Opioid abstinence syndrome

Answer 290

b. Opioid tolerance

Question 291

A 38-year-old man has come into the urgent care center with severe hip pain after falling from a ladder at work. He says he has taken several pain pills over the past few hours but cannot remember how many he has taken. He hands the nurse an empty bottle of acetaminophen (Tylenol). The nurse is aware that the most serious toxic effect of acute acetaminophen overdose is which condition? a. Tachycardia b. Central nervous system depression c. Hepatic necrosis d. Nephropathy

Answer 291

c. Hepatic necrosis

Question 292

A 57-year-old woman being treated for end-stage breast cancer has been using a transdermal opioid analgesic as part of the management of pain. Lately, she has been experiencing breakthrough pain. The nurse expects this type of pain to be managed by which of these interventions? a. Administering NSAIDs b. Administering an immediate-release opioid c. Changing the opioid route to the rectal route d. Making no changes to the current therapy

Answer 292

b. Administering an immediate-release opioid

Question 293

The nurse is reviewing herbal therapies. Which is a common use of the herb feverfew? a. Muscle aches b. Menstrual cramps c. Joint pain d. Incision pain after surgery

Answer 293

b. Menstrual cramps

Question 294

A patient is to receive acetylcysteine (Mucomyst) as part of the treatment for an acetaminophen (Tylenol) overdose. Which action by the nurse is appropriate when giving this medication? a. Giving the medication undiluted for full effect b. Avoiding the use of a straw when giving this medication c. Disguising the flavor with soda or flavored water d. Preparing to give this medication via a nebulizer

Answer 294

c. Disguising the flavor with soda or flavored water

Question 295

A patient is receiving gabapentin (Neurontin), an anticonvulsant, but has no history of seizures. The nurse expects that the patient is receiving this drug for which condition? a. Inflammation pain b. Pain associated with peripheral neuropathy c. Depression associated with chronic pain d. Prevention of seizures

Answer 295

b. Pain associated with peripheral neuropathy

Question 296

The nurse is assessing a patient who has been admitted to the emergency department for a possible opioid overdose. Which assessment finding is characteristic of an opioid drug overdose? a. Dilated pupils b. Restlessness c. Respiration rate of 6 breaths/min d. Heart rate of 55 beats/min

Answer 296

c. Respiration rate of 6 breaths/min

Question 297

The drug nalbuphine (Nubain) is an agonist-antagonist (partial agonist). The nurse understands that which is a characteristic of partial agonists? a. They have anti-inflammatory effects. b. They are given to reverse the effects of opiates. c. They have a higher potency than agonists. d. They have a lower dependency potential than agonists.

Answer 297

d. They have a lower dependency potential than agonists.

Question 298

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen (Tylenol). Which patient should not receive acetaminophen? a. A patient with a fever of 101° F (38.3° C) b. A patient who is complaining of a mild headache c. A patient with a history of liver disease d. A patient with a history of peptic ulcer disease

Answer 298

c. A patient with a history of liver disease

Question 299

A patient arrives at the urgent care center complaining of leg pain after a fall when rock climbing. The radiographs show no broken bones, but he has a large bruise on his thigh. The patient says he drives a truck and does not want to take anything strong because he needs to stay awake. Which statement by the nurse is most appropriate? a. “It would be best for you not to take anything if you are planning to drive your truck.” b. “We will discuss with your doctor about taking an opioid because that would work best for your pain.” c. “You can take acetaminophen, also known as Tylenol, for pain, but no more than 1000 mg per day.” d. “You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg/day.

Answer 299

d. “You can take acetaminophen, also known as Tylenol, for pain, but no more than 3000 mg/day.

Question 300

A patient is suffering from tendonitis of the knee. The nurse is reviewing the patient’s medication administration record and recognizes that which adjuvant medication is most appropriate for this type of pain? a. Antidepressant b. Anticonvulsant c. Corticosteroid d. Local anesthesia

Answer 300

c. Corticosteroid

Question 301

During a fishing trip, a patient pierced his finger with a large fishhook. He is now in the emergency department to have it removed. The nurse anticipates that which type of anesthesia will be used for this procedure? a. No anesthesia b. Topical benzocaine spray on the area c. Topical prilocaine/lidocaine (EMLA) cream around the site d. Infiltration of the puncture wound with lidocaine

Answer 301

d. Infiltration of the puncture wound with lidocaine

Question 302

While monitoring a patient who had surgery under general anesthesia 2 hours ago, the nurse notes a sudden elevation in body temperature. This finding may be an indication of which problem? a. Tachyphylaxis b. Postoperative infection c. Malignant hypertension d. Malignant hyperthermia

Answer 302

d. Malignant hyperthermia

Question 303

When assessing patients in the preoperative area, the nurse knows that which patient is at a higher risk for an altered response to anesthesia? a. The 21-year-old patient who has never had surgery before b. The 35-year-old patient who stopped smoking 8 years ago c. The 40-year-old patient who is to have a kidney stone removed d. The 82-year-old patient who is to have gallbladder removal

Answer 303

d. The 82-year-old patient who is to have gallbladder removal

Question 304

When administering a neuromuscular blocking drug, the nurse needs to remember which principle? a. It is used instead of general anesthesia during surgery. b. Only skeletal muscles are paralyzed; respiratory muscles remain functional. c. It causes sedation and pain relief while allowing for lower doses of anesthetics. d. Artificial mechanical ventilation is required because of paralyzed respiratory muscles.

Answer 304

d. Artificial mechanical ventilation is required because of paralyzed respiratory muscles.

Question 305

A patient is being prepared for an oral endoscopy, and the nurse anesthetist reminds him that he will be awake during the procedure but probably will not remember it. What type of anesthetic technique is used in this situation? a. Local anesthesia b. Moderate sedation c. Topical anesthesia d. Spinal anesthesia

Answer 305

b. Moderate sedation

Question 306

A patient has been taking phenobarbital for 2 weeks as part of his therapy for epilepsy. He tells the nurse that he feels tense and that “the least little thing” bothers him now. Which is the correct explanation for this problem? a. These are adverse effects that usually subside after a few weeks. b. The drug must be stopped immediately because of possible adverse effects. c. This drug causes the rapid eye movement (REM) sleep period to increase, resulting in nightmares and restlessness. d. This drug causes deprivation of REM sleep and may cause the inability to deal with normal stress.

Answer 306

d. This drug causes deprivation of REM sleep and may cause the inability to deal with normal stress.

Question 307

A 50-year-old man who has been taking phenobarbital for 1 week is found very lethargic and unable to walk after eating out for dinner. His wife states that he has no other prescriptions and that he did not take an overdose—the correct number of pills is in the bottle. The nurse suspects that which of these may have happened? a. He took a multivitamin. b. He drank a glass of wine. c. He took a dose of aspirin. d. He developed an allergy to the drug.

Answer 307

b. He drank a glass of wine.

Question 308

A patient is brought to the emergency department for treatment of a suspected overdose. The patient was found with an empty prescription bottle of a barbiturate by his bedside. He is lethargic and barely breathing. The nurse would expect which immediate intervention? a. Starting an intravenous infusion of diluted bicarbonate solution b. Administering medications to increase blood pressure c. Implementing measures to maintain the airway and support respirations d. Administrating naloxone (Narcan) as an antagonist

Answer 308

c. Implementing measures to maintain the airway and support respirations

Question 309

A patient tells the nurse that he likes to drink kava herbal tea to help him relax. Which statement by the patient indicates that additional teaching about this herbal product is needed? a. “I will not drink wine with the kava tea.” b. “If I notice my skin turning yellow, I will stop taking the tea.” c. “I will not take sleeping pills if I have this tea in the evening.” d. “I will be able to drive my car after drinking this tea.”

Answer 309

d. “I will be able to drive my car after drinking this tea.”