Practice Question ch 15

Question 1

What would the nurse do to determine the correct distance to insert a nasogastric tube?

1. Measure from center of forehead to top of nose to end of sternum.
2. Measure from tip of nose to tip of earlobe to the xiphoid process.
3. Measure from lips to tip of ear to just below the umbilicus .
4. Measure from tip of ear to midway between end of sternum and umbilicus

Answer 1

2

Question 2

After inserting a nasogastric tube, the nurse would check for proper placement by which methods ? ( Select all that apply .)

1. The fact that the patient no longer complains of pain or nausea
2. The ability to inject 30 mL of normal saline with ease
3. Gurgling or a swishing sound heard with a stethoscope over the stomach when air is injected into the tube
4. The ability to aspirate gastric contents with a syringe
5. Placement of the end of the tube in a glass of water and watching for bubbling

Answer 2

3,4

Question 3

If the patient is suspected of having a fecal impaction, which type of enema would the nurse anticipate the health care provider to order?

1. Soapsuds enema
2. Polystyrene sulfonate (Kayexalate) enema
3. Oil retention enema
4. Tap water enema

Answer 3

3

Question 4

Bladder training instructions are being given to a patient who has a history of urinary incontinence . The nurse should give the patient which instruction?

1. “Wait until you feel the urge to void.
2. “Don’t void any more often than every 4 to 6 hours.
3. “Void every 1.5 to 2 hours while you are awake.
4. “Void any time you feel the urge.”

Answer 4

3

Question 5

A nurse is preparing to insert a nasogastric tube. The nurse should place the patient in which position?

1. On the right side.
2. Low Fowler’s position .
3. High Fowler’s position .
4. Supine with head of bed flat.

Answer 5

3

Question 6

A male patient with urinary incontinence has been using an external (condom ) catheter. The nurse is evaluating the patient’s technique of applying the device. Which finding would indicate that the nurse should give the patient further instructions ? (Select all that apply .)

1. Washing the penis with warm, soapy water and drying the area well before applying the device
2. Spiraling the tape around the penis to secure the device
3. Using elastic tape and wrapping in a spiral pattern to secure the device
4. Checking the penis carefully for any signs of irritation before applying the device
5. Changing the catheter after each time of urination

Answer 6

2,3,5

Question 7

What is considered a noninvasive method of collecting urine for the incontinent patient ?

1. Suprapubic catheterization
2. Reinsertion of a Foley catheter
3. Catheter irrigation
4. Condom catheterization

Answer 7

4

Question 8

. A patient with a colostomy continues to worry about odor. Which statement would be appropriate for the nurse to tell the patient about colostomy odor?

1. “It occurs only when the colostomy appliance is changed .”
2. It is caused by certain foods that can be omitted from the diet.”
3. It is mainly caused by poor hygiene and can be remedied.”
4. It is far more noticeable to the patient than to others.”

Answer 8

2

Question 9

The nurse is instructing the patient in performing Kegel exercises . The patient should be instructed to contract the muscles he or she would use to stop the flow of urine. What is the proper technique for performing Kegel exercises ?

1. Contract for 3 to 4 seconds and relax for 3 to 4 seconds .
2. Contract for 3 to 4 seconds and relax for 10 seconds
3. Contract for 10 seconds and relax for 3 to 4 seconds .
4. Contract for 10 seconds and relax for 10 seconds .

Answer 9

4

Question 10

A bladder retraining program for a patient in an extended-care facility should include which intervention ? (Select all that apply )

1. Providing negative reinforcement when the patient is incontinent .
2. Having the patient wear clothing protectors to help decrease embarrassment .
3. Putting the patient on q 2 hr toilet schedule during the day .
4. Promoting the intake of caffeine to stimulate voiding .
5. Encouraging the use of the bedpan .

Answer 10

2,3

Question 11

. The nurse is caring for a patient with a new ostomy. What is the best nursing strategy for encouraging patient self-care of an ostomy ?

1. Plan to change the pouch when family members will be present, have the patient watch, and have the patient and family listen to the procedure .
2. Frequently tell the patient that if he or she does not learn stoma self-care , no one is going to do it for him or her .
3. Encourage the patient to watch the stoma care procedure , gradually encouraging participation .
4. Shield the patient from sight of the stoma until the patient actually asks to see it.

Answer 11

3

Question 12

A patient has a nasogastric tube inserted . What type of patient teaching should the nurse give the patient about the NG tube ? (Select all that apply .)

1. ” Be careful to not pull on the tube . “
2. ” Call the nurse if you feel as if you are going to vomit.”
3. Turn the suction off if you feel as if you are goingto vomit .”
4. ” Refrain from coughing while the tube is in place .”
5. ” Let the staff know if the tape holding the tube is irritating your skin .”

Answer 12

1,2,5

Question 13

To maintain proper drainage of an indwelling catheter , it is important to perform which action ?

1. Irrigate the catheter every 2 to 4 hours.
2. Ensure that the collection device is below bladder level.
3. Place the tubing under the patient’s leg to prevent pulling on the bladder neck .
4. Demonstrate to the patient how to disconnect the device while ambulating .

Answer 13

2

Question 14

The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause which complication ? ( Select all that apply .)

1. Fungal infection
2. Bacterial infection
3. Yeast infection
4. Irritation of the stoma
5. Skin breakdown around the stoma

Answer 14

4,5

Question 15

The nurse is administering a cleansing enema . Before administering the enema , the nurse assists the patient into which position ?

1. Supine
2. On right side
3. Left Sims position
4. Left side with head of bed elevated 45 degrees

Answer 15

3

Question 16

The nurse caring for a patient with a Foley catheter should perform which actions to lower the risk for infection ? (Select all that apply .)

1. Keep bag below the level of the bed.
2. Provide perineal care twice a day .
3. Coil tubing on the bed .
4. Keep the drainage system closed .
5. Limit fluid intake to 300 chift

Answer 16

1,2,3,4

Question 17

The nurse is administering a routine enema to an adult patient . The patient complains of cramping and the urge to defecate . Which nursing intervention is the best to carry out?

1. Quickly finish instilling the rest of the solution
2. Briefly stop the instillation .
3. Instruct the patient to hold his or her breath and bear down .
4. Immediately discontinue the instillation and withdraw the enema tubing from the rectum .

Answer 17

2

Question 18

When providing routine indwelling catheter care , the nurse should be most diligent in cleaning which areas ?

1. The perineal area
2. The area surrounding the urinary meatus
3. The labia majora and the labia minora
4. The perineal area and 2 inches of the

Answer 18

4

Question 19

Online practice 1-10

Answer 19

ch 15

Question 20

A nurse is caring for a client who will perform fecal occult blood testing at home . Which of the following information should be included when explaining the procedure to the client?

A. Eating more protein is optimal prior to testing.
B. One stool specimen is sufficient for testing.
C. A red color change indicates a positive test.
D. The specimen cannot be contaminated with urine.

Answer 20

Ati ch 43

D

Question 21

A nurse is providing dietary teaching for a client who reports constipation . Which of the following foods should the nurse recommend ?

A. Macaroni and cheese
B. One medium apple with skin
C. One cup of plain yogurt
D. Roast chicken and white rice

Answer 21

Ati ch 43

B

Question 22

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect ? ( Select all that apply .)

A. Bradycardia
B. Hypotension
C. Elevated temperature
D. Poor skin turgor
E. Peripheral edema

Answer 22

Ati ch 43

B,C,D

Question 23

.While a nurse is administering a cleansing enema , the client reports abdominal cramping. Which of the following actions should the nurse take?

A. Have the client hold their breath briefly and bear down.
B. Clamp the enema tubing.
C. Remind the client that cramping is common at this time .
D. Raise the level of the enema fluid container .

Answer 23

Ati ch 43

B

Question 24

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure . Which of the following steps should the nurse take? ( Select all that apply.)

A. Warm the enema solution prior to instillation .
B. Position the client on the left side with the right leg flexed forward .

C. Lubricate the rectal tube or nozzle .

D. Slowly insert the rectal tube about 5 cm (2 in).

E. Hang the enema container 61 cm ( 24 in) above the client’s anus.

Answer 24

Ati ch 43

A,B,C

Question 25

A nurse is teaching a client who reports stress urinary incontinence . Which of the following instructions should the nurse include? (Select all that apply.)

A. Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements
D. Avoid drinking alcohol .
E. Use the Credé maneuver .

Answer 25

Ati ch 44

B,D

Question 26

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

A. Check to see whether the catheter is patent .
B. Reassure the client that it is not possible for them to urinate.
C. Recatheterize the bladder with a larger-gauge catheter
D. Collect a urine specimen for analysis .

Answer 26

Ati ch 44

A

Question 27

A nurse is caring for a client who has a prescription for a 24- hr urine collection . Which of the following actions should the nurse take ?

A. Discard the first voiding .
B. Keep the urine in a single container at room temperature .
C. Dispose of the last voiding
D. Ask the client to urinate into the toilet , stop midstream , and finish urinating into the specimen container .

Answer 27

Ati ch 44

A

Question 28

. A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs . Which of the following factors should the nurse include? (Select all that apply )

A. Frequent sexual intercourse
B. Lowering of testosterone levels
C. Wiping from front to back to clean the perineum
D. Location of the urethra closer to the anus
E. Frequent catheterization

Answer 28

Ati ch 44

A,D,E

Question 29

A nurse is preparing to initiate a bladder -retraining program for a client who has incontinence . Which of the following actions should the nurse take ? (Select all that apply .)

A. Restrict the client’s intake of fluids during the daytime .
B. Have the client record urination times .
C. Gradually increase the urination intervals .
D. Remind the client to hold urine until the next scheduled urination time .
E Provide a sterile container for urine .

Answer 29

Ati ch 44

b,c,d

Question 30

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings . When the nurse pours water into the syringe after the formula drains from the syringe , the client asks the nurse why the water is necessary . Which of the following responses should the nurse make?

A. “Water helps clear the tube so it doesn’t get clogged.”
B. “Flushing helps make sure the tube stays in place.”
C. This will help you get enough fluids.”
D. “Adding water makes the formula less concentrated .”

Answer 30

Ati ch 54

A

Question 31

A nurse is caring for a client who is receiving continuous enteral feedings . Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding ?

A. Auscultate breath sounds
B. Stop the feeding .
C. Obtain a chest x -ray.
D. Initiate oxygen therapy .

Answer 31

Ati ch 54

B

Question 32

A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place . Which of the following actions is the nurse’s highest assessment priority before performing this procedure ?

A. Check how long the feeding container has been open .
B. Verify the placement of the NG tube .
C. Confirm that the client does not have diarrhea .
D. Make sure the client is alert and oriented .

Answer 32

Ati ch 54

B

Question 33

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.)

A. Auscultate bowel sounds.
B. Assist the client to an upright position .
C. Test the pH of gastric aspirate .
D. Warm the formula to body temperature.
E. Discard any residual gastric contents

Answer 33

Ati ch 54

A,B,C

Question 34

A nurse is preparing to insert an NG tube for a client who requires gastric decompression . Which of the following actions should the nurse perform before beginning the procedure ? ( Select all that apply .)

A. Review a signal the client can use if feeling any distress .
B. Lay a towel across the client’s chest .
C. Administer oral pain medication .
D. Obtain a Dobhoff tube for insertion .
E. Have a petroleum - based lubricant available .

Answer 34

Ati ch 54

A,B