Test 2: Evolve Questions

Question 1

Which of the following skills can be delegated to nursing assistive personnel (NAP) in caring for patients receiving enternal nutrition?

a) providing pH testing of fluid withdrawn through a feeding tube
b) providing oral hygiene to patients with nasogastric tubes
c) irrigating a feeding tubeto maintain patency
d) inserting feeding tube

Answer 1

b) providing oral hygiene to patients with nasogastric tubes

Policies governing the administration of tube feeding by nursing assistive personnel vary according to the acuity of the patient’s condition, the type of tube, and the health care setting. However, among these choices, only “B” can be delegated by nurses to nursing assistive personnel.

Question 2

Which of the following is the most serious complication of tube feeding?

a) diarrhea
b) aspiration pneumonia
c) nausea
d) electrolyte imbalance

Answer 2

b) aspiration pneumonia

Aspiration is a common and potentially life-threatening complication of enteral nutrition.

Question 3

Which of the following measures is most effective in preventing feeding tube occlusion

a) diluting formula to 1/2 strength
b) irrigating the tube with water every 4 hours
c) substituting cranberry juice for water as flush solution
d) mixing medications with formula before administration

Answer 3

b) irrigating the tube with water every 4 hours

Studies have shown that regular flushing with water is the most effective way to keep feeding tubes patent and functional.

Question 4

Adherence to which of the following measures aims to avoid misconnections between the enteral administration set and intravenous systems and other medical tubing or device?

a) tracing the line to its point of origin before making a connection
b) using only luer-lok syringes or extension sets on enteral sytems
c) auscultating the epigastric area while instilling air through the tube
d) clearly labeling administration sets “tube feeding only”
e) instructing patients and family caregivers to seek nursing assitance before reconnecting tubing that has separated

Answer 4

Choices “A,” “D,” and “E” include recommendations aimed at avoiding misconnections between enteral feeding tubing and intravenous systems or other medical tubing or devices. Luer-Lok syringes are compatible with intravenous tubing and should not be used to administer tube feeding. Only catheter-tip and oral syringes should be used. Auscultating the epigastric area while instilling air through the tube is an ineffective technique for verifying tube position and could cause serious harm if air was inadvertently injected into the intravenous tubing.

Question 5

Which laboratory value are important for monitoring patients with risk of refeeding syndrome

a) triglycerides
b) albumin
c) liver function tests
d) electrolytes (K, Mg, phosphorus)

Answer 5

d) Electrolytes (K, Mg, phosphorus)

With refeeding syndrome, electrolytes (K, Mg, phosphorus) shift into the cell with glucose and serum levels drop, requiring careful monitoring and additional supplementation.

Question 6

When should beside glucose levels be checked with a new PN start?

a) Every 24 hours until stable levels
b) every 12 hours until stable levels
c) every 8 hours until stable levels
d) every 6 hours until stable levels

Answer 6

d) every 6 hours until stable levels

Levels should be checked every 6 hours until stable. Less frequent monitoring may result in undetected hyperglycemia that is more difficult to correct.

Question 7

When should beside glucose levels be checked to prepare a patient for discharge with cyclic home PN?

a) every 6 hours
b) once during the PN infusion
c) two hours after infusion begins and 2 hours after the infusion ends
d) every 4 hours during PN infusion

Answer 7

c) two hours after infusion begins and 2 hours after the infusion ends

to prepare a patient for discharge with home PN, glucose checks should be take at times that reflect likely peak and trough levels.

Question 8

What is indicative by a weight gain in excess of 1 pound over 24 hours in a hospitalized patient receiving PN

a) excessive caloric intake
b) fluid retention
c) inadequate hydration
d) broken scale

Answer 8

b) fluid retention

Fluid retention is the most likely cause of such rapid weigh gain in such a brief period of time.. Excessive caloric intake would take longer than 24 hours to affect weight. A broken scale is unlikely to result in such a rapid shift in weight; however, if scale malfunction is a possibility, assess by rechecking the weight on a different scale. In adequate hydration would result in weight loss not gain.

Question 9

Where is PN mixed, and why?

a) at the bedside, for the convenience of the nurse
b) in laminar airflow hood in a pharmacy, to reduce the risk of microbial and pyrogen contamination
c) in a satellite pharmacy on a nursing unit, so the PN will not be sent to the wrong floor
d) in the outpatient pharmacy, because of staffing levels

Answer 9

b) in a laminar airflow hood in a pharmacy, to reduce the risk of microbial and pyrogen contamination

Only PN mixed in the controlled environment of a pharmacy with a laminar airflow hood and under sterile technique is safe to administer to a patient. None of the other settings listed here are suitable because they would not have laminar airflow hoods

Question 10

What should the nurse we aware of regarding a request for organ and tissue donation at the time of death?

a) Specially educated personnel make these requests.
b) These requests are usually made by the nurse caring for the client at the time of death.
c) Professionals should be very selective in whom they ask for organ and tissue donation.
d) Only clients who have given prior instruction regarding donation can become donors.

Answer 10

a) Specially educated personnel make these requests.

A specially trained professional makes requests for organ and tissue donation. The person requesting organ or tissue donation provides information about who can legally give consent, which organs or tissues can be donated, and how donations will affect burial or cremation. If the deceased did not leave behind instructions for organ and tissue donation, the family may give consent. In some jurisdictions and situations, it would be appropriate for nurses to discuss corneal tissue donation with family members.

Question 11

As a home health nurse, you are asked by a family member what he should do if the client’s serious chronic illness continues to worsen even with increased medical interventions. You recognize that the family member is posing a question about goals of care at the end of life. What should you do?

a) Encourage the family to think more positively about the client’s new therapy.
b) Avoid the discussion because it has to do with medical, not nursing, diagnoses.
c) Begin the discussion by asking the family member what he believes the goals should be.
d) Initiate a discussion about advance directives with the client, family, and health care team.

Answer 11

c) Begin the discussion by asking the family member what he believes the goals should be.

You must first assess the family’s goals before any further discussions can take place. Then, with the appropriate knowledge, you can continue discussions regarding options for future care, either disease treatment or end-of-life care, based on the family’s needs and wishes.

Question 12

A client’s family member remarks to you, “The doctor said he will provide palliative care. What does that mean?” Which of the following is the nurse’s best response?

a) “Palliative care aims to relieve or reduce the symptoms of a disease.”
b) “Palliative care is given to those who have less than 6 months to live.”
c) “The goal of palliative care is to cure a serious illness or disease.”
d) “Palliative care means that the client and family take a more passive role and the doctor focuses on the physiological needs of the client. Death will most likely occur in the hospital.”

Answer 12

a) “Palliative care aims to relieve or reduce the symptoms of a disease.”

The goal of palliative care is the prevention, relief, reduction, or soothing of symptoms of disease or disorders without effecting a cure. Palliative care is for clients of any age, with any diagnosis, and at any time, not just during the last few months of life. Generally, clients accepted into a hospice program have less than six months to live. Palliative care aims to relieve pain and other distressing symptoms, not cure the disease. Palliative care is a philosophy of total care. Care options encompass the physical, psychological, social, spiritual, and existential aspects of the client’s illness. Care is provided by an interdisciplinary team, and the client and family take an active role in decision making. The location of death may or may not be the hospital.

Question 13

A woman experiences the loss of a very early term pregnancy. Her friends do not mention the loss, and someone suggests to her that she can “always try again.” The woman feels confusion over her sadness and stops talking about it with others. Which type of grief may the woman be experiencing?

a) Delayed
b) Anticipated
c) Exaggerated
d) Disenfranchised

Answer 13

d) Disenfranchised

Disenfranchised grief is experienced when a person’s relationship to the deceased is not socially sanctioned, the loss cannot be openly acknowledged or publicly shared, or the loss seems of less significance to others. A person experiences anticipatory grief, the unconscious process of disengaging or letting go, before the actual loss or death occurs. Exaggerated grief occurs when the individual exhibits bizarre or unusual behaviours. Delayed grief occurs when a person avoids the pain of a loss by suppressing or postponing normal grief responses.

Question 14

A family member of a recently deceased client talks casually with you at the time of the client’s death and expresses relief that she will not have to visit at the hospital anymore. Which of the following may apply to this family member in terms of her grief?

a) Denial
b) Anticipatory grief
c) Dysfunctional grief
d) Yearning and searching

Answer 14

a) denial

In the denial stage, a person acts as though nothing has happened and refuses to accept the fact of a loss. This is a normal stage and a self-protective mechanism. In dysfunctional grief, the grieving person has a prolonged or significantly difficult time moving forward after a loss. Emotional outbursts of tearful sobbing and acute distress characterize Bowlby’s second stage of grief, termed yearning and searching. A person experiences anticipatory grief, the unconscious process of disengaging or letting go, before the actual loss or death occurs, especially in situations of prolonged or predicted loss.

Question 15

When caring for dying and grieving clients, a self-care goal might be which of the following?

a) Learn not to take the loss so seriously.
b) Limit involvement with clients who are grieving.
c) Maintain life balance and reflect on the meaning of your work.
d) Admit that you are not well suited to caring for grieving clients and families.

Answer 15

c) Maintain life balance and reflect on the meaning of your work.

For nurses who work with dying and grieving clients, the maintenance of life balance and reflection on the purpose of the work are the key to longevity in the career. Loss is serious, and nurses do take loss seriously. Involvement with grieving clients can be healthy for you. Involvement of the care team in providing support to each other is vital. Nurses need to determine what discipline in nursing works for them.

Question 16

During post-mortem care, the nurse should give priority to which of the following?

a) Locating the client’s clothing
b) Providing culturally and religiously sensitive care in body preparation
c) Transporting the body to the morgue as soon as possible to prevent body decomposition
d) Providing all post-mortem care to protect the deceased’s family from having to see the body

Answer 16

b) Providing culturally and religiously sensitive care in body preparation

Providing the integrity of rituals and mourning practice where possible gives families a sense of fulfilled obligations and promotes acceptance of death. If family members want to provide post-mortem care, then the nurse should be sensitive to their needs. The body should be transported to the morgue when the family is ready. Locating the client’s clothing is not a priority; it can be done after the other tasks are completed.

Question 17

A client has recently been told he has terminal cancer. As the nurse enters the room, he yells, “My eggs are cold, and I’m tired of having my sleep interrupted by noisy nurses!” The nurse interprets the client’s behaviour as which of the following?

a) The result of previous losses
b) The result of maturational loss
c) An expression of disenfranchised grief
d) An expression of the anger stage of dying

Answer 17

d) An expression of the anger stage of dying

In the anger stage of Kübler-Ross’s stages of dying, the individual resists the loss and may strike out at everyone and everything—in this case, the nurse. Disenfranchised grief occurs when a person experiences a loss that cannot be openly acknowledged, is not socially sanctioned, or cannot be publicly shared. A maturational loss is any life change that occurs in the developmental process and is normally expected during a lifetime. Previous losses may compound the feeling of loss and influence the individual’s reaction when an additional loss occurs, but this question did not mention the client’s previous losses.

Question 18

When helping a client work through grief, the nurse knows that which of the following is true?
a) Most clients want to be left alone.
b) A person’s perception of a loss has little to do with the grieving process.
c) The stages of grief may occur in the standard order, they may be skipped, or they may recur.
d_ Coping mechanisms that were effective in the past are often disregarded in response to the pain of a loss.

Answer 18

c) The stages of grief may occur in the standard order, they may be skipped, or they may recur.

Grief is manifested in a variety of ways that are unique to the individual and based on personal experiences, cultural expectations, and spiritual beliefs. The coping mechanisms that were effective in the past are repeated as a first response to the pain of a loss. When older coping strategies are unsuccessful, new coping mechanisms are attempted. The type of loss and the perception of the loss influence the depth and duration of grief a person experiences. The nurse must not assume that clients want to be left alone. If a client chooses not to share feelings or concerns, the nurse should convey a willingness to be available when needed. Sometimes clients need to begin resolving their grief before they can discuss their loss.

Question 19

It is one day after the client underwent a mastectomy for the treatment of her breast cancer. The client is crying when the nurse enters the room. Which of the following is the nurse’s best response?

a) “Let me get you something for pain.”
b) “You seem upset. Would you like to tell me about what is bothering you?”
c) “Cheer up. The worst is behind you now, and you’ll start feeling better soon.”
d) “You shouldn’t be crying now. Just wait until you go home and you’re all alone without us to help you.”

Answer 19

b) “You seem upset. Would you like to tell me about what is bothering you?”

The nurse should use therapeutic communication skills to clarify the feelings of the client. The nurse should use open-ended questions, attentive listening, and presence to allow the client to freely share her thoughts and concerns.

Question 20

A client in the end stage of terminal cancer is hospitalized. His family members are sitting at his bedside. What can you do to best aid the family at this time?

a) Find simple and appropriate care or comfort activities for the family to perform.
b) Limit the time visitors may stay so they do not become overwhelmed by the situation.
c) Avoid telling family members about the client’s actual condition so they will not lose hope.
d) Discourage spiritual practices because this will have little meaning for the client at this time.

Answer 20

a) Find simple and appropriate care or comfort activities for the family to perform.

It is helpful for the nurse to find simple care and comfort activities for the family to perform, such as feeding the client, washing the client’s face, combing the hair, applying unscented hand lotions, or filling out the client’s menu card. This helps family members demonstrate their caring for the client and enables the client to feel their closeness and concern. Older adults often become particularly lonely at night and may feel more secure if a family member stays at the bedside during the night. The nurse should allow visitors to remain with dying clients at any time if the client wants them there. It is up to the family members to determine if they are feeling overwhelmed, not the nurse. The nurse should keep the family informed so the family can anticipate the type of symptoms the client will likely experience and the implications for care. Facilitating connections to spirituality and supporting the expression of culturally held beliefs can provide comfort for many clients.

Question 21

When caring for a terminally ill client, it is important for the nurse to maintain the client’s dignity. This can be facilitated by doing which of the following?

a) Spending time to let the client share his or her life experiences
b) Making decisions for the client so the client does not have to make them
c) Placing the client in a private room to provide privacy at all times
d) Decreasing emphasis on attending to the client’s appearance because such personal care only increases the client’s fatigue

Answer 21

a) Spending time to let the client share his or her life experiences

Spending time to let the client share his or her life experiences enables the nurse to know the client better. Knowing the client then facilitates choosing therapies or activities that promote client decision making and autonomy and thus promote the client’s self-esteem and dignity. Basic to promoting a client’s self-esteem and dignity is attending to the client’s appearance and surroundings. Cleanliness, absence of body odours, wearing of attractive clothing, and personal grooming all contribute to a sense of worth. Helping the client make his or her own decisions helps maintain autonomy. Being autonomous plays a vital role in maintaining the client’s dignity. The client should not be placed in a private room unless the client specifically requests this, or it is required for care purposes (for example, MRSA, VRE, or offensive odours).

Question 22

What are the stages of dying defined by Elisabeth Kübler-Ross?

a) Denial, anger, bargaining, depression, and acceptance
b) Anticipatory grief, perceived loss, actual loss, and renewal
c) Numbing, yearning and searching, disorganization and despair, and reorganization
d) Accepting the reality of loss, working through the pain of grief, adjusting to the environment without the deceased, and emotionally relocating the deceased and moving on with life

Answer 22

a) Denial, anger, bargaining, depression, and acceptance

Denial, anger, bargaining, depression, and acceptance are Elisabeth Kübler-Ross’s five behaviour-oriented stages of dying.

Question 23

Which of the following defines bereavement?

a) The emotional response to loss
b) The outward, social expression of loss
c) Postponement of the awareness of the reality of the loss
d) The inner feelings and outward reactions of the survivor

Answer 23

d) The inner feelings and outward reactions of the survivor

Bereavement includes grief and mourning. Option A is the definition of grief. Option B is the definition of mourning. Postponement of the awareness of the reality of loss describes what may occur during Kübler-Ross’s bargaining stage of dying.

Question 24

A client for whom a “do not resuscitate” order is in place passes away. After verifying that the client has no pulse or respirations, what should the nurse do next?

a) Call the transplant team to retrieve vital organs.
b) Call the funeral director to come and get the body.
c) Have family members say goodbye to the deceased.
d) Remove all tubes and equipment (unless tissue donation is to take place), clean the body, and position the body appropriately.

Answer 24

d) Remove all tubes and equipment (unless tissue donation is to take place), clean the body, and position the body appropriately.

If family is not present at the time of death, the body of the deceased should be prepared before family members come in to view and say their goodbyes. If family members are present, allow them to say goodbye before suggesting that they temporarily leave the room while the body of the deceased is prepared. This includes removing all equipment, tubes, supplies, and dirty linens according to protocol; bathing the client; applying clean sheets; and removing garbage from the room. The body should be cleaned and positioned before the family is given the option to view or not to view the body. Organ transplant and tissue donation would first have to be discussed with the family. The funeral home is not called until after family members have had the opportunity to say their goodbyes, the death has been “pronounced,” and a death certificate has been completed.

Question 25

The nurse should assess the client’s and family’s wishes for end-of-life care. What is it important for the nurse to remember?

a) Keep what is learned about a client’s preferences to yourself.
b) Avoid self-reflection because it may interfere with caring for dying clients.
c) Have family members follow hospital routines rather than engage in their specific cultural or spiritual practices in end-of-life care.
d) Find a health care professional who is experienced in discussing end-of-life issues if you feel uncomfortable doing so.

Answer 25

d) Find a health care professional who is experienced in discussing end-of-life issues if you feel uncomfortable doing so.

The nurse must assess the client’s and family’s wishes for end-of-life care, including the preferred place for death, the level of life-sustaining measures to employ, and expectations regarding pain and symptom management. If the nurse feels uncomfortable in assessing a client’s wishes, then he or she must find a health care professional who is experienced in discussing end-of-life issues and can assist in communicating a client’s preferences to the total health care team. The nurse cannot keep what is learned about a client’s preferences private but must maintain confidentiality within the team. Good interdisciplinary teamwork is essential to providing quality end-of-life care. Self-reflection is a valuable tool in maintaining professionalism and knowing when to get away from a situation and take care of oneself. Facilitating connections to preferred spiritual practices and supporting the expression of culturally held beliefs are very important and can provide comfort to the client and the family.

Question 26

The nurse notes that a woman who recently began cancer treatment appears quiet and withdrawn, says she does not believe the treatments will make any difference, does not ask about her progress, and has missed two chemotherapy sessions. Based on these assessment data, the nurse would gather more information to consider making which of the following nursing diagnoses?

a) Anxiety
b) Powerlessness
c) Spiritual distress
d) Anticipatory grieving

Answer 26

b) Powerlessness

The area to consider with this client is powerlessness (she does not believe the treatments will help anyway). This client does not show signs of the other areas based on the information given in the situation.

Question 27

The nurse suggests that a client receive a palliative care consultation for symptom management of anxiety and increasing pain. A family member asks the nurse if this means the client is dying and is now “in hospice.” The nurse gives which following explanation?

a) Hospice (end-of-life care) and palliative care are the same.
b) Palliative care is for any client, at any time, for any disease, in any setting.
c) Palliative care strategies are primarily designed to treat the client’s illness.
d) Palliative care interventions relieve the symptoms of illness and treatment.

Answer 27

b) Palliative care is for any client, at any time, for any disease, in any setting.

Palliative care is the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness. It is appropriate for clients of any age, in any setting, and for any disease. Hospice care focuses specifically on individuals with a limited life expectancy, whereas palliative care focuses on symptoms, not the disease process.