week 7 book ch 45, 46, & 47

Question 1

clear liquid diet may include

Answer 1

broth,
tea,
carbonated beverages,
clear fruit juices,
gelatin,
popsicles

Question 2

full liquid diet may include

Answer 2

ice cream
strained or blended cream soups, custards,
refined cooked cereals,
vegetable juice,
pureed vegetables,
all fruit juices,
sherbets,
puddings,
frozen yogurt

Question 3

Pureed foods

Answer 3

scrambled eggs;
pureed meats, vegetables, and fruits;
mashed potatoes and gravy

Question 4

Mechanical soft foods

Answer 4

all cream soups,
ground or finely diced meats, flaked fish,
cottage cheese,
cheese,
rice,
potatoes,
pancakes,
light breads,
cooked vegetables,
cooked or canned fruits,
bananas,
soups,
peanut butter, eggs (not fried)

Question 5

The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.)

1. Heart disease
2. Sepsis
3. Hemorrhage
4. Skin breakdown
5. Diarrhea

Answer 5

2. Sepsis
3. Hemorrhage
4. Skin breakdown

Question 6

The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.)

1. Serum total protein
2. Potassium
3. Lipids
4. Albumin

5 Serum BUN

Answer 6

1. Serum total protein
   5 Serum BUN

Question 7

The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention?

1. Suction her mouth and throat.
2. Turn her on her side.
3. Put on oxygen at 2 L nasal cannula.
4. Stop feeding her.

Answer 7

4. Stop feeding her.

Question 8

A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse’s priority action?

1. Have the patient turn on the left side and perform a Valsalva maneuver.
2. Clamp the intravenous (IV) tubing to prevent more air from entering the line.
3. Have the patient take a deep breath and hold it.
4. Notify the health care provider immediately.

Answer 8

1. Have the patient turn on the left side and perform a Valsalva maneuver.

Question 9

A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition?

1. When 25% of the patient’s nutritional needs are met by the tube feedings
2. When bowel sounds return
3. When the central line has been in for 10 days
4. When 75% of the patient’s nutritional needs are met by the tube feedings

Answer 9

4. When 75% of the patient’s nutritional needs are met by the tube feedings

Question 10

A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention?

1. Assess bowel sounds.
2. Raise the head of the bed to at least 45 degrees.
3. Continue the feedings; this is normal gastric residual for this feeding.
4. Hold the feeding until you talk to the primary care provider.

Answer 10

3. Continue the feedings; this is normal gastric residual for this feeding.

Question 11

Which action can a nurse delegate to assistive personnel (AP)?

1. Performing glucose monitoring every 6 hours on a patient
2. Teaching the client about the need for enteral feeding
3. Administering enteral feeding bolus after tube placement has been verified
4. Evaluating the client’s tolerance of the enteral feeding

Answer 11

1. Performing glucose monitoring every 6 hours on a patient

Question 12

Which statement made by the parents of a 2-month-old infant requires further education by the nurse?

1. “I’ll continue to use formula for the baby until he is at least a year old.”
2. “I’ll make sure that I purchase iron-fortified formula.”
3. “I’ll start feeding the baby cereal at 4 months.”
4. “I’m going to alternate formula with whole milk, starting next month.”

Answer 12

4. “I’m going to alternate formula with whole milk, starting next month.”

Question 13

A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse?

1. Fastening tube to the gown with new tape
2. Placing client supine while giving a bath
3. Monitoring the client’s weight as ordered
4. Ambulating patient with enteral feedings still infusing

Answer 13

2. Placing client supine while giving a bath

Question 14

A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.)

1. Change the dressing using sterile technique.
2. Change TPN containers every 48 hours.
3. Change the TPN tubing every 24 hours.
4. Monitor glucose levels to watch and assess for glucose intolerance.
5. Elevate head of the bed 45 degrees to prevent aspiration.

Answer 14

1. Change the dressing using sterile technique.
2. Change the TPN tubing every 24 hours.

Question 15

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.)

1. Ask the patient about any allergies and reactions.
2. Instruct the patient that a full bladder is required for the test.
3. Instruct the patient to save all urine in a special container.
4. Ensure that informed consent has been obtained.
5. Instruct the patient that facial flushing can occur when the contrast media is given.

Answer 15

1. Ask the patient about any allergies and reactions.
2. Ensure that informed consent has been obtained.
3. Instruct the patient that facial flushing can occur when the contrast media is given.

Question 16

What is a critical step when inserting an indwelling catheter into a male patient?

1. Slowly inflate the catheter balloon with sterile saline.
2. Secure the catheter drainage tubing to the bedsheets.
3. Advance the catheter to the bifurcation of the drainage and balloon ports.
4. Advance the catheter until urine flows, then insert ¼ inch more.

Answer 16

3. Advance the catheter to the bifurcation of the drainage and balloon ports.

Question 17

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day?

1. Limit oral fluid intake to avoid possible urinary incontinence.
2. Expect patient complaints of suprapubic fullness and discomfort.
3. Report the time and amount of first voiding.
4. Instruct patient to stay in bed and use a urinal or bedpan.

Answer 17

3. Report the time and amount of first voiding.

Question 18

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse’s initial intervention(s)? (Select all that apply.)

1. Increase the rate of the CBI.
2. Assess the patency of the drainage system.
3. Measure urine output.
4. Assess vital signs.
5. Administer ordered pain medication.

Answer 18

2. Assess the patency of the drainage system.
3. Measure urine output.

Question 19

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?

1. Recommend that she be evaluated for an overactive bladder (OAB) medication.
2. Establish a toileting schedule.
3. Recommend that she be evaluated for an indwelling catheter.
4. Start a bladder-retraining program.

Answer 19

2. Establish a toileting schedule.

Question 20

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.)

1. Maintain regular bowel elimination.
2. Limit water intake to 1 to 2 glasses a day.
3. Wear cotton underwear.
4. Cleanse the perineum from front to back.
5. Practice pelvic muscle exercise (Kegel) daily.

Answer 20

1. Maintain regular bowel elimination.
2. Wear cotton underwear.
3. Cleanse the perineum from front to back.

Question 21

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.

1. Insert and advance catheter.
2. Lubricate catheter.
3. Inflate catheter balloon.
4. Cleanse urethral meatus with antiseptic solution.
5. Drape patient with the sterile square and fenestrated drapes.
6. When urine appears, advance another 2.5 to 5 cm.
7. Prepare sterile field and supplies.
8. Gently pull catheter until resistance is felt.
9. Attach drainage tubing.

Answer 21

5. Drape patient with the sterile square and fenestrated drapes.
6. Prepare sterile field and supplies.
7. Lubricate catheter
8. Cleanse urethral meatus with antiseptic solution.
9. Insert and advance catheter.
10. When urine appears, advance another 2.5 to 5 cm.
11. Inflate catheter balloon.
12. Gently pull catheter until resistance is felt.
13. Attach drainage tubing.

Question 22

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.)

1. Attach a 3-mL syringe to the inflation port.
2. Allow the balloon to drain into the syringe by gravity.
3. Initiate a voiding record/bladder diary.
4. Pull the catheter quickly.
5. Clamp the catheter before removal.

Answer 22

2. Allow the balloon to drain into the syringe by gravity.
3. Initiate a voiding record/bladder diary.

Question 23

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)?

1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution
2. Hanging the urinary drainage bag below the level of the bladder

3 Emptying the urinary drainage bag daily

4. Irrigating the urinary catheter with sterile water

Answer 23

2. Hanging the urinary drainage bag below the level of the bladder

Question 24

There is no urine when a catheter is inserted 3 inches into a female’s urethra. What should the nurse do next?

1. Remove the catheter and start all over with a new kit and catheter.
2. Leave the catheter there and start over with a new catheter.
3. Pull the catheter back and reinsert at a different angle.
4. Ask the patient to bear down and insert the catheter farther.

Answer 24

2. Leave the catheter there and start over with a new catheter.

Question 25

Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient’s hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

Answer 25

2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

Question 26

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.

Answer 26

1. Stop the instillation.

Question 27

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.

Answer 27

1. Increase fiber and fluids in the diet. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day.

Question 28

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately

Answer 28

1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine whether the ostomy is healing appropriately

Question 29

Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

Answer 29

5. Remove the old pouch. 8. Cleanse and dry the peristomal skin. 7. Assess the stoma and the skin around it. 2. Measure the stoma. 6. Trace the correct measurement onto the back of the wafer. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 1. Close the end of the pouch.

Question 30

Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

Answer 30

1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain

Question 31

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

Answer 31

3. Collect one fecal smear from three separate bowel movements.

Question 32

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient’s underwear.

Answer 32

2. Initiate bowel or habit training program to promote continence.

Question 33

The patient states, “I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold.” Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

Answer 33

4. Lactose intolerance

Question 34

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?

Answer 34

4. Have you experienced frequent, small liquid stools recently?