Test 3 Study

The mother of a newborn tells the nurse, "I am concerned about my baby. When she
first goes to sleep, her eyes dart around under her eyelids, she doesn't breathe regularly,
and she sometimes twitches." What advice should the nurse give this mother?
1. Please bring your baby in immediately for a checkup.
2. These are common behaviors in newborns and are normal.
3. You should ask the physician about these symptoms at your next checkup.
4. If your baby does this again, take her to the emergency department.

The parents of a 6-month-old tell the nurse that they are exhausted because their baby
wakes up several times every night. What advice should the nurse give these parents?
1. Be certain that the baby is truly awake before picking him up for feeding.
2. Let the baby "cry it out" for a few nights until he can sleep through the night.
3. Continue to respond to the baby whenever he is restless during the night.
4. Bring the baby in for a possible sleep study to check for sleeping disorders.

The 70-year-old client tells the nurse, "I can go to sleep without a problem, but then I
wake up in a couple of hours and can't go back to sleep." What nursing action would
help promote rest and sleep in this client?
1. Have the client develop a bedtime ritual of quiet music and a glass of wine.
2. Encourage the client to avoid taking pain medication prior to sleep.
3. Evaluate if the client perceives sleeplessness to be a serious problem.
4. Have the client perform moderate exercises before bedtime.

A client complains of not being able to stay awake during the day even after sleeping
throughout the night. What should the nurse suggestion to this client?
1. Go to your physician for a physical examination.
2. Go to a mental health professional for evaluation of possible depression.
3. Purchase an over-the-counter sleep aid to deepen nighttime sleep.
4. Drink more caffeinated beverages in the daytime to stay awake.

The nurse is developing a plan of care for a client diagnosed with narcolepsy. Which
intervention should the nurse include in this plan of care?
1. Encourage the client to take an over-the-counter medication to improve nighttime
sleep.
2. Be certain the client has the prescription for modafinil (Provigil) filled.
3. Have the client purchase sodium oxybate (Xyrem) over the counter to prevent
daytime drowsiness.
4. Be certain the client obtains antihistamines to control nasal stuffiness.

The client is being treated with a nasal continuous positive airway pressure device
(CPAP) for sleep apnea. What finding indicates that this treatment has been helpful to
the client?
1. The client has lost 7 pounds since treatment began.
2. The client sleeps so soundly that he snores.
3. The client's diabetes is now under control.
4. The client reports a decrease in morning headache.

The nurse is admitting a critically ill client to the intensive care unit. What question
should the nurse ask regarding this client's sleep history?
1. No questions should be asked.
2. “When do you usually go to sleep?”
3. “Do you have any problems with sleeping?”
4. “What are your bedtime rituals?”

The client who has sleep apnea reports falling asleep while driving, almost being
involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis
should be a priority for this client?
1. Disturbed Sleep Pattern related to difficulty staying asleep
2. Risk for Impaired Gas Exchange related to sleep apnea
3. Disturbed Thought Processes related to chronic insomnia
4. Risk for Injury related to somnambulism

The nurse is working with a client to develop an expected outcome for the nursing
diagnosis Disturbed Sleep Pattern, difficulty staying asleep related to anxiety
secondary to multiple life stressors. Which expected outcome would be most applicable
to this client's situation?
1. The client will sleep at least 8 hours each night.
2. The client will list three positive coping mechanisms for anxiety relief.
3. The client will report getting sufficient sleep to provide energy for daily activities.
4. The client will manifest less anxiety after taking prescribed medications.

The nurse is planning interventions for a client who has difficulty falling asleep. Which
intervention regarding sleep times would be most helpful?
1. Maintain a regular bedtime and wake-up time for all days of the week.
2. If bedtime is delayed on one night, go to bed that much earlier the next night.
3. If daytime drowsiness occurs, go to bed earlier that night.
4. Sleep at least 1 hour later on mornings you don't have to go to work.

The client reports difficulty sleeping. Which environmental intervention should the
nurse recommend?
1. Play soft music throughout the night.
2. Keep a television on in the bedroom.
3. Provide white noise with a fan.
4. Play a talk radio station.

The client reports difficulty sleeping and awakening several times during the night.
What intervention should the nurse recommend for the client when unable to sleep?
1. Get out of bed, go into another room, and pursue some relaxing activity until drowsy.
2. Get out of bed, go into another room, and exercise until tired before trying to go back
to sleep.
3. Sit in bed and watch the bedroom television until drowsy.
4. Stay in bed with eyes closed and do some mental arithmetic until sleepy

The hospitalized client requests a bedtime snack. Which food should the nurse offer
this client?
1. Hot chocolate
2. Tea and crackers
3. Cereal with milk
4. Chips and salsa

The client has been prescribed zolpidem (Ambien) for the short-term management of
insomnia. What information should the nurse include when teaching the client about
this medication?
1. For best results, take the medication just prior to bedtime.
2. Take the medication at dinnertime to avoid gastric upset.
3. Do not take the medication with any liquid that contains calcium.
4. Drink an entire glass of water with the dose to avoid kidney stones

The client who has obstructive sleep apnea is being treated with a nasal continuous
positive airway pressure (CPAP) device, but has just been prescribed modafinil
(Provigil). What client statement indicates that teaching about these therapies has been
effective?
1. "I am so glad that I won't have to sleep in this machine anymore."
2. "Once I get regulated on the Provigil, I will wean myself off the CPAP."
3. "I will continue using my CPAP machine at night."
4. "I can turn down the pressure on my CPAP machine in about 1 week."

A client questions why a medication that is used to treat Parkinson's disease has been
prescribed for the diagnosis of periodic limb movement disorder (PLMD). What should
the nurse do?
1. Contact the physician.
2. Assure the client that medications used to treat Parkinson's disease are also used to
treat PLMD.
3. Tell the client not to take the medication because there is most likely an error.
4. Check with the pharmacy to make sure the correct medication has been provided to
the client

The client has complained of stiffness and muscle tension in his back. The nurse
suggests a back rub, but the client declines the offer. What action should the nurse take?
1. Encourage the client to accept the back rub, saying how much it will relax the back
muscles.
2. Document that the client is noncompliant with the nursing plan of care.
3. Accept the declination but tell the client to call if he changes his mind.
4. Instruct the UAP to rub the client's back while assisting him to change into a clean
gown

A 5-year-old client has recurrent night terrors. What nursing intervention should the
nurse use to help alleviate this problem?
1. Have the child walk around in the room when night terrors occur.
2. The next morning, ask the child to describe the event.
3. Have the child empty the bladder prior to going to bed.
4. Use an additional pillow behind the child's head at night

The nurse is completing the admission assessment on a client who has obstructive sleep
apnea. Which findings should the nurse expect when assessing this client?
Standard Text: Select all that apply.
1. Reddened uvula
2. Large soft palate
3. Obesity
4. Short neck
5. Deviated septum

The nurse is working on a hospital committee tasked with reducing environmental
distractions to sleep within the hospital. Which recommendations by the committee
would be helpful?
Standard Text: Select all that apply.
1. Turn off all overhead lights on the unit and use night-lights and flashlights.
2. Establish a time at which radios and televisions should be turned off or down.
3. Discontinue use of the paging system after 2100.
4. Conduct nursing reports in the hallway.
5. Open curtains between beds in semiprivate rooms.

A client tells the nurse that because of work and life responsibilities, sleep has “become
optional.” What is the best response the nurse should make to this client?
1. “Be sure to get extra sleep when you can.”
2. “A lack of sleep can affect hormone levels and bodily functions.”
3. “Everyone has different needs for sleep to in order to function.”
4. “You must be very productive.”

The nurse is assessing a client in the intensive care unit who is asleep. What
physiological changes will the nurse observe in this client?
Standard Text: Select all that apply.
1. Lower respiratory rate
2. Increased muscle tension
3. Increased lower extremity edema
4. Lower blood pressure
5. Lower heart rate

A client with diabetes asks the nurse why his blood glucose level is higher on days
when he sleeps less. What should the nurse explain to the client?
1. During sleep, the hormone cortisol is inhibited. If sleep is interrupted, cortisol levels
will remain elevated, impacting blood glucose.
2. Because the client is awake more, it is likely the client is eating more, which is
impacting the blood glucose level.
3. There is no relationship between sleep and blood glucose levels.
4. The body needs cortisol for the extra energy created by the lack of sleep

A hospitalized client is being woken up every hour during the night for care and
procedures. The nurse realizes that the lack of NREM sleep can have which
physiological effect?
1. Decrease urine output
2. Increase thirst
3. Increase susceptibility to infection
4. Decrease heart rate

A client has not had uninterrupted sleep for several nights, and is irritable. What other
assessment findings should the nurse associate with the client’s lack of REM sleep?
Standard Text: Select all that apply.
1. Depression
2. Confusion
3. Disorientation
4. Impaired memory
5. Muscle weakness

The nurse, seeing a client asleep, turns off the television in the room. The client opens
her eyes and says “I was watching that. I wasn’t sleeping.” The nurse realizes that the
client was demonstrating which stage of NREM sleep?
1. IV
2. III
3. II
4. I

The parent of a preschool-age child asks the nurse what can be done to reduce the
number of nightmares the child experiences. What should the nurse suggest to this
parent?
1. Provide hot chocolate prior to bedtime.
2. Limit or eliminate television.
3. Engage in a physical activity before bedtime.
4. Play a computer game before bedtime

A client reports the need to urinate during the night and then not being able to fall back
asleep. The nurse should document this assessment finding as which factor that
influences sleep?
1. Illness
2. Stimulant
3. Diet
4. Lifestyle

A client is working two jobs, caring for aged parents, and maintaining a household for
the family. The nurse realizes that this emotional stress will have what impact on the
client’s sleep?
1. More REM sleep
2. Less Stage 1 and Stage II NREM sleep
3. More NREM sleep
4. Less deep sleep and more awakenings during the night

A client who smokes cigarettes tells the nurse that sleep is light, and that he awakens
easily. What should the nurse suggest to help this client with sleep?
1. Smoke no cigarettes 1 hour before sleep.
2. Smoke no cigarettes after the evening meal.
3. Limit the number of cigarettes smoked during the day.
4. Adjust to the lack of sleep, because those who smoke do not get sufficient sleep

A client tells the nurse about having problems falling and staying asleep. What should
the nurse ask the client to gain more information about this client problem?
Standard Text: Select all that apply.
1. “How often does this happen?”
2. “How much coffee do you drink each day?”
3. “How do you feel when you wake up in the morning?”
4. “When do you eat your evening meal?”
5. “What have you done to deal with this sleeping problem?”

After an assessment, the nurse is concerned that an older client is experiencing changes in sleep.
What findings did the nurse use to make this clinical decision?
Standard Text: Select all that apply.
1. Is wide awake around 3 AM
2. Takes a nap after lunch every day
3. Returns to sleep after using the bathroom
4. Goes to sleep before 9 PM most evenings
5. Wakes up and looks at the clock every hour

The nurse suspects that an adult is not getting an adequate amount of nightly sleep. What
information caused the nurse to have this suspicion?
Standard Text: Select all that apply.
1. Enrolled in online classes
2. Raising two children ages 4 and 8
3. Experiences chronic pain from sciatica
4. Attends religious services every Sunday and Wednesday
5. Works one job steady night turn and another part-time late afternoon

The nurse is caring for an 8-month-old infant. What is the best tool the nurse should use
for evaluating pain in this infant?
1. FLACC scale
2. Wong-Baker FACES
3. Visual analog scale
4. Numeric rating scale

The nurse is preparing to discharge a client home with a prescription for ibuprofen
(Motrin). What should the nurse instruct as a common side effect of this medication?
1. Gastrointestinal (GI) distress
2. Shakiness
3. Tremors
4. Rash

Which of the following objective assessment data will the nurse obtain before
administering a prescribed opioid medication to a client?
1. Pain level as stated by client
2. Any nausea the client may be feeling
3. Respiratory rate
4. Color of skin

The nurse provides an oral opiate to a client with pain. In how many hours should the
nurse expect the client to need another dose of the medication?
1. 2 hours
2. 4 hours
3. 6 hours
4. 8 hours

The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache;
however, the client has been vomiting all day. Which route should the nurse use to
administer the medication?
1. Oral
2. Vaginal
3. Rectal
4. Intravenous

A client recovering from a left below-the-knee amputation is experiencing left foot pain.
The nurse realizes the client is experiencing which type of pain?
1. Phantom limb pain
2. Acute pain
3. Chronic pain
4. Narcotic-induced pain

The nurse is providing discharge instructions to a client prescribed an opioid
medication. What should the nurse suggest to decrease the risk of constipation with this
medication?
1. Take an antihistamine three times per day.
2. Drink 6 to 8 glasses of water per day.
3. Assess respiratory rate before taking medication.
4. Assess heart rate before taking medication

The nurse is caring for a client who is using morphine through patient-controlled
analgesia (PCA). What medication should the nurse have readily available?
1. Naloxone hydrochloride (Narcan)
2. Acetaminophen (Tylenol)
3. Diphenhydramine hydrochloride (Benadryl)
4. Normal saline

The client is taking meperidine (Demerol) and experiencing pruritus. Which
medication should the nurse expect the physician to order?
1. Naloxone hydrochloride (Narcan)
2. Acetaminophen (Tylenol)
3. Diphenhydramine hydrochloride (Benadryl)
4. Normal saline

The nurse is admitting a client to the emergency department with complaints of severe
abdominal pain. What is the nurse's first action?
1. Administer IV pain medication as ordered.
2. Start an IV line of lactated Ringer's.
3. Assess pain using a scale of 1 to 10.
4. Place a Foley catheter to bedside drainage.

A client is surprised to learn of the diagnosis of a heart attack when there was no chest
pain experienced but only some left shoulder pain. The nurse should explain that the
client experienced which type of pain?
1. Phantom pain
2. Referred pain
3. Visceral pain
4. Chronic pain

A client rates pain as being 7 on a scale from 0 to 10. What should the nurse document
as this client's pain intensity?
1. Mild pain
2. Moderate pain
3. Severe pain
4. Physiological pain

A client is experiencing pain after spraining an ankle. The nurse realizes that the client
is most likely experiencing which type of pain?
1. Mild pain
2. Severe pain
3. Somatic pain
4. Visceral pain

The client scheduled to undergo minor surgery states, "The physician will not give me
pain medication after surgery because my surgery is only minor." What is the best
response by the nurse?
1. "You can experience pain after minor surgery, so you can have pain medication."
2. "You are correct. The physician will not order any pain medication."
3. "You are correct. I will need to teach you nonpharmacologic pain relief measures."
4. " You can only have about half the dose because your surgery is minor."

The nurse is performing discharge teaching for a client taking an NSAID. The client
states he has heard that taking an antacid with this medication will help decrease the
incidence of upset stomach. What is the nurse's best response?
1. "Antacids reduce the absorption and therefore the effectiveness of the NSAID."
2. "Antacids help to reduce the incidence of gastric bleeding that could occur with the
use of NSAIDs."
3. "Antacids should never be taken with an NSAID."
4. "Antacids help to reduce the incidence of pain."

The nurse is caring for a postpartum client receiving pain medication through an
epidural catheter. Which assessment finding should the nurse report immediately to the
physician?
1. Pulse rate: 80
2. Respiratory rate: 8
3. Blood pressure: 120/80
4. Pain rating of 4 on scale of 1 to 10

A client states that a cramping pain started 2 hours ago and is not accompanied by any
nausea or vomiting. Which type of pain is this client most likely experiencing?
1. Chronic pain
2. Phantom pain
3. Visceral pain
4. Acute pain

The nurse is preparing to conduct a pain assessment. What should the nurse include in
this assessment?
Standard Text: Select all that apply.
1. Duration
2. Location
3. Intensity
4. Etiology
5. Neurology

A client experiencing pain has been prescribed aspirin. The nurse realizes that this
medication will affect which pain process?
1. Transduction
2. Transmission
3. Perception
4. Modulation

A client is complaining of having the same type of pain that he experienced prior to
being diagnosed with cancer. The nurse realizes that which process will influence this
client’s perception of pain?
1. Transmission
2. Modulation
3. Perception
4. Transduction

A client tells the nurse that an ice pack works well to reduce the intensity of back pain.
The nurse realizes that the client is implementing
1. a placebo.
2. distraction.
3. guided imagery.
4. the gate control theory of pain

A client recovering from hip surgery is reluctant to ambulate because of the amount of
pain that occurred with walking prior to the surgery. What can the nurse do to help this
client with pain control?
1. Provide pain medication before every ambulation session.
2. Address the client’s fear of pain with walking.
3. Tell the client that the pain is now gone.
4. Explain that the client is confusing postoperative pain with the pain before the
surgery.

The nurse is caring for an adolescent client who is experiencing postoperative pain.
What interventions should the nurse use to help this client?
Standard Text: Select all that apply.
1. Talk with the client about pain.
2. Provide privacy.
3. Present choices for dealing with pain.
4. Encourage distraction with music or television.
5. Allay fears and anxiety.

An older client who refuses medication for pain is irritable and unable to sleep. What
should the nurse explain to the client to encourage the use of pain medication?
Standard Text: Select all that apply.
1. There are high-dose medications that will eradicate the pain.
2. The lack of pain control is causing the inability to sleep.
3. The lack of pain control is causing irritability.
4. The risks of taking pain medication are low in the older population.
5. The lack of pain control will affect mobility and activity tolerance.

A client with pain has had previous episodes of uncontrolled pain in the past and is
worried about the current pain pattern. Which diagnosis would be appropriate for the
nurse to include for this client?
1. Anxiety
2. Ineffective Coping
3. Deficient Knowledge
4. Hopelessness

From an assessment, the nurse learns that the client is having difficulty sleeping
because of pain in the hips and knees due to arthritis. The client is weak and fatigued.
Which diagnoses would be applicable to the client at this time?
Standard Text: Select all that apply.
1. Anxiety
2. Hopelessness
3. Ineffective Health Maintenance
4. Insomnia
5. Impaired Physical Mobility

A client experiencing chronic pain is not getting relief with pain medication. What
should the nurse do to help this client?
1. Ask the physician to change the prescribed pain medication.
2. Reassess the pain and consider another pain relief measure.
3. Limit interaction with the client.
4. Stop using alternative pain relief measures, if not effective

A client’s pain level is assessed as being severe. Which intervention would be the most
applicable for the client at this time?
1. Provide NSAID medication as prescribed.
2. Coach the client with guided imagery.
3. Suggest the client read or watch television until the pain subsides
4. Provide opioid analgesic as prescribed.

A client recovering from back surgery is refusing pain medication for fear of becoming
addicted. What should the nurse say to the client?
1. “I understand.”
2. “There are ways to treat addictions to pain medications.”
3. “If the medication is taken to treat pain, you will not become addicted to it.”
4. “All pain medication causes addiction. There is nothing that can be done to prevent
it.”

A client experiencing pain after surgery says “Something must be wrong” because the
pain is so severe. What is the best response for the nurse to make to the client?
1. “The amount of tissue disrupted from the surgery is not related to the degree of pain
you feel.”
2. “That could be so.”
3. “Taking pain medication for many years has made the medication ineffective now.”
4. “Are you sure the pain is as bad as you are saying it is?”

A client has been taking medication for back pain for several months, and has seen
several different health care providers in efforts to receive pain medication. The nurse
is concerned that the client is exhibiting
1. tolerance.
2. addiction.
3. physical dependence.
4. pseudoaddiction.

A client repeatedly asks the nurse “How much longer until I can get more pain
medication?” Once the medication is provided, the client stops asking for it. The nurse
identifies the client’s behavior as being
1. addiction.
2. tolerance.
3. pseudoaddiction.
4. physical dependence

A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare
to administer what medications to the client?
Standard Text: Select all that apply.
1. Nortriptyline
2. Amitriptyline
3. Tramadol
4. Meloxicam
5. Gabapentin

A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications
should the nurse consider for the client at this time?
Standard Text: Select all that apply.
1. Acetaminophen (Tylenol)
2. Ibuprofen (Motrin)
3. Naproxen (Naprosyn)
4. Hydrocodone (Vicodin)
5. Methadone (Dolophine)

After receiving medication for mild pain, the client states that the pain is getting worse.
What should the nurse plan to do for this client?
1. Administer another dose of a nonopioid medication.
2. Administer an opioid for severe pain.
3. Administer an opioid for moderate pain.
4. Administer two doses of an opioid for moderate pain.

A client is prescribed a medication that is a blend of an opioid analgesic with an NSAID.
The nurse realizes that this medication will have which effects on the client?
Standard Text: Select all that apply.
1. Encourage the development of tolerance.
2. Encourage the development of addiction.
3. Maximize pain control while minimizing toxicity.
4. Maximize pain control while minimizing side effects.
5. Reduce the onset of pseudoaddiction

A client is diagnosed with chronic low back pain syndrome. The nurse realizes that
which analgesic delivery route might be beneficial for this client?
1. Topical
2. Rectal
3. Transmucosal
4. Transdermal

A client tells the nurse that at home, the dog helps distract the client from chronic hip
pain. The nurse realizes that the client is utilizing which form of nonpharmacologic
pain control?
1. Body
2. Mind
3. Social interactions
4. Spirit

The nurse is preparing to instruct a client on nonpharmacologic interventions that target
the body for pain control. What should the nurse include in these instructions?
Standard Text: Select all that apply.
1. Massage
2. Acupressure
3. Self-hypnosis
4. Exercise
5. Nutritional supplements

The nurse is preparing a client for a back massage. Which positions would be the best
for the client to receive this massage?
Standard Text: Select all that apply.
1. Supine
2. Fowler’s
3. Trendelenburg
4. Prone
5. Side-lying

A client who is on postoperative day 1 after abdominal surgery is requesting a back rub.
The nurse realizes this care should be provided by
1. the registered nurse.
2. unlicensed assistive personnel.
3. no one, because the client cannot assume the prone position.
4. the physician.

The nurse wants to assign back rubs to unlicensed assistive personnel (UAP). Before
doing so, the nurse should first determine whether
Standard Text: Select all that apply.
1. unlicensed assistive personnel know how to perform a back rub.
2. there any clients who have intravenous fluids infusing.
3. there any clients who should not have a back rub performed.
4. there any clients who are prescribed to take nothing by mouth.
5. there any clients who do not want a back rub done by unlicensed assistive personnel.

The nurse has completed a back massage for a client. What should the nurse document
about this procedure?
Standard Text: Select all that apply.
1. Effectiveness of pain medication using a rating scale from 0 to 10
2. Position to perform the massage
3. Content of communication that occurred during the back massage
4. Amount of lotion used during the back massage
5. Client response

A client with a long leg cast is complaining of knee discomfort. Which
nonpharmacologic intervention can the nurse use to help this client?
1. Apply ice to the knee over the cast.
2. Rub the knee of the non-casted leg.
3. Apply heat to the knee over the cast.
4. Rub the foot of the casted extremity.

A client watching a comedy on television is laughing. When asked about the amount of
pain on a scale from 0 to 10, the client reports a level that is 2 below the previous
assessment. The nurse realizes the client’s pain was influenced by which type of
distraction?
1. Visual
2. Tactile
3. Intellectual
4. Behavioral

The health care provider is writing medication orders for a client recovering from spinal fusion
surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should
the nurse consider providing to the client?
Standard Text: Select all that apply.
1. Oxymorphone (Opana)
2. Hydrocodone (Vicodin)
3. Oxycodone (OxyContin)
4. Morphine sulfate (morphine)
5. Hydromorphone hydrochloride (Dilaudid)

The nurse is caring for a client receiving pain medication through an epidural catheter. What
should the nurse include to ensure safety when caring for this client?
Standard Text: Select all that apply.
1. Secure all tubing connections with gauze.
2. Apply tape over all injection ports on the tubing.
3. Cleanse the insertion site with alcohol swabs once a day.
4. Label the tubing, infusion bag, and pump with the word “epidural.”
5. Post a sign above the client’s bed indicating that an epidural is being used.

The parent of a newborn infant reports that the baby wakes up every 2 hours and only
takes about 2 ounces of formula before going back to sleep. What instruction should the
nurse give this parent?
1. Make the baby wait at least 3 hours between feedings.
2. Continue to feed the baby with this on-demand schedule.
3. When the baby gets sleepy during feeding, use techniques such as moving around
and tickling to encourage wakefulness.
4. Offer the baby less formula to prevent waste.

What criteria should the nurse use to evaluate to determine if an infant's regurgitation,
or spitting up, should be further investigated?
1. How often the baby spits up
2. How much the baby spits up at a time
3. If the baby is gaining weight adequately
4. The consistency of the regurgitated matter

The parents of a 7-month-old child have started offering solid foods to their baby. The
baby has enjoyed and tolerated rice cereal, applesauce, and other fruits. Which food
should the nurse recommend to be introduced next?
1. Strained beef
2. Green beans
3. Squash
4. Strained chicken

The nurse has advised the client to consume alcohol only in moderation. What
guideline should the nurse provide as a "moderate" alcohol intake?
1. Two drinks per week for women, three for men
2. Two drinks per day for women, three for men
3. One drink per day for women, two for men
4. One drink per week for women, two for men

The nurse completes triceps skinfold measurement on a client. In order to obtain the
most meaningful data, how soon should the nurse repeat this measurement?
1. 2 days
2. 10 days to 2 weeks
3. 1 month
4. 1 year

The client's lab studies reveal a normal serum albumin with a prealbumin of 10. How
should the nurse interpret the significance of these readings?
1. The client has had recent protein malnutrition.
2. The client is now relatively well nourished with malnutrition 6 to 8 months ago.
3. The client is at risk for development of malabsorption syndromes.
4. Carbohydrate malnutrition has occurred over the last 6 months.

A client reports following the "food pyramid" to guide nutritional intake. How should
the nurse evaluate this information?
1. Because this food pyramid is produced by the U.S. Department of Agriculture, the
client is likely consuming necessary levels of all essential nutrients.
2. The food pyramid is most useful when applied to the nutritional intake of children.
3. The food pyramid is not very useful because it does not take fluid intake and
combination foods into consideration.
4. Following the appropriate food pyramid is helpful, but there are additional factors to
consider in a balanced diet.

The nurse has instructed an overweight client to follow a 2,000-calorie diet by
substituting foods considered low in calories for those higher in calories. How should
the client interpret the food label to decide if a food is low in calories?
1. The product label will state "lighter" or "reduced calories."
2. The Nutrition Facts label will have the letter "L" located in the lower right corner.
3. Nutritional labeling on the product will indicate less than 40 calories per serving.
4. The product will contain no more than 11% fat.

Nitrogen balance testing is planned for a client. What instruction to the staff caring for
this client is essential?
1. Remove the client's oxygen cannula 10 minutes prior to the test.
2. Accurate measurement of food intake is very important.
3. All urine output should be collected for 48 hours.
4. Keep the client NPO beginning at midnight before the test.

A client who has undergone a gastrointestinal surgery is permitted to have a clear liquid
diet on the second postoperative day. Which fluid should the nurse order from the diet
kitchen for this client?
1. Apricot nectar
2. Cranberry juice
3. Chicken broth
4. Cherry ice pop

Unlicensed assistive personnel are assigned the task of feeding breakfast to older
clients with alterations in mobility and orientation. What instruction should the nurse
include in this delegation?
1. Breakfast should be completed quickly so that baths may begin.
2. Give fluids before and after each bite of solid foods.
3. Stand to the left of right-handed clients during feeding.
4. Engage the client in conversation during the meal.

The nurse has delegated administration of tube feeding to a specially trained UAP.
What action should be taken by the nurse in regard to this delegation?
1. Order the equipment to give the feeding.
2. Check the tube for placement.
3. Set up the equipment and mix the feeding.
4. Regulate the rate of the feeding.

The nurse notices that the client's continuous open system tube-feeding set is almost
empty. What action should the nurse take?
1. Add tube feeding to the set.
2. Discontinue the feeding and hang a closed system bag.
3. Wash out the set and add new feeding.
4. Flush the set with clear carbonated soda and discontinue.

As the nasogastric tube is passed into the oropharynx, the client begins to gag and
cough. What is the correct nursing action?
1. Remove the tube and attempt reinsertion.
2. Give the client a few sips of water.
3. Use firm pressure to pass the tube through the glottis.
4. Have the client tilt the head back to open the passage.

The nurse notes that the tube-fed client has shallow breathing and dusky color. The
feeding is running at the prescribed rate. What should the nurse do first?
1. Place the client in high Fowler's position.
2. Turn off the tube feeding.
3. Assess the client's lung sounds.
4. Assess the client's bowel sounds.

The client has a body mass index (BMI) of 18. How should the nurse interpret this
finding?
1. The client is malnourished.
2. The client is underweight.
3. The client is normal.
4. The client is overweight

On admission, the client weighs 165 lb (75 kg). The client reports that this is a weight
loss from 180 lb (82 kg). What is this client’s percent weight loss?
1. 4.5%
2. 6.25%
3. 8.3%
4. 10.0%

The client is weighed each month while residing in the long-term care facility. This
month the client weighs 110 lb (50 kg). The nurse compares this weight to the last 3
months' results and discovers the client has lost 22 lb (10 kg). There has been no
attempt to lose this weight. How should the nurse interpret this weight loss?
1. No malnutrition
2. Mild malnutrition
3. Moderate malnutrition
4. Severe malnutrition

The nurse is reviewing laboratory data for a client who is receiving total parenteral
nutrition. Which laboratory value should be immediately brought to the physician's
attention?
1. BUN of 60
2. Prealbumin of 15
3. Serum glucose of 328
4. Potassium of 3.5

What nursing diagnosis is the most important for the nurse to include in the care plan of
a client who has just been started on total parenteral nutrition (TPN) therapy?
1. Risk for Infection
2. Imbalanced Nutrition: Less Than Body Requirements
3. Activity Intolerance
4. Fluid Volume Deficit

A client reports that an adolescent family member has started a vegan diet. Which
additions to meals should the nurse recommend to help ensure that the adolescent does
not become deficient in calcium?
Standard Text: Select all that apply.
1. Tofu
2. Soybeans
3. Brewer’s yeast
4. Raisins
5. Okra

During diet teaching with a client diagnosed with diabetes, the nurse should instruct
that the most prevalent monosaccharide is
1. fructose.
2. galactose.
3. corn syrup.
4. glucose.

The nurse is instructing a client on foods that are considered complete proteins. What
will the nurse include in these instructions?
Standard Text: Select all that apply.
1. Meat
2. Gelatin
3. Eggs
4. Chicken
5. Fish

A client is diagnosed with an elevated cholesterol level. What should the nurse instruct
the client regarding foods to avoid?
Standard Text: Select all that apply.
1. Fish
2. Milk
3. Liver
4. Chicken
5. Egg yolk

The nurse is planning an educational program for community members on ways to
improve nutritional intake. What information should the nurse include about
carbohydrate digestion and metabolism?
Standard Text: Select all that apply.
1. Enzymes are needed to digest carbohydrates.
2. The breakdown of carbohydrates results in simple sugars.
3. Carbohydrates are a major source of body energy.
4. The simple sugar glucose provides a readily available source of energy.
5. Pancreatic amylase enhances the use of glucose by the body cells.

A client is diagnosed as having a negative nitrogen balance. What should the nurse
instruct the client about this finding?
1. Discuss ways to reduce protein in the diet.
2. Review how to limit carbohydrates in the diet.
3. Discuss ways to increase protein in the diet.
4. Analyze reasons why fats should be limited in the diet.

A client diagnosed with negative nitrogen balance tells the nurse about participating in
ritualistic fasts as a part of his culture. The client abstains from all food for several days
at a time. What should the nurse discuss with the client regarding this practice?
1. The amount of weight the client will lose during the fasts
2. The need to ingest some carbohydrates for body functions
3. The amount of calories the client will need to ingest after fasting for several days
4. The importance of the practice to the client

A client asks the nurse for help in selecting foods, as some are “good” and others are
“bad.” How should the nurse respond to the client?
Standard Text: Select all that apply.
1. “Eat a wide variety of foods to furnish adequate nutrients.”
2. “Avoid starchy foods.”
3. “Limit foods with high-fructose corn syrup.”
4. “Eat three meals a day to reduce calories.”
5. “Eat moderately to maintain correct body weight.”

A client tells the nurse that fresh fruit should be eaten only on an empty stomach, as it
will cause other foods to ferment in the stomach. The nurse realizes this client’s
nutritional status is influenced by
1. lifestyle.
2. culture.
3. beliefs about food.
4. religious practices.

The nurse is planning instruction for a client who is underweight. What should be
included in this teaching?
Standard Text: Select all that apply.
1. Discuss factors contributing to inadequate nutrition and weight loss.
2. Discuss ways to manage, minimize, or alter the factors contributing to
malnourishment.
3. Discuss principles of a well-balanced diet and high- and low-calorie foods.
4. Provide information about community agencies that can assist in providing food.
5. Provide information about ways to increase calorie intake.

The nurse is planning interventions for a client to improve the appetite. What actions
would be appropriate for this client?
Standard Text: Select all that apply.
1. Select small portions.
2. Avoid unpleasant treatments immediately before or after a meal.
3. Ensure a clean environment free of unpleasant sights and odors.
4. Encourage oral hygiene before a meal.
5. Provide medication for pain or other symptoms after a meal.

The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What
should the nurse do before providing this feeding?
1. Assess tube placement.
2. Measure vital signs.
3. Assist the client to a prone position.
4. Lower the head of the bed

The nurse has finished providing a tube feeding to a client. What should the nurse
document about this procedure?
Standard Text: Select all that apply.
1. Name of physician prescribing the feedings
2. Solution provided
3. Amount of fluid
4. Duration of the feeding
5. Client tolerance of the feeding

A client receives several tube feedings each day. After documenting the client’s
tolerance of the feedings and assessments in the medical record, the nurse should also
document the amount of feeding provided on the
1. graphic sheet.
2. dietary consultation notes.
3. vital signs record.
4. intake and output record

The nurse is concerned that an older client is at risk for aspiration. What feeding techniques
should the nurse instruct the family to use once the client is discharged?
Standard Text: Select all that apply.
1. Thicken all fluids.
2. Use the chin-tuck method.
3. Place the client in a seated position
4. Focus on food preferences.
5. Keep the head of the bed at a 30-degree angle.

The nurse is assessing a client's urinary elimination. Which factor should the nurse keep
in mind as influencing this elimination?
1. Age
2. Body image
3. Knowledge
4. Socioeconomic status

The nurse realizes that which client is at risk for difficulty in urinary elimination?
1. A client who had bladder cancer and now has a newly created ileal conduit
2. A 25-year-old female client with low self-esteem
3. An 80-year-old male reporting frequent urination at night
4. The client with hypertension who takes a diuretic every day for blood pressure

A client tells the nurse about the need to get up several times throughout the night to
void. The nurse suspects the client is experiencing nocturia due to which factor?
1. Decrease in bladder tone
2. Decrease in blood supply
3. Decrease in number of nephrons
4. Decrease in cardiac output

Which intervention would the nurse plan to help a client prevent a urinary tract
infection?
1. Encourage the use of bubble baths.
2. Have the client increase sugar in the diet.
3. Instruct the client to empty the bladder completely.
4. Wipe from back to front.

The nurse should incorporate which instructions into the teaching plan for a client with
a urinary diversion?
1. Change the appliance several times a day.
2. Increase fluid intake.
3. Notify the physician if the stoma is deep pink and shiny.
4. Strands of blood may appear in the urine.

Which nursing intervention is appropriate when caring for a client with a retention
catheter?
1. Don sterile gloves.
2. Gently retract the labia majora away from the urinary meatus.
3. Observe urine in the drainage bag.
4. Retape the catheter to the thigh.

Which nursing diagnosis would be appropriate for a client who has a retention catheter
if the drainage bag is found lying on the floor?
1. Risk for Impaired Skin Integrity related to catheter placement
2. Risk for Infection related to improper handling
3. Self-Care Deficit related to presence of a retention catheter
4. Risk for Incontinence related to an obstruction

The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary
Incontinence. Which outcome would be related to sphincter incompetence?
1. The client will empty her bladder every time she voids.
2. The client will improve her incontinence within 1 month.
3. The client will perform four to five squeezes for 5 to 10 seconds.
4. The client will stop the flow of urine when voiding.

Which goals should the nurse identify as appropriate for a client with the nursing
diagnosis Urinary Pattern Alteration related to an enlarged prostate?
1. The client will avoid bladder distention.
2. The client will maintain fluid imbalance.
3. The client will remain free of skin breakdown.
4. The client will voice increased discomfort.

The RN is admitting a client to the medical unit for a urinary disorder. Which physical
assessment techniques should the nurse use in assessing this client's urinary system?
1. Auscultation and inspection
2. Inspection and percussion
3. Observation and auscultation
4. Palpation and observation

A client is rushed to the emergency department with what the physicians suspect to be
necrosis of the urinary diversion stoma. What evidence presented by the client leads to
this conclusion?
1. Black with sloughing
2. Moist stoma
3. Pink and shiny
4. Slight bleeding from stoma

A client’s results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC
10–15, glucose negative, specific gravity 1.012, and protein negative. How should the
nurse interpret the results?
1. Dehydration
2. Diabetic ketoacidosis
3. Trauma
4. Urinary tract infection

A client's urinalysis is reported as being normal. What were the client's results?
1. Blood present and no ketones
2. Dark amber color and output less than 500 cc in 24 hours
3. pH 6 and no glucose present
4. Specific gravity 1.035 and faint aromatic odor

A client is prescribed propranolol (Inderal). What should the nurse instruct the client
about this medication?
1. The medication should be discontinued abruptly.
2. Notify the physician if you experience urinary retention.
3. Take a laxative every day.
4. Take the medication on an empty stomach.

A client is having issues with urinary elimination. What should the nurse instruct this
client to promote urinary elimination?
1. Don't interrupt your day by going to the bathroom; wait until you're at a good
stopping place.
2. Drink 8 to 10 glasses of water daily.
3. Urine color changes are not important.
4. Wash with soap and water every other day.

A client is instructed on the care of an indwelling urinary catheter. Which returned
demonstration by the client indicates that teaching has been effective?
1. The client empties the drainage bag once a day.
2. The client hangs the drainage bag on the towel rod.
3. The client refuses drinks one to two 8-ounce glasses of fluid each day.
4. The client takes a shower each day.

A client recovering from a transurethral resection of the prostate (TURP) with a
three-way indwelling catheter expresses the need to urinate. Which action should the
nurse take to help this client?
1. Deflate and then reinflate the balloon.
2. Irrigate the catheter.
3. Reposition the catheter.
4. Retape the catheter to the abdomen.

A client is diagnosed with an elevated aldosterone level. The nurse realizes that this
finding will affect what aspect of urinary elimination?
1. Increased urine output
2. Urinary incontinence
3. Decreased urine output
4. Urinary retention

A client has a spinal cord injury at the cervical spine area. The nurse realizes that this
injury will affect which aspect of urinary elimination in the client?
1. Elimination of urine from the bladder
2. Ability of the kidneys to absorb solutes
3. Ureteral function
4. Urethra function

A client is complaining of pain with urination. The nurse realizes that the client needs to
be assessed for which health problems?
Standard Text: Select all that apply.
1. Urethral stricture
2. Renal failure
3. Urethral injury
4. Bladder injury
5. Urinary infection

A client needs a test to determine the amount of residual urine. The nurse realizes that
this assessment is used for which reason(s)?
Standard Text: Select all that apply.
1. To evaluate the glomerular filtration rate
2. To determine the extent of renal failure
3. To determine the amount of retained urine after voiding
4. To determine the need for medications
5. To evaluate fluid volume status

A client’s urine pH is 8.0. What further assessments would be indicated for this client?
Standard Text: Select all that apply.
1. Intake of fruits and vegetables
2. Intake of cranberries
3. Intake of high-protein foods
4. Symptoms of diarrhea
5. Symptoms of a urinary tract infection

The nurse is instructing a client on ways to manage stress urinary incontinence. What
should be included in this client’s teaching?
Standard Text: Select all that apply.
1. Limit intake of caffeine.
2. Limit intake of alcohol.
3. Increase intake of citrus juices.
4. Limit evening fluid intake.
5. Increase intake of beverages with artificial sweeteners.

The nurse is concerned that a client is at risk for the development of urinary tract
infections. What did the nurse assess to come to this conclusion?
1. The client is wearing tight clothing.
2. The client is employed as a computer operator.
3. The client drinks 8–10 8-ounce glasses of water and low-calorie beverages each day.
4. The client exercises for 30–60 minutes most days of the week.

The nurse is concerned that an older client with a retention catheter is developing a
urinary tract infection. What assessment finding caused this concern?
1. Elevated blood pressure
2. Elevated heart rate
3. Confusion
4. Leg pain

The nurse is applying an external urinary device to a client. Before attaching the device
to the drainage bag, what should the nurse do?
1. Wash his or her hands.
2. Document the client’s tolerance of the procedure.
3. Instruct the client about the drainage system.
4. Ensure that the condom is not twisted.

The nurse is performing urinary catheterization for a client. After using the
nondominant hand to separate the client’s labia for cleansing, the nurse will maintain
this hand as being
1. sterile.
2. contaminated.
3. able to evaluate the effectiveness of the catheter balloon.
4. clean.

The nurse wants to delegate the application of a condom catheter to unlicensed assistive
personnel (UAP). What must the nurse assess prior to delegating this task?
1. Assess whether the client has unique needs.
2. Measure the client’s intake.
3. Assist the client out of bed to a chair.
4. Assess changes in the client’s mobility status.

The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP).
Which task should the nurse question before delegating to this level of health care
provider?
1. Measuring intake and output
2. Assessing vital signs for clients who are clinically stable
3. Performing complete morning care for a client recovering from a stroke
4. Inserting a urinary catheter into a client

The nurse is documenting the insertion of a retention catheter for a client. What should
be included in this documentation?
Standard Text: Select all that apply.
1. Catheter size
2. Location of the drainage bag
3. Amount of urine that drained after insertion
4. Name of the physician who prescribed the insertion of the catheter
5. Client tolerance of the procedure

A UAP has applied a condom catheter to a client. The nurse should document what
information about this procedure?
Standard Text: Select all that apply.
1. Number of ml of fluid used to inflate the balloon
2. Location of the drainage bag
3. Name of the UAP who applied the device
4. Time and date that the condom catheter was applied
5. Integrity of the penis

The nurse has completed closed irrigation of a client’s retention catheter. What specific
information should the nurse document about this procedure?
1. Number of ml of solution used to inflate the balloon of the catheter
2. Abnormal drainage, such as blood clots, pus, or mucous shreds
3. Location of the draining bag
4. Technique used to conduct the irrigation

An older female client with a history of urinary tract infections has an indwelling urinary catheter.
What should the nurse do to reduce this client’s risk of developing an infection because of the
catheter?
Standard Text: Select all that apply.
1. Maintain a sterile closed drainage system.
2. Clean the peri-urethral area with antiseptics.
3. Ensure the catheter and tubing are not kinked.
4. Wash his or her hands before manipulating the catheter.
5. Keep the collection bag below the level of the bladder

A client asks the RN why it is more difficult to use a bedpan for defecating than sitting
on the toilet. Which would be the nurse’s best response?
1. The sitting position decreases the contractions of the muscles of the pelvic floor.
2. The sitting position increases the downward pressure on the rectum, making it easier
to pass stool.
3. The sitting position increases the pressure within the abdomen.
4. The sitting position inhibits the urge to urinate, allowing one to defecate.

A client asks the nurse why expelled flatus is foul-smelling. What should the nurse
respond?
1. The actions of microorganisms within the gastrointestinal tract are responsible for
the odor.
2. The client's emotions are causing the gas formation.
3. The sensory nerves in the rectum are being stimulated.
4. The client has swallowed too much air while eating.

The home care nurse is reviewing a list of clients prior to making visits. For which
client should the nurse plan interventions to decrease the risk of developing
constipation?
1. An adult who is on bed rest
2. An infant who is breast-fed
3. A school-age child at recess
4. A toddler who is now walking

The nurse is taking care of a client who states that he ignores the urge to defecate when
he is at work. Which response should the nurse make to explain why this practice
should be changed?
1. "If you continue to ignore the urge to defecate, the urge is ultimately lost."
2. "It is best to suppress the urge rather than suffer embarrassment at work."
3. "This is a common practice, and it will strengthen the reflex later."
4. "You will get the urge later; don't worry."

The nurse is preparing to assess a client's fecal elimination status. Which activity will
the nurse complete during this assessment?
1. Obtain a nursing history.
2. Interpret results of diagnostic tests.
3. Perform a physical examination.
4. Set goals with the client

The nurse determines that an adult client's feces are normal. What did the nurse assess
to come to this conclusion?
1. Black in color
2. Cylindrical in shape
3. Pungent in odor
4. Yellow in color

The nurse is caring for a client who experiences frequent bouts of diarrhea. What
should the nurse instruct the client to do?
1. Change the daily routine.
2. Decrease fluid consumption.
3. Increase fiber in the diet.
4. Note the precipitating event.

The nurse is caring for a client who is experiencing constipation. Which client behavior
indicates that teaching was effective?
1. The client continues to ask for his pain medication.
2. The client decreases his fluid consumption.
3. The client refuses to eat the bran flakes on his tray.
4. The client walks around the unit several times a day.

A client has a bowel movement of hard, dry, but formed stool. The nurse associates
these characteristics with
1. bowel incontinence.
2. constipation.
3. diarrhea.
4. fecal impaction.

What nursing diagnosis should the nurse select as appropriate to address bowel
evacuation for a client who is on bed rest?
1. Bowel Incontinence
2. Constipation
3. Diarrhea
4. Disturbed Body Image

The nurse is identifying goals for a client experiencing diarrhea. What goal should the
nurse select for this client?
1. Client will defecate regularly.
2. Client will increase the amount of sugar in the diet.
3. Client will limit fluid intake.
4. Client will regain normal stool consistency.

The nurse is instructing a client on ostomy care. What should be included in this
teaching?
1. Change the drainage pouch daily.
2. Clothing of a special style will be needed now that a pouch is worn.
3. Stick a pin into the drainage pouch to relieve any gas buildup.
4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed.

Which assessment technique will the nurse use first when examining a client with a
fecal elimination problem?
1. Auscultation
2. Inspection
3. Palpation
4. Percussion

The nurse suspects that a client is experiencing compromised gastrointestinal function.
What assessment data did the nurse use to make this clinical decision?
1. Bowel sounds active in all four quadrants
2. Clay-colored stool
3. Increased appetite
4. Semisolid and moist stool

A client has a history of an inconsistent fecal elimination pattern. What should the nurse
instruct this client to improve this health problem?
1. Drink two to four glasses of water daily.
2. Include more spicy foods and sugar in the diet.
3. Include more whole grains in the diet.
4. Use enemas as desired.

The nurse is caring for the stoma of a client who has a colostomy. Which action is the
most appropriate?
1. Apply pressure over the stoma.
2. Clean the stoma and pat dry.
3. Dilate the stoma.
4. Scrub the stoma.

A client is prescribed to receive a cleansing enema. What should the nurse instruct the
client prior to administering this enema?
1. Hold the solution for a short time.
2. Lie in the left lateral position.
3. Lie in the right lateral position.
4. Take fast breaths through the nose.

A client is prescribed a saline enema. Because this solution is hypertonic, the nurse
would expect the enema to cause which action?
1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon
2. Exerts a lower osmotic pressure than the surrounding interstitial fluid
3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon
4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon

After eating dinner, a client asks for help to get to the bathroom because of an extreme
urge to defecate. The nurse realizes that the client has experienced which physiological
function of the colon?
1. Flatus
2. Mass peristalsis
3. Haustral churning
4. Peristalsis

The nurse determines that a client’s fecal elimination is pale in color. This finding
supports which client behavior obtained during the health history?
1. The client rarely eats animal protein, and ingests milk and cheese at several meals
each day.
2. The client rarely eats fruits or vegetables.
3. The client uses laxatives routinely.
4. The client drinks 8 to 10 8-ounce glasses of water each day.

An older client tells the nurse that in order to have a daily bowel movement, the client
uses laxatives most days of the week. What should the nurse tell this client?
Standard Text: Select all that apply.
1. Normal patterns of elimination are different for everyone.
2. Increase fiber intake to 20–35 grams a day.
3. Engage in enjoyable exercise.
4. Ignore the urge to have a bowel movement.
5. Drink six to eight glasses of fluid daily.

A client recovering from abdominal surgery is demonstrating abdominal distention
from trapped flatus. What can the nurse do to help this client?
1. Assist the client to move in bed.
2. Restrict fluids.
3. Obtain an order for a rectal tube.
4. Provide a diet rich in foods that create flatulence.

A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool,
anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is
experiencing
1. constipation.
2. diarrhea.
3. trapped flatus.
4. fecal impaction.

A client has occasional bouts of constipation, and asks the nurse what can be done to
prevent these episodes in the future. What should the nurse instruct the client to do?
Standard Text: Select all that apply.
1. Establish a regular exercise regimen.
2. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet.
3. Maintain fluid intake of 2000 to 3000 mL a day.
4. Do not ignore the urge to defecate.
5. Use over-the-counter medications to treat constipation.

A hospitalized client tells the nurse of the inability to have a bowel movement because
“too many people are around.” What should the nurse do to promote normal fecal
elimination for this client?
1. Provide a laxative.
2. Assist the client to the bathroom to ensure privacy.
3. Restrict fluids.
4. Assist the client with ambulation.

A client has received an oil retention enema. The nurse should instruct the client that
the enema will take effect within
1. 1 to 3 hours.
2. 10 to 20 minutes.
3. 5 to 10 minutes.
4. 10 to 15 minutes

A client experiencing hard, dry feces is scheduled for an enema. The nurse recognizes
that what type of solution would be best for the client?
Standard Text: Select all that apply.
1. Hypertonic
2. Hypotonic
3. Soapsuds
4. Oil retention
5. Isotonic

The nurse is discussing different types of ostomy appliances with a client with a new
ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance
should
Standard Text: Select all that apply.
1. be changed daily.
2. protect the skin.
3. collect stool.
4. control odor
5. be open, so the client can empty it sporadically throughout the day.

The nurse is delegating activities regarding fecal elimination to unlicensed assistive
personnel (UAP). Which activity can UAP safely perform to meet a client’s fecal
elimination needs?
1. Provide a fracture pan to a client on bed rest.
2. Provide a client who has a fecal impaction and prolapsed rectum with a cleansing
enema
3. Change a client’s ostomy device.
4. Irrigate a client’s ostomy.

During morning care, a UAP notes that thick green drainage is seeping around the
appliance of a client’s new ostomy. What should the UAP have been instructed to do?
1. Clean around the drainage.
2. Remove the ostomy appliance and cover the stoma with toilet tissue.
3. Perform complete ostomy care.
4. Report the drainage to the nurse

While administering an enema, the client complains of abdominal cramping. What
should the nurse do?
1. Raise the height of the solution container.
2. Clamp the flow for 30 seconds, and restart at a slower rate.
3. Discontinue the enema infusion.
4. Assist the client to a supine position.

A client has received a return-flow enema. What should the nurse document about this
procedure?
Standard Text: Select all that apply.
1. Number of times the solution was changed.
2. Type of solution.
3. Length of time the solution was retained.
4. The amount, color, and consistency of the return.
5. Client relief of flatus and abdominal distention.

The nurse has completed care with a client who has a new ostomy. What should the
nurse document about the care provided?
Standard Text: Select all that apply.
1. Any change in stoma size
2. Condition of the skin around the stoma
3. Amount and type of drainage
4. Client’s response to the procedure
5. Degree of bowel sounds after care provided

During an assessment, the nurse notes that a client’s stool is black. Which medication should the nurse consider as causing this client’s change in stool color?
Standard Text: Select all that apply.
1. Iron
2. Aspirin
3. Antacids
4. Antibiotics
5. Pepto-Bismol

The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when
caring for this client?
Standard Text: Select all that apply.
1. Assess perianal skin.
2. Irrigate the pouch every shift.
3. Maintain the drainage system.
4. Change the bag every 72 hours.
5. Explain the purpose of the system to the client.

The nurse is caring for a client with a tracheostomy. For what protective mechanism
will the nurse monitor in the client?
1. The ability to cough
2. Filtration and humidification of inspired air
3. The sneeze reflex initiated by irritants in the nasal passages
4. Decrease in oxygen-carrying capacity of the trachea

When planning care, for which client should the nurse include close observation for a
decreased or absent cough reflex?
1. The client with a nasal fracture
2. The client with impairment of vagus nerve conduction
3. The client with a sinus infection
4. The client with reduction in respiratory membrane conduction

The client complains of difficulty breathing. Which assessment findings should the
nurse associate with that complaint?
1. Use of accessory muscles
2. Increased respiratory depth
3. Increased respiratory rate
4. Decreased respiratory depth
5. Decreased respiratory rate

The client has been admitted with complaints of shortness of breath of 2 weeks duration
and has received the nursing diagnosis Impaired Gas Exchange. Which admission
laboratory result would support the choice of this diagnosis?
1. Increased hematocrit
2. Decreased BUN
3. Increased blood sugar
4. Increased sedimentation rate

A client diagnosed with chronic obstructive lung disease who is receiving oxygen at 1.5
liters per minute via nasal cannula is complaining of shortness of breath. What action
should the nurse take?
1. Increase the oxygen to 3 liters per minute via nasal cannula.
2. Lower the head of the client's bed to the semi-Fowler's position.
3. Have the client breathe through pursed lips.
4. Encourage the client to breathe more rapidly.

After learning of a terminal illness and life expectancy, the client begins to
hyperventilate and complains of being light-headed with the fingers, toes, and mouth
tingling. What action should be taken by the nurse?
1. Prepare to resuscitate the client.
2. Have the client concentrate on slowing down respirations.
3. Place the client in Trendelenburg's position and ask him to cough forcefully.
4. Administer 25 mg of meperidine (Demerol) according to the prn pain order.

The client is experiencing severe shortness of breath, but is not cyanotic. What
laboratory value should the nurse review in an attempt to understand this phenomenon?
1. Blood sugar
2. Hemoglobin and hematocrit
3. Cardiac enzymes
4. Serum electrolytes

A client has a medical condition that often results in the development of metabolic
acidosis. The nurse should observe this client for the development of which breathing
pattern as a result of this condition?
1. Cheyne-Stokes
2. Biot's
3. Cluster
4. Kussmaul's

Upon assessment, the nurse notes that a client has dyspnea, crackles in both lung bases,
and tires easily upon exertion. Which nursing diagnosis is best supported by these
assessment details?
1. Ineffective Breathing Pattern
2. Anxiety
3. Ineffective Airway Clearance
4. Impaired Gas Exchange

The nurse encourages the client to expectorate sputum rather than swallowing it. What
is the rationale for this direction?
1. Sputum contains bacteria that should be expectorated.
2. Swallowing sputum is dangerous to the system.
3. The nurse should view the sputum for quality and quantity.
4. The client is likely to aspirate the sputum while attempting to swallow it.

The nurse is planning a time schedule for a client's twice-daily postural drainage.
Which time schedule would be best?
1. 0800 and 1100
2. 1200 and 1800
3. 0700 and 2000
4. 0900 and 2100

A client is receiving oxygen by nonrebreather mask, but the bag is deflating on
inspiration. What action should be taken by the nurse?
1. Turn the client to the left side.
2. Increase the percentage of oxygen being delivered.
3. Check for an airtight seal between the client's face and the mask.
4. Increase the liter flow of oxygen being delivered.

The nurse has placed an oropharyngeal airway in a client. What action should the nurse
take at this time?
1. Tape the airway in place.
2. Suction the client.
3. Turn the client's head to the side.
4. Insert a nasal trumpet.

A client has a newly created tracheostomy for mechanical ventilation after a surgical
procedure. What action should the nurse plan for this client?
1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.
2. Remove the tracheostomy ties and replace them with an elastic bandage.
3. Remove the tracheostomy inner cannula.
4. Tape the tracheostomy obturator to the head of the bed.

The nurse needs to hyperinflate a client prior to suctioning. How should the nurse
proceed with this requirement?
1. Turn the suction level up to 60 cm prior to inserting the catheter.
2. Increase the oxygen flow to the client by 20% prior to suctioning.
3. Provide 2 to 3 breaths at 1.5 times the tidal volume prior to suction.
4. Instruct the client to cough forcefully from the abdomen prior to suction

The nurse who is assessing a client's chest tube insertion site notices a fine crackling
sound and feeling upon palpating the area. What action should the nurse take?
1. Discontinue the chest tube suction.
2. Collaborate with the client's physician.
3. Mark the area involved and remove the tube.
4. Reinforce the chest tube dressing

The nurse is preparing to assist with the removal of a chest tube that is a simple
insertion without a purse-string suture. What materials should the nurse gather for this
procedure?
1. An occlusive dressing
2. A 4 × 4 gauze
3. An adhesive gauze pad dressing
4. A non-adherent gauze dressing

The nurse has completed discharge teaching for a client who will be going home on
oxygen therapy. What statement made by the client would indicate that this client needs
further instruction?
1. "I will replace my cotton blankets with polyester ones."
2. "My son will not be able to smoke when I am around."
3. "I will have my electrical appliance checked for grounding."
4. "I will buy a fire extinguisher for my bedroom."

A client with a nasotracheal tube in place has been restless and pulling at the tube. How
should the nurse assess if the tube is still in place?
1. Count the client's respirations.
2. Assess the depth of the client's respirations.
3. Auscultate for bilateral breath sounds.
4. Deflate the cuff and listen for minimal leak

The nurse has just initiated oxygen by nasal cannula for a client with the medical
diagnosis of chronic obstructive pulmonary disease. What is the nurse's next action?
1. Fill the humidifier with normal saline.
2. Pad the tubing where it contacts the client's ears.
3. Set the oxygen delivery to 5 liters.
4. Secure the cannula with ties around the client's head.

The nurse who is performing care for a client with a new tracheostomy needs to change
the ties. What is the best method for changing these ties?
1. Remove the old ties, clean the area well, and then put on new ties.
2. Attach the new tape and tie with a square knot behind the client's neck.
3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and
replace the ties.
4. Remove the outer cannula, replace the soiled ties, and reinsert.

The nurse is planning the care of a client who has need for frequent suctioning. What
should the nurse delegate to the UAP?
1. Both oral and tracheal suctioning
2. Only oral suctioning
3. Only tracheal suctioning
4. Neither oral nor tracheal suctioning

During tracheal suctioning, the nurse notes that the client' heart rate has increased from
80 to 100 bpm. Based upon this assessment, what action should the nurse take?
1. Immediately discontinue suctioning.
2. Prepare to resuscitate the client.
3. Continue to suction until the airway is clear.
4. Complete the suction episode as quickly as possible.

A client who is being mechanically ventilated has copious amounts of secretions
ranging from thick and tenacious to frothy. In preparing to suction this client, the nurse
should take which action?
1. Hyperventilate the client using the settings on the mechanical ventilator.
2. Hyperventilate the client using a manual resuscitator.
3. Avoid hyperventilation, but instill normal saline into the endotracheal tube.
4. Avoid hyperventilation and increase the oxygen to 100% for several breaths.

A client has been prescribed both a bronchodilator and a steroid medication that is
delivered by inhaler. What information is essential to teach this client in regard to these
medications?
1. The medications cannot be used on the same day.
2. The steroid inhaler should be used when immediate effects are necessary.
3. The bronchodilator should be used only when absolutely necessary and only after the
steroid inhaler.
4. Both medications have the possible side effect of increased heart rate.

A client complains of difficulty breathing. What will the nurse most likely assess in this
client?
Standard Text: Select all that apply.
1. Use of accessory muscles
2. Increased respiratory depth
3. Increased respiratory rate
4. Decreased respiratory depth
5. Decreased respiratory rate

A client who was a victim of a house fire is coughing. The nurse realizes that the
purpose of the cough is to
1. improve oxygenation.
2. remove irritants from the nasal passages.
3. remove irritants from the trachea or bronchi.
4. close the glottis.

A client is experiencing atelectasis. The nurse anticipates that this client will have an
alteration in
1. Ventilation.
2. Alveolar gas exchange.
3. Transportation of oxygen and carbon dioxide.
4. Systemic diffusion.

A client is demonstrating signs of hypoxia. What laboratory value will help the nurse
determine the client’s degree of effective gas exchange?
1. Blood glucose
2. Serum potassium
3. Serum sodium
4. Arterial blood gas

The nurse is determining a client’s ability to transport oxygen from the lungs to body
tissues. What factors will influence this ability?
Standard Text: Select all that apply.
1. Cardiac output
2. Exercise
3. Diet
4. Erythrocyte count
5. Hematocrit

A client’s blood gas analysis results show an increase in carbon dioxide level. What
will the nurse most likely assess in this client?
1. Decreased respiration rate
2. Increased respiration rate
3. Increased blood pressure
4. Decreased bowel sounds

A client’s blood gas results reveal a low oxygen level. The nurse realizes that which
area of the body will respond to this level and influence respirations?
1. Alveoli
2. Trachea
3. Bronchioles
4. Carotid bodies

An older client is prescribed diazepam (Valium). What should the nurse monitor in this
client?
1. Respirations
2. Urine output
3. Muscle tone
4. Appetite

The nurse is assessing an older client. What effects of aging should the nurse keep in
mind during this assessment?
Standard Text: Select all that apply.
1. Decreased cough reflex
2. Stiffening of blood vessels
3. Alteration in protein synthesis
4. Dry mucous membranes
5. Increased risk of aspiration

A client is diagnosed with congestive heart failure. The nurse should assess the client
for which conditions that can alter this client’s respiratory function?
1. Conditions that affect the airway.
2. Conditions that affect transport.
3. Conditions that affect the movement of air.
4. Conditions that affect diffusion

The nurse is conducting a health history for a client with a respiratory disorder. What
should the nurse include in this assessment?
Standard Text: Select all that apply.
1. Lifestyle
2. Presence of cough
3. Sputum production
4. Pain
5. Diet

A client is concerned about maintaining a healthy respiratory system. What should the
nurse instruct the client to do to promote a healthy respiratory status?
Standard Text: Select all that apply.
1. Use pursed-lip breathing.
2. Exercise regularly.
3. Do not smoke.
4. Breathe through the nose.
5. Breathe through the mouth.

Which client statement indicates to the nurse that instruction about the use of a
humidifier has been effective?
1. “A humidifier takes moisture out of the air.”
2. “A humidifier tightens secretions.”
3. “A humidifier prevents my lungs from getting too dry.”
4. “A humidifier replaces the use of oxygen.”

The nurse documents that a prescribed expectorant has been effective for a client. What
did the nurse evaluate in this client?
1. Respiratory rate 24 and labored
2. Audible wheeze upon auscultation
3. High-pitched cough present
4. Presence of a productive cough

The nurse is performing nasotracheal suctioning of a client. What should the nurse do
when suctioning this client?
1. Apply suction for 5–10 seconds.
2. Plan to suction for 10 minutes.
3. Apply suction while inserting the catheter.
4. Apply suction for 20–30 seconds.

The nurse wants to delegate the Yankauer suctioning of a client to UAP. What will the
nurse ensure that UAP know before delegating this activity?
1. How to apply suction during the insertion of the catheter
2. Not to apply suction during the insertion of the catheter
3. How to maintain sterile technique
4. How to listen for lung sounds

The nurse has completed nasopharyngeal suctioning of a client. What should the nurse
document about this procedure?
Standard Text: Select all that apply.
1. Amount, consistency, color, and odor of sputum
2. Amount of sterile solution used to flush the catheter
3. Lung sounds before the procedure
4. Lung sounds after the procedure
5. Oxygen saturation after the procedure

The nurse is documenting the completion of tracheostomy suctioning and tracheostomy
care in a client’s medical record. What should this documentation include?
Standard Text: Select all that apply.
1. Lung sounds before and after suctioning
2. Characteristics of suctioned sputum
3. Integrity of the skin around the stoma
4. Side on which the tracheostomy tie knot is located
5. Flow rate of oxygen

The nurse is planning care for a client who was admitted after having a myocardial
infarction. Based upon this history, the nurse's greatest concern is that this client might
develop which health problem?
1. Chronic renal failure
2. A gastric ulcer
3. Hypoxemia
4. A cerebral vascular accident

Before administering the prescribed medication propranolol (Inderal) to a client, the nurse
contacts the health care provider to question the order. What health problems did the client have
that caused the nurse to question the medication order?
Standard Text: Select all that apply.
1. COPD
2. Asthma
3. Arthritis
4. Gastritis
5. Heart failure

The nurse is planning care for a client with an oral endotracheal tube. Which interventions should
be included in this client’s plan of care?
Standard Text: Select all that apply.
1. Insert an oropharyngeal airway.
2. Provide nasal care every 2 to 4 hours.
3. Provide oral hygiene every 2 to 4 hours.
4. Adjust non-humidified airflow as prescribed.
5. Move the tube to opposite sides of the mouth every 8 hours.