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    Exam Review

    1. A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?
      A)Kennet
      B)Frestat
      C)Dairy products
      D)Caffeinated beverage
    2. A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?
      A)Encourage the client to drink cold fluids.
      B)Place the client on a low-fiber diet.
      C)Request a prescription for mineral oil for the client.
      D)Increase the client's fluid intake.
    3. A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)(SATA)
      A)A client who has right-sided heart failure and 4+ edema to the lower extremities
      B)A client who is ambulatory following a cardiac catheterization 4 hr ago
      C)A client who has type 1 diabetes mellitus and is hyperglycemic
      D)A client who has protein calorie malnutrition
      E)A client who has postoperative delirium
    4. A nurse is teaching a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?
      A)"Use a moisturizer on your skin after cleaning."
      B)"Allow your skin to air dry after bathing."
      C)"Rub your skin firmly when cleaning."
      D)"Wash your skin daily with hot water."
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    Exam Review

    1. A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)(SATA)
      A)Cut the opening of the pouch one 8 of an inch larger than the stoma.
      B)Place a gauze over the stoma while changing the pouch.
      C)Use povidone-iodine to clean around the stoma.
      D)Expect the stoma to turn a purple-blue color as it heals.
      E)Empty the ostomy pouch when it becomes one-third full of contents.
    2. A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor for pressure ulcer?
      A)Male
      B)Immobility
      C)Adequate hydration
      D)Anemia
    3. A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)(SATA)
      A)A client who has right-sided heart failure and 4+ edema to the lower extremities
      B)A client who is ambulatory following a cardiac catheterization 4 hr ago
      C)A client who has type 1 diabetes mellitus and is hyperglycemic
      D)A client who has protein calorie malnutrition
      E)A client who has postoperative delirium
    4. A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply)(SATA)
      A)Cut the opening of the pouch one 8 of an inch larger than the stoma.
      B)Place a gauze over the stoma while changing the pouch.
      C)Use povidone-iodine to clean around the stoma.
      D)Expect the stoma to turn a purple-blue color as it heals.
      E)Empty the ostomy pouch when it becomes one-third full of contents.
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    Exam Review

    1. A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?
      A)An adolescent who has a cervical fracture and is in a halo brace
      B)A middle adult who has a fractured radius and an arm cast
      C)An older adult who has a hip fracture and is in Buck's traction
      D)A young adult who has a femur fracture and is in skeletal balanced suspension traction
    2. The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?
      A)Adequate nutrition delays wound healing and increases risk of infection.
      B)Chronic wounds heal better in a dry, open environment so leave them open to air.
      C)Fat tissue heals more rapidly because there is less vascularization.
      D)Long term steroid use diminishes the inflammatory response and delays wound healing.
    3. A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
      A)Remind the client he might feel a constant urge to void.
      B)Weigh the client every evening.
      C)Monitor the client's urine output every 6 hr.
      D)Restrict the client's oral fluid intake.
    4. A nurse is completing the 8-hr 1&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
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    Exam Review

    1. A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
      A)A postoperative client whose blood pressure at 0800 was 138/86 mm Hg and now at 1000 is 90/60 mm Hg
      B)A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 100 mg/dL
      C)A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
      D)A client who reports pain as 1 on a scale of 1 to 10 at 0800 now reports pain as 3
    2. A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?
      A)Parasites
      B)Steatorrhea
      C)Blood
      D)Bacteria
    3. A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?
      A)Place the client supine with knees bent.
      B)Assess the client for manifestations of shock.
      C)Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.
      D)Raise the head of the client's bed 15° to 20°.
    4. You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: (Select All that Apply.)(SATA)
      A)A 5-year-old female who is a quadriplegic.
      B)A 5-year-old with a Braden Scale score of 7.
      C)A 5-year-old female who has controlled diabetes and is ambulating three times a day.
      D)A 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.
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    Exam Review

    1. A nurse is providing teaching to a client who has a new colostomy, and had a bowel preparation before surgery. Which of the following information should the nurse include in the teaching?
      A)"You can expect fecal output within 24 hours"
      B)"You will need to increase your dietary intake of raw vegetables."
      C)"You can expect the stoma to be purplish in color for the first week"
      D)"You may experience a small amount of bleeding around the stoma"
    2. A nurse is assessing a client's wound dressing, and observes a clear watery drainage. The nurse should document this drainage as which of the following?
      A)Serous
      B)Purulent
      C)Serosanguineous
      D)Sanguineous
    3. A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?
      A)Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
      B)Include intact skin at the wound edges in the culture.
      C)Swab an area of skin away from the wound to identify the usual flora.
      D)Irrigate the wound with an antiseptic prior to obtaining the specimen.
    4. A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
      A)Apply cornstarch to keep the skin dry.
      B)Provide the client with a diet high in protein.
      C)Massage bony prominences to promote circulation.
      D)Reposition the client every 3 hr.
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