NR 224 FUNDAMENTALS FINAL EXAM REVISION GUIDE UPDATED (100Q&A)

NR 224 FUNDAMENTALS FINAL EXAM 1. A nurse is teaching a client how to perform personal ileostomy care prior to discharge. The client says “I don’t think that I am going to be able to take care of this myself.” Which is the most appropriate response from the nurse? a. In time you will be better at this than I am. b. Don’t worry about it, most clients feel like you do at first. c. What part of the ileostomy care are you having trouble with? d. I agree. This is a difficult process. This response opens up communication about the client’s real concerns and enables the nurse to address teaching moments to help them feel more confident with self-care. The other responses are not therapeutic and dismiss the client’s concerns. Question 2 The adult child of a client who has had a colon resection will be caring for their parent at home. The client’s son tells the nurse “I don’t know how I am going to care for my mom now”. Which is the best nursing response? a. A home health nurse will be stopping by tomorrow to answer your questions. b. Your mother has been taught to care for her colostomy independently. c. What part of your mother’s care are you concerned with? d. It is quite simple. I’ll change the colostomy bag before she is discharged. This gives the client an opportunity to discuss their concerns with the nurse. The nurse can then make an appropriate plan to assure the family and client receive any supportive care after discharge. The other responses do not encourage discussion and belittle the son’s concerns. Question 3 A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from PACU. The float nurse is most qualified to care for which client? a. A client who is postoperative following a lobectomy and has a chest tube b. A client who is being discharged to a long-term care facility c. A client who needs teaching prior to initiating cardiac rehabilitation activities d. A client who needs teaching about insulin self-administration Float nurses should be assigned to an area for which they have been trained and have experience.  Question 4 A client asks the nurse what causes constipation. Choose the best response by the nurse. Correct Answer a. Constipation occurs when the bowel absorbs too much water b. Eating too many processed foods cause constipation c. When the bowel releases too much water it causes constipation d. Using over the counter laxatives causes constipation Constipation occurs when the large intestine absorbs too much fluid. Clients are encouraged to increase high fiber foods along with drinking plenty of fluids to maintain regularity. Diarrhea is caused when the bowel releases too much water. Using over the counter laxatives may cause diarrhea, not constipation. Question 5 The nurse caring for a post-operative client performs an abdominal assessment. The nurse does not hear any bowel sounds over the left lower quadrant of the abdomen. What is the most likely reason for this? a. The client has been NPO for several hours b. Post-operative clients may develop an ileus resulting in absent bowel sounds c. There is gas in the abdomen d. The client emptied their bowels before surgery An ileus is a portion of the bowel where peristalsis has temporarily slowed or stopped. The nurse will not auscultate bowel sounds in the area of an ileus. NPO status would result in hypoactive bowel sounds throughout the entire abdomen. Gas in the intestine would cause highpitched bowel sounds. Emptying the bowel before surgery would have little to no effect on bowel sounds. Question 6 The nurse admits a client who is to undergo a colonoscopy. The nurse understands that this will be required in preparation for the procedure. a. NPO status for 24 hours b. A complete bowel cleanse c. Clear liquids after midnight d. A fleet enema to prep the bowel Clients who will undergo a colonoscopy usually remain NPO for 8-12 hours prior to the procedure. A complete bowel cleanse is required to rid the area of stool that may interfere with visualization and collection of tissue specimens. A fleet enema alone would not be enough to clear the bowel. Question 7 A nurse is teaching a client about colorectal cancer testing. The nurse expects the provider to first perform this test for colorectal screening. a. Colonoscopy b. Barium enema c. Fecal occult blood test d. Cat scan of the lower intestine The provider will first do a fecal occult blood (guiac) test to determine the presence of microscopic blood in the stool. This is often an early sign of colorectal cancer. The other procedures may be done as a follow-up to the guiac test. Question 8 A nurse is caring for a client with a newly placed colostomy. The nurse teaches the client they may have formed stool after the bowel has healed because the surgeon placed the stoma where? a. Ascending colon b. Transverse colon c. Descending colon d. Sigmoid colon Ostomies placed in the sigmoid colon may eventually have formed stool. The lower down in the colon that the ostomy is placed, the more likely the client will have formed stool. Higher ostomy positioning results in liquid or semi-formed stool. Question 9 The nurse is administering a tap water enema to a client in preparation for bowel surgery. The nurse correctly positions the enema bag containing the fluid where? a. 12 inches above the anus for a regular enema b. 6-10 inches above the anus for a high enema c. To shoulder height then lower it 6 inches d. On an IV pole 18 inches above the bed The correct placement for a regular enema is to hold the container 12 inches above the client’s anus. Question 10 The nurse correctly positions a client for a fleets enema by placing them in this position: a. Supine with the knees flexed b. Prone with the right leg flexed c. On the left side with the right leg flexed d. On the right side with both knees flexed Correct positioning for administering an enema is to place the client on their left side with their right leg bent to follow the natural curve of the colon. Question 11 The nurse is preparing a new ostomy flange for the client’s abdomen. Choose the correct action by the nurse. a. Scrub the skin on the abdomen with antiseptic soap b. Report the appearance of a red, moist stoma c. After measuring the diameter of the stoma cut the opening of the wafer d. Tape the wafer in place in a window-pane format The nurse must carefully measure the diameter of the stoma and cut the wafer to fit, leaving 1/8 “ around the stoma to prevent skin breakdown and allow for adequate circulation to the stoma. The skin under the wafer should be gently cleansed and prepped with an adhesive wipe. A red, moist stoma is normal. The wafer does not need to be taped in place as it has its own self- adhesive surface that contacts the client’s skin. Question 12 The nurse would plan to perform more frequent perineal care to prevent skin breakdown for this client. a. Client with an indwelling catheter b. Client who uses a walker to ambulate c. Client with urinary frequency d. Client with an incision on their abdomen The client with urinary frequency will need more frequent skin care due to the caustic effects of urine sitting on the skin for prolonged periods. A client with indwelling catheter would not have urine on the skin. The client who uses a walker does not necessarily have any problem with continence. A client with an abdominal incision does not need special perineal care. Question 13 A female nurse is upset because a male client has requested only a male nurse help them with personal care. What is the best response from the charge nurse? a. The female nurse should ask the client what they did to offend them. b. The client may have gender identity issues. c. The client may have been abused by their mother. d. The client’s religious beliefs may prevent a female care-giver. A client’s ethnic, cultural or religious beliefs may prevent them from having certain gender’s provide personal, intimate care. Question 14 Select the priority nursing intervention for performing a complete bed bath on a client. a. Provide for privacy b. Allow the client to do as much of the bath as they can c. Identify the client with 2 identifiers before beginning d. Ask another nurse to assist with the bathing Before performing any nursing action, the nurse must make certain they have the correct client. Therefore, it is a priority to first identify the client using 2 identifiers. Question 15 1 / 1 pts Choose the adjunct therapy that can help improve circulation and assist in debridement of wounds. a. Hydrotherapy b. Electrical stimulation therapy c. Phototherapy d. Ultrasound therapy Hydrotherapy uses warm water to both provide stimulation to increase circulation and gently washes loose tissue away from wounds. EST therapy stimulates nerve endings to treat pain and promote healing. Phototherapy uses ultraviolet light to treat some skin disorders. Ultrasound therapy uses sonic waves to treat pain. Question 16 A nurse is providing oral care for a client who is immobile. Choose the correct nursing action for this client. a. Apply petroleum jelly to the client’s lips after oral care b. Turn the client on the side before starting oral care c. Use the thumb and index finger to keep the client’s mouth open d. Use a stiff toothbrush to clean the client’s teeth The nurse should turn this client onto their side during oral care to help drain fluid from the mouth and prevent aspiration. A water soluble lubricant, not petroleum jelly is used on the lips. The nurse should use a bite block or oral airway to keep the mouth open. A soft toothbrush is recommended for oral care to prevent trauma to the mucous membranes. Question 17 The nurse caring for a client with C. Difficile must use which personal protective equipment? a. Gown only b. Gown and surgical mask c. Mask and clean gloves d. Gown and clean gloves A client with C. Difficile is placed on contact precautions. The nurse must wear a gown and clean gloves. Question 18 The nurse is providing enteric feeding to a client. A priority action on the part of the nurse to prevent infection is this: a. Use a bottle of feeding solution that has been kept refrigerated b. Use only a sterile irrigation syringe to flush before and after feeding c. Perform handwashing before and after administering the feeding d. Insert a new feeding tube every 24 hours A priority nursing action before performing any nursing intervention is to do handwashing. Feeding solutions do not always need refrigeration and they can spoil even under refrigeration. It is not necessary to use a sterile irrigation to flush during feedings. Feeding tubes are replaced only when they become occluded and cannot be cleared or when determined by the provider. Question 19 Choose the correct statement regarding sterile gloves. a. Sterile gloves do not require handwashing prior to donning b. The outside of the glove may only be touched by another sterile glove c. If there is a tear in the package the glove may still be used d. Once the gloves have been used they may be reused after washing Sterile asepsis requires only sterile touch sterile. Handwashing is required before donning sterile gloves. A package tear renders the gloves contaminated. Sterile gloves may not be reused. Question 20 A student nurse notices a family member walking into a room under contact isolation. The student stops the visitor and instructs them how to don the appropriate protective equipment. The student is practicing this: a. Malpractice b. Humility c. Accountability d. Feasibility The student nurse is acting accountably when they practice safe client care by teaching the visitor infection control. Question 21 A nurse is caring for a client who has a Clostridium difficile infection. Which cleansing agent should the nurse use for hand hygiene? a. Chlorhexidine b. Povidone-iodine c. Hand soap d. Alcohol-based hand rub Hand soap should be used to wash hands with soap and water. Spore-forming bacteria, like Clostridium difficile require washing with soap and water to wash the organisms down the drain. The nurse should wash their hands for at least 15 seconds. Question 22 The nurse is teaching a nursing assistant on correct use of personal protective equipment (PPE). The nurse knows the teaching was understood when the NA demonstrates this: a. Wears gloves whenever coming into contact with a client b. Wears gloves and a gown when bathing a client with open skin lesions c. Wears gloves constantly to avoid having to wash hands d. Wears gloves when delivering a lunch tray The only time the NA must use PPE is when bathing or caring for a client where there is a high likelihood of contact with body fluids, infectious drainage or contaminated equipment and supplies. The NA must always wash hands before and after donning gloves. Question 23 The nurse is teaching students the importance of hand hygiene. Choose the most correct statement. a. “If you wear gloves you do not need to wash your hands” b. “Rub all surfaces of your hands with an alcohol rub for 20-30 seconds” c. “Use an alcohol rub if your hands are visibly soiled” d. “If you don’t have an infection, your hands won’t infect others” If alcohol rubs are used, the nurse must rub all surfaces of the hands for 20-30 seconds to decrease the amount of pathogens on the hands. It is always necessary to wash the hands before and after donning gloves. If hands are visibly soiled, soap and water should be used to wash them. It is possible to transfer bacteria from other individuals, not just yourself, on your hands. Question 24 The nurse is preparing to exit the room of a client who has been placed on contact precautions. Identify the sequence to be followed when removing the personal protective equipment (PPE). 1. Wash hands 2. Place discarded PPE in the designated trash container 3. Remove gloves 4. Remove the gown 5. Remove protective eyewear if used a. 3, 4, 5, 2, 1 b. 1, 3, 4, 5, 2 c. 3, 5, 4, 2, 1 d. 1, 3, 5, 4, 2 The correct order for removing PPE for contact precautions is: remove the gloves, eyewear, gown, discard the soiled equipment and wash hands. Question 25 The nurse uses medical asepsis when caring for clients when they do this. a. Use sterile equipment to start an intravenous line b. Maintain a sterile field c. Properly empty and discard wound drains d. Hand a surgeon surgical instruments Medical asepsis prevents the transmission of pathogens through proper cleaning and disposal of contaminated equipment and body fluids and tissues. Handwashing is an important aspect of medical asepsis. Use of gloves and other PPE and the practice of special precautions are all included under medical asepsis. Surgical asepsis requires only sterile items touch other sterile items. Question 26 A nurse is teaching a group of new mothers on infant care. The nurse includes which information on teaching about infection prevention. a. Infants will not get sick if you keep them at home. b. Handwashing before caring for the baby is only necessary if someone in the house is sick. c. Infants have immature immune systems and are more susceptible to infections than older children. d. Placing infants in the same room as a sibling who is sick will help them develop immunity. Infants do not have well-developed immune systems and all steps should be taken to prevent unnecessary exposure to illness to prevent infection. Question 27 An older client tells the nurse that they never get a flu shot because at their age, they’ve had every kind of flu there is. Choose the best response from the nurse. a. Flu viruses are specific and you may not be immune to newer strains. b. Older adults have natural immunity and don’t need immunization. c. Older adults who contract the flu are less sick than younger adults. d. The risk is greater that an older adult will contract the flu from getting immunized. Flu viruses are specific and despite being exposed to other strains the client may not be immune to a new strain. It is important for them to stay current with immunizations to prevent serious illness with complications that can be fatal. Question 28 The nurse is caring for an older adult who complains they don’t eat as much as they used to. Their overall physical and mental condition is good. Choose the best response from the nurse. a. Try to eat your meals with a companion. Having company often improves the appetite. b. It must be difficult cooking for yourself. You can always freeze left-overs. c. Older adults have fewer energy needs. It’s not unusual to eat less than you used to. d. Make an appointment with your provider if you start to lose weight. Older adults have fewer energy needs so they may not eat as much as they used to. Question 29 A nurse is assessing a young woman diagnosed with anorexia nervosa. The nurse suspects the client is not eating all of the food on their prescribed diet when they observe this: a. They make frequent bathroom visits after meals b. Food waste is often found in the trash after family visits c. The client does not gain any weight between weigh-ins d. The client has very specific meal preferences