NSG 219 Final
The nurse is caring for a patent with an indwelling urinary catheter. The nurse is aware
that what nursing action helps prevent infection in a patient with an indwelling urinary
catheter?
A. Vigorously clean the meatus area daily.
B. Apply powder to the perineal area twice a day.
C. Empty the drainage bag at least every 8 hours.
D. Irrigate the catheter every 8 hours with normal saline. - ANS- C. Empty the drainage
bag at least every 8 hours.
A patient with cancer of the bladder has just returned to the unit from the PACU after
surgery to create an ileal conduit. The nurse is monitoring the patient's urine output
hourly and notifies the physician when the hourly output is less than what?
A 30 mL/hr
B. 50mL/hr
C. 100mL/hr
D. 125mL/hr - ANS- A 30 mL/hr
After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit
with a nasogastric tube to low,
intermittent suction and a patient-controlled analgesia (PCA) machine for pain control.
Which nursing action should be included in the postoperative plan of care?
A. Support the surgical Incision during patient coughing and turning in bed.
B. Remind the patient that PCA use may slow the return of bowel function.
C. Offer sips of fruit juices at frequent intervals.
D. Irrigate the nasogastric (NG) tube frequently. - ANS- A. Support the surgical Incision
during patient coughing and turning in bed.
The nurse will be teaching self-management to patients after gastric bypass surgery.
Which information will the nurse plan to include?
A. Choose foods high in fiber to promote bowel function.
B. Developing flabby skin can be prevented by exercise.
C. Drink fluids between meals but not with meals.
D. Choose high-fat foods for at least 30% of intake. - ANS- C. Drink fluids between meals
but not with meals.
Which action should the nurse in the emergency department anticipate for a young adult
patient who has had several acute episodes of bloody diarrhea?
A. Administer antidiarrheal medication.
B. Obtain a stool specimen for culture.
C. Teach the adverse effects of acetaminophen (Tylenol).
,D. Provide teaching about antibiotic therapy. - ANS- B. Obtain a stool specimen for
culture.
A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports
increasing abdominal pain. The patient has no bowel sounds and 200 ml of bright red
nasogastric (NG) drainage in the past hour. What is the highest priority action by the
nurse?
A. Contact the surgeon.
B. Give prescribed morphine.
C. Monitor drainage.
D. Irrigate the NG tube. - ANS- A. Contact the surgeon.
Which patient should the nurse assess first after receiving change-of-shift report?
A. A patient who is crying after receiving a diagnosis of esophageal cancer
B. A patient with esophageal varices who has a rapid heart rate
C. A patient with a history of gastrointestinal bleeding who has melena
D. A patient with nausea who has a dose of metoclopramide (Regian) due - ANS- B. A
patient with esophageal varices who has a rapid heart rate
A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours
ago. Which assessment finding is most important for the nurse to address immediately?
A. The patient is experiencing intermittent waves of nausea.
B. The patient has no breath sounds in the left anterior chest.
C. The patient reports 7/10 (0 to 10 scale) abdominal pain.
D. The patent has hypoactive bowel sounds in all four quadrants - ANS- B. The patient
has no breath sounds in the left anterior chest.
The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What
Information is most important to report to the health care provider?
A Absent bowel sounds in all quadrants
B. Scant nasogastric (NG) tube drainage
C. Temperature 102.1° F (38.9° C)
D. Hemoglobin (Hgb) 10.8 g/dL - ANS- C. Temperature 102.1° F (38.9° C)
The nurse is performing a nutritional assessment on a newly admitted client with a
diagnosis of recent weight loss and malnutrition. Which finding is consistent with a
diagnosis of malnutrition?
A. Moist skin
B. Muscle growth
C. Increase in subcutaneous fat
D. Decreased pigmentation of the hair - ANS- D. Decreased pigmentation of the hair
, The nurse is caring for a client that is 24 hours post-operative colostomy. The nurse
assess the client and stoma site every 4 hours. Of the following descriptions, which
indicates a normal stoma?
A. Stoma is pink, mildly swollen, scant amount of blood noted.
B. Stoma is red, swollen, and bleeding.
C. Stoma is pink, with a large amount of edema, scant amount of blood noted.
D. Stoma is dark red, no edema or bleeding noted. - ANS- A. Stoma is pink, mildly
swollen, scant amount of blood noted.
The nurse is performing an initial assessment on a 55 year old client with reports of
abdominal pain and changes in bowel patterns. During the history portion of the
assessment what is most important to the nurse to ask the client?
A. "When was your last bowel movement?"
B. "Have you had a colonoscopy in the last 10 years?'
C. "Have you had a influenza vaccine this season?"
D. "Have you had any problems voiding?" - ANS- B. "Have you had a colonoscopy in the
last 10 years?'
The nurse notes redness, warmth, and a purulent drainage at the insertion site of a
central venous catheter in a client receiving total parenteral nutrition (TP). The nurse
notifies the health care provider of this finding because:
A. Infections of a central venous catheter site can lead to septicemia.
B. The client is experiencing an allergy to the TPN solution.
C. The TPN solution has infiltrated and must be stopped.
D. The client is allergic to the dressing material covering the site. - ANS- A. Infections of
a central venous catheter site can lead to septicemia.
The nurse is assessing a client who is being admitted from the emergency room with a
history of vomiting bright red blood for
the past 24 hours. What would be a priority nursing assessment?
A. Inquire as to how much emesis the client has had in the past 6 hours.
B. Evaluate bowel sounds and palpate the abdomen for areas of tenderness.
C. Determine the quality of bilateral breath sounds.
D. Monitor the blood pressure and pulse. - ANS- D. Monitor the blood pressure and
pulse.
The nurse is making an initial client assessment. The client has a peripheral parenteral
nutrition infusing and the bag is almost empty. A new bag is not yet available from the
pharmacy. What is the best nursing action?
A. Plan on hanging D5W until the new solution is available.
B. Slow the rate of infusion until the new solution arrives.
C. Flush the line with a heparin flush solution and hang new solution when it arrives.
D. Slow the infusion and periodically check the client's blood glucose until the solution is
available. - ANS- A. Plan on hanging D5W until the new solution is available.
The nurse is caring for a patent with an indwelling urinary catheter. The nurse is aware
that what nursing action helps prevent infection in a patient with an indwelling urinary
catheter?
A. Vigorously clean the meatus area daily.
B. Apply powder to the perineal area twice a day.
C. Empty the drainage bag at least every 8 hours.
D. Irrigate the catheter every 8 hours with normal saline. - ANS- C. Empty the drainage
bag at least every 8 hours.
A patient with cancer of the bladder has just returned to the unit from the PACU after
surgery to create an ileal conduit. The nurse is monitoring the patient's urine output
hourly and notifies the physician when the hourly output is less than what?
A 30 mL/hr
B. 50mL/hr
C. 100mL/hr
D. 125mL/hr - ANS- A 30 mL/hr
After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit
with a nasogastric tube to low,
intermittent suction and a patient-controlled analgesia (PCA) machine for pain control.
Which nursing action should be included in the postoperative plan of care?
A. Support the surgical Incision during patient coughing and turning in bed.
B. Remind the patient that PCA use may slow the return of bowel function.
C. Offer sips of fruit juices at frequent intervals.
D. Irrigate the nasogastric (NG) tube frequently. - ANS- A. Support the surgical Incision
during patient coughing and turning in bed.
The nurse will be teaching self-management to patients after gastric bypass surgery.
Which information will the nurse plan to include?
A. Choose foods high in fiber to promote bowel function.
B. Developing flabby skin can be prevented by exercise.
C. Drink fluids between meals but not with meals.
D. Choose high-fat foods for at least 30% of intake. - ANS- C. Drink fluids between meals
but not with meals.
Which action should the nurse in the emergency department anticipate for a young adult
patient who has had several acute episodes of bloody diarrhea?
A. Administer antidiarrheal medication.
B. Obtain a stool specimen for culture.
C. Teach the adverse effects of acetaminophen (Tylenol).
,D. Provide teaching about antibiotic therapy. - ANS- B. Obtain a stool specimen for
culture.
A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports
increasing abdominal pain. The patient has no bowel sounds and 200 ml of bright red
nasogastric (NG) drainage in the past hour. What is the highest priority action by the
nurse?
A. Contact the surgeon.
B. Give prescribed morphine.
C. Monitor drainage.
D. Irrigate the NG tube. - ANS- A. Contact the surgeon.
Which patient should the nurse assess first after receiving change-of-shift report?
A. A patient who is crying after receiving a diagnosis of esophageal cancer
B. A patient with esophageal varices who has a rapid heart rate
C. A patient with a history of gastrointestinal bleeding who has melena
D. A patient with nausea who has a dose of metoclopramide (Regian) due - ANS- B. A
patient with esophageal varices who has a rapid heart rate
A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours
ago. Which assessment finding is most important for the nurse to address immediately?
A. The patient is experiencing intermittent waves of nausea.
B. The patient has no breath sounds in the left anterior chest.
C. The patient reports 7/10 (0 to 10 scale) abdominal pain.
D. The patent has hypoactive bowel sounds in all four quadrants - ANS- B. The patient
has no breath sounds in the left anterior chest.
The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What
Information is most important to report to the health care provider?
A Absent bowel sounds in all quadrants
B. Scant nasogastric (NG) tube drainage
C. Temperature 102.1° F (38.9° C)
D. Hemoglobin (Hgb) 10.8 g/dL - ANS- C. Temperature 102.1° F (38.9° C)
The nurse is performing a nutritional assessment on a newly admitted client with a
diagnosis of recent weight loss and malnutrition. Which finding is consistent with a
diagnosis of malnutrition?
A. Moist skin
B. Muscle growth
C. Increase in subcutaneous fat
D. Decreased pigmentation of the hair - ANS- D. Decreased pigmentation of the hair
, The nurse is caring for a client that is 24 hours post-operative colostomy. The nurse
assess the client and stoma site every 4 hours. Of the following descriptions, which
indicates a normal stoma?
A. Stoma is pink, mildly swollen, scant amount of blood noted.
B. Stoma is red, swollen, and bleeding.
C. Stoma is pink, with a large amount of edema, scant amount of blood noted.
D. Stoma is dark red, no edema or bleeding noted. - ANS- A. Stoma is pink, mildly
swollen, scant amount of blood noted.
The nurse is performing an initial assessment on a 55 year old client with reports of
abdominal pain and changes in bowel patterns. During the history portion of the
assessment what is most important to the nurse to ask the client?
A. "When was your last bowel movement?"
B. "Have you had a colonoscopy in the last 10 years?'
C. "Have you had a influenza vaccine this season?"
D. "Have you had any problems voiding?" - ANS- B. "Have you had a colonoscopy in the
last 10 years?'
The nurse notes redness, warmth, and a purulent drainage at the insertion site of a
central venous catheter in a client receiving total parenteral nutrition (TP). The nurse
notifies the health care provider of this finding because:
A. Infections of a central venous catheter site can lead to septicemia.
B. The client is experiencing an allergy to the TPN solution.
C. The TPN solution has infiltrated and must be stopped.
D. The client is allergic to the dressing material covering the site. - ANS- A. Infections of
a central venous catheter site can lead to septicemia.
The nurse is assessing a client who is being admitted from the emergency room with a
history of vomiting bright red blood for
the past 24 hours. What would be a priority nursing assessment?
A. Inquire as to how much emesis the client has had in the past 6 hours.
B. Evaluate bowel sounds and palpate the abdomen for areas of tenderness.
C. Determine the quality of bilateral breath sounds.
D. Monitor the blood pressure and pulse. - ANS- D. Monitor the blood pressure and
pulse.
The nurse is making an initial client assessment. The client has a peripheral parenteral
nutrition infusing and the bag is almost empty. A new bag is not yet available from the
pharmacy. What is the best nursing action?
A. Plan on hanging D5W until the new solution is available.
B. Slow the rate of infusion until the new solution arrives.
C. Flush the line with a heparin flush solution and hang new solution when it arrives.
D. Slow the infusion and periodically check the client's blood glucose until the solution is
available. - ANS- A. Plan on hanging D5W until the new solution is available.
