NR324 CJE Exam Questions Correctly
Answered Graded A+.
NPO - correct answer no food or fluid at all by mouth
Hearing aids amplify sounds, but do not help clients - correct answer interpret what they hear
Amplification of sound in a loud environment can be - correct answer distracting and disturbing
Hearing aids: client education - correct answer use the lowest setting that allows hearing without
feedback
clean the ear mold with mild soap and water while keeping the hearing aid dry
when not in use for an extended period of time, turn it off and remove the battery
keep replacement batteries on hand
Non-Pharmacological Comfort Measures - correct answer Distraction
Biofeedback
Self hypnosis
Guided Imagery
Heat & Cold applications
Relaxation techniques
Transcutaneous Electrical Nerve Stimulation (TENS)
Music therapy
Massage
Sleep and rest considerations - correct answer Follow normal routine
Position
Decrease noise/distraction, lighting, anxiety
Do not wake client up for prn sleep medications
,PRN sleep meds (should not be administered routinely--give when other measures fail)
White noise
No caffeine, alcohol, or tobacco
Clients who have latex allergies: - correct answer Use silicon or Teflon products
Coudé catheter "bent tip": - correct answer most commonly used for male clients with some kind of
blockage or obstruction
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following
actions is the nurse's priority at this time?
A.Obtain a walker for the client to use to transfer back to bed.
B.Call for additional staff to assist with the transfer.
C.Use a transfer belt and assist the client back into bed.
D.Determine the client's ability to help with the transfer. - correct answer D
A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the
following actions is the nurse's highest assessment priority before performing this procedure?
A.Check how long the feeding container has been open.
B.Verify the placement of the NG tube.
C.Confirm that the client does not have diarrhea.
D.Make sure the client is alert and oriented. - correct answer B
A nurse is talking with a client about ways to help sleep and rest. Which of the following
recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.)
A. Practice muscle relaxation techniques.
B. Exercise each morning.
, C. Take an afternoon nap.
D. Alter the sleep environment for comfort.
E. Limit fluid intake at least 2 hr before bedtime. - correct answer A, B, D, and E.
The nurse needs to evaluate a patient's intake for the last 8 hours. For breakfast, the patient had two
cups of coffee and 4 oz of orange juice; for lunch: 8 oz of iced tea, a cup of ice chips, and 1 cup chicken
broth. The patient also has fluids running at 20ml/hr of 0.9% normal saline. Urine output for the 8-hour
shift was 800ml. What should the nurse record as the net intake? _____mL - correct answer 560ml
Breast Self Exam (BSE) - correct answer Feel for lumps using the finger pads
lye down with the arm up by the head
Palpate each breast from the sternum to the posterior axillary line
Compress the nipples carefully to check for discharge (note the color, consistency, and odor of any
discharge)
GI Assessment - correct answer Inspection
Auscultation-bowel sounds
Percussion--tympany/ resonant hollow organs
Palpation- tenderness
GI stethoscope order - correct answer RLQ>RUQ>LUQ>LLQ
It normally takes _____ to _____ minutes to hear bowel sounds - correct answer 5-20 min
Bowel Elimination Assessment - correct answer Usual pattern, frequency, description of stool (Color,
Consistency, Shape, Amount, Odor, Constituents)
Recent changes
Aids to elimination
Problems
Presence of artificial orifices
Answered Graded A+.
NPO - correct answer no food or fluid at all by mouth
Hearing aids amplify sounds, but do not help clients - correct answer interpret what they hear
Amplification of sound in a loud environment can be - correct answer distracting and disturbing
Hearing aids: client education - correct answer use the lowest setting that allows hearing without
feedback
clean the ear mold with mild soap and water while keeping the hearing aid dry
when not in use for an extended period of time, turn it off and remove the battery
keep replacement batteries on hand
Non-Pharmacological Comfort Measures - correct answer Distraction
Biofeedback
Self hypnosis
Guided Imagery
Heat & Cold applications
Relaxation techniques
Transcutaneous Electrical Nerve Stimulation (TENS)
Music therapy
Massage
Sleep and rest considerations - correct answer Follow normal routine
Position
Decrease noise/distraction, lighting, anxiety
Do not wake client up for prn sleep medications
,PRN sleep meds (should not be administered routinely--give when other measures fail)
White noise
No caffeine, alcohol, or tobacco
Clients who have latex allergies: - correct answer Use silicon or Teflon products
Coudé catheter "bent tip": - correct answer most commonly used for male clients with some kind of
blockage or obstruction
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following
actions is the nurse's priority at this time?
A.Obtain a walker for the client to use to transfer back to bed.
B.Call for additional staff to assist with the transfer.
C.Use a transfer belt and assist the client back into bed.
D.Determine the client's ability to help with the transfer. - correct answer D
A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the
following actions is the nurse's highest assessment priority before performing this procedure?
A.Check how long the feeding container has been open.
B.Verify the placement of the NG tube.
C.Confirm that the client does not have diarrhea.
D.Make sure the client is alert and oriented. - correct answer B
A nurse is talking with a client about ways to help sleep and rest. Which of the following
recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.)
A. Practice muscle relaxation techniques.
B. Exercise each morning.
, C. Take an afternoon nap.
D. Alter the sleep environment for comfort.
E. Limit fluid intake at least 2 hr before bedtime. - correct answer A, B, D, and E.
The nurse needs to evaluate a patient's intake for the last 8 hours. For breakfast, the patient had two
cups of coffee and 4 oz of orange juice; for lunch: 8 oz of iced tea, a cup of ice chips, and 1 cup chicken
broth. The patient also has fluids running at 20ml/hr of 0.9% normal saline. Urine output for the 8-hour
shift was 800ml. What should the nurse record as the net intake? _____mL - correct answer 560ml
Breast Self Exam (BSE) - correct answer Feel for lumps using the finger pads
lye down with the arm up by the head
Palpate each breast from the sternum to the posterior axillary line
Compress the nipples carefully to check for discharge (note the color, consistency, and odor of any
discharge)
GI Assessment - correct answer Inspection
Auscultation-bowel sounds
Percussion--tympany/ resonant hollow organs
Palpation- tenderness
GI stethoscope order - correct answer RLQ>RUQ>LUQ>LLQ
It normally takes _____ to _____ minutes to hear bowel sounds - correct answer 5-20 min
Bowel Elimination Assessment - correct answer Usual pattern, frequency, description of stool (Color,
Consistency, Shape, Amount, Odor, Constituents)
Recent changes
Aids to elimination
Problems
Presence of artificial orifices
