NR 224 Final Practice Exam. Questions and Answers. (Rationale Provided)

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.Correct! 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 high-pitched bowel sounds. Emptying the bowel before surgery would have little to no effect on bowel sounds.