Basic Care And Comfort Report

Student Exam Results

Student Information lazaro Last Name: briselda First Name: Exam:

Reference:

RN Lesson 5 Posttest

Objective:

Total Attempts: 1

RN Lesson 5 Posttest - Physiological Integrity: Basic Care and Comfort

Total Submitted Attempts : 1 Student Mark for this Objective: 45%

Mark: 45 % Correct Responses: 9 / 20

Incorrect (Ref: )A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? Learner Response:

A) Increase oral fluid intake

Correct Response:

C) Keep conversations short

Feedback:

Keeping conversations short will promote the client's comfort by decreasing demands on the client's breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client's rest. Monitoring vital signs is an important assessment but not related to promoting the client's comfort. Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar. Daniels, R. (2003). Delmar's manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Incorrect (Ref: )What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? Learner Response:

D) Absence of bowel movements

Correct Response:

B) Oozing liquid stool

Feedback:

When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care. (4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is Learner Response:

D) Aspiration for gastric contents

Correct Response:

A) Abdominal x-ray

Feedback:

Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Incorrect (Ref: )When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula Learner Response:

A) Every four to six hours

Correct Response:

B) Continuously

Feedback:

Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier.

Incorrect (Ref: )The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? B) Medium banana Learner Response: D) Baked potato Correct Response:

Feedback:

A baked potato contains 610 milligrams of potassium. Lutz, C.A., & Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd ed.). Philadelphia: F.A. Davis Company. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier.

Correct (Ref: )Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? B) Obtain a health and dietary history Learner Response: B) Obtain a health and dietary history Correct Response:

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Student Exam Results

Feedback:

Initially, the nurse should obtain information about the chronicity of and details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment plan. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier. Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis: Elsevier.

Incorrect (Ref: )The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to avoid Learner Response:

A) glycerine suppositories

Correct Response:

C) laxatives

Feedback:

Some elders are constipated because they have used over-the-counter laxatives for a long time. In addition, many people do not eat enough fiber, drink enough water, or exercise adequately. Certain medications, including opioid analgesics, are constipating. Elders are rarely constipated because of organic or pathological reasons. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis: Elsevier.

Correct (Ref: )The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction? B) Sliced turkey sandwich and canned pineapple Learner Response: B) Sliced turkey sandwich and canned pineapple Correct Response:

Feedback:

Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods. Lutz, C.A., & Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd ed.). Philadelphia: F.A. Davis Company. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? B) Decreased sodium and potassium Learner Response: B) Decreased sodium and potassium Correct Response:

Feedback:

Children with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein. Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson Delmar Learning. McCampbell, L.S., & Renfro, A.R. (2002). Wong's nursing care of infants and children. (7th ed.). St. Louis: Elsevier.

Incorrect (Ref: )A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? Learner Response:

B) An obese client who uses a wheelchair

Correct Response:

A) A 79 year-old malnourished client on bed rest

Feedback:

Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care. (4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )Which statement best describes the effects of immobility in children? Learner Response:

A) Immobility prevents the progression of language and fine motor development

Correct Response:

B) Immobility in children has similar physical effects to those found in adults

Feedback:

Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults. Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier. Ashwill, J., Droske, S., & James, S. (2002). Nursing care of children: principles and practice. (2nd ed.). Philadelphia: Elsevier.

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Student Exam Results

Correct (Ref: )After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest? D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange Learner Response: D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange Correct Response:

Feedback:

Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats. Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier. Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care. (4th ed.). Philadelphia: Elsevier.

Correct (Ref: )A client with diarrhea should avoid which of the following? Learner Response:

A) Orange juice

Correct Response:

A) Orange juice

Feedback:

Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract. Lutz, C.A., & Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd ed.). Philadelphia: F.A. Davis Company. Beare, P., & Myers, J. (1998). Adult health nursing. (3rd ed.). St. Louis: Elsevier.

Incorrect (Ref: )An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be Learner Response:

D) Encourage him to increase his activity

Correct Response:

A) Assess the severity and location of the pain

Feedback:

Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than "pain") to reveal the presence of pain. There is no evidence that pain of older adults is less intense than younger adults. It is important for the nurse to assess the pain thoroughly before implementing pain relief measures. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Estes, M.E.Z. (2002). Health assessment and physical examination. (2nd ed). Albany, NY: Delmar.

Correct (Ref: )An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? B) Check the client's gag reflex Learner Response:

Correct Response:

B) Check the client's gag reflex

Feedback:

When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care. (4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to C) avoid exercise activities that increase the risk of fracture Learner Response: A) exercise doing weight bearing activities Correct Response:

Feedback:

Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment & management of clinical problems. St. Louis: Elsevier. Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care. (4th ed.). Philadelphia: Elsevier.

Correct (Ref: )The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? C) Reposition every two hours Learner Response: C) Reposition every two hours Correct Response:

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Student Exam Results

Feedback:

Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care. (4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to B) get the description of the location and intensity of the pain Learner Response: C) accept the client's report of pain Correct Response:

Feedback:

Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report." Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier. Price, S.A. & Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol? D) Bed in lowest position, wheels locked, place bed against wall Learner Response: D) Bed in lowest position, wheels locked, place bed against wall Correct Response:

Feedback:

It is no longer advisable to use only the lower side rails. Using all 4 side rails (upper and lower siderails at the top and bottom of the bed) is an inappropriate use of restraint without an order. If all 4 are pulled up, an order for protective restraints is needed that usually has to be renewed in 48 to 72 hours along with more frequent documentation. Having all 4 side rails raised limits the client's autonomy and freedom of movement. Using 3 of the 4 side rails pulled up is acceptable, because clients can safely exit the bed on their own initiative. Placing the bed against the wall permits getting out of bed on only 1 side. Locking the wheels keeps the bed from sliding. Keeping the bed in the lowest position (without bending limbs to restrict movement) provides a shorter distance to the ground if the client chooses to get out of bed. Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client? C) Perform frequent oral care with a tooth sponge Learner Response: C) Perform frequent oral care with a tooth sponge Correct Response:

Feedback:

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Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize. Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar. Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

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Student Exam Results

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