Q&a Basic Care And Comfort

Results for Lesson 5: Basic Care and Comfort Questions are numbered by the order in which they appeared in the test. Represents the correct answer. Question 1 The nurse has been teaching a client with congestive heart Answers Correct B failure about proper nutrition. Which of these lunch Student's D selections indicates the client has learned about sodium restriction? A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream Review Information: The correct answer is B: Sliced turkey sandwich and canned pineapple 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 highsodium foods. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby. Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Question 2 When administering enteral feeding to a client via a Answers Correct B jejunostomy tube, the nurse should administer the formula Student's B A) every four to six hours B) continuously C) in a bolus D) every hour Review Information: The correct answer is B: continuously 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. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 3 A client with diarrhea should avoid which of the Answers Correct A following? Student's A A) orange juice B) tuna C) eggs D) macaroni Review Information: The correct answer is A: orange juice Orange juice is contraindicated for a client with diarrhea because it increases the motility of the gastrointestinal tract. Beare, P. and Myers, J. (1998). Adult Health Nursing. (3rd Edition). St. Louis, Missouri: Mosby. Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Question 4 The nurse is teaching the client to select foods rich in Answers Correct D potassium to help prevent digitalis toxicity. Which choice Student's A indicates the client understands dietary needs? A) three apricots B) medium banana C) naval orange D) baked potato Review Information: The correct answer is D: baked potato A baked potato contains 610 milligrams of potassium. Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders. Lutz, C.A. and Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd edition). Philadelphia: F.A. Davis Company.

Question 5

A nurse is assessing several clients in a long term health Answers Correct A care facility. Which client is at highest risk for Student's A development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) An incontinent client who has had 3 diarrhea stools D) An 80 year-old ambulatory diabetic client Review Information: The correct answer is A: A 79 year-old malnourished client on bed rest 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. Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 6 The nurse is teaching an 87 year-old client methods for Answers Correct C maintaining regular bowel movements. The nurse would Student's A caution the client to avoid A) glycerine suppositories B) fiber supplements C) laxatives D) stool softeners Review Information: The correct answer is C: laxatives 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. Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 7

The nurse is caring for a 7 year-old with acute Answers Correct B glomerulonephritis (AGN). Findings include moderate Student's B edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids Review Information: The correct answer is B: Decreased sodium and potassium Children with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein. McCampbell, L.S. & Rentro, A.R. (2002). Wong’s Nursing Care of Infants and Children. (7th edition). St. Louis, Missouri: Mosby. Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA: Thompson, Delmar, Learning.

Question 8 A nurse is working with a client in an extended care Answers Correct D facility. Which bed position is preferred for a client, who is Student's D at risk for falls, as part of a prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway Knees bent, head slightly elevated, bed in lowest C) position Bed in lowest position, wheels locked, place bed D) against wall Review Information: The correct answer is D: Bed in lowest position, wheels locked, place bed against wall 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. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 9 A client is being maintained on heparin therapy for deep Answers Correct C vein thrombosis (DVT). The nurse must closely monitor Student's C which of the following laboratory values? A) bleeding time B) platelet count C) activated PTT D) clotting time Review Information: The correct answer is C: activated PTT Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The Activated Prothromboplastin Time (APTT) test is a highly sensitive test to monitor the client on heparin. Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning. Deglin, J.D. and Vallerand, A.H. (2001). Davis’ drug guide for nurses. (7th edition). Philadelphia: F.A. Davis Company.

Question 10 Which statement best describes the effects of immobility Answers Correct B in children? Student's A Immobility prevents the progression of language and A) fine motor development Immobility in children has similar physical effects to B) those found in adults Children are more susceptible to the effects of C) immobility than are adults Children are likely to have prolonged immobility D) with subsequent complications Review Information: The correct answer is B: Immobility in children has similar physical effects to those found in adults 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. Ashwill, J., Droske, S. & James, S. (2002). Nursing care of children: principles and practice (2nd ed.). Philadelphia: Saunders. Wong, D.L., Perry, S.E., & Hockenberry, M.J. (2002). Maternal Child Nursing. (2nd edition). Mosby: St. Louis, Missouri.

Question 11

An 85 year-old client complains of generalized muscle Answers Correct A aches and pains. The first action by the nurse should be Student's A A) assess the severity and location of the pain B) obtain an order for an analgesic C) reassure him that this is not unusual for his age D) encourage him to increase his activity Review Information: The correct answer is A: assess the severity and location of the pain 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. Estes, M.E.Z. (2002). Health Assessment and Physical Examination, (2nd Ed). Albany, NY: Delmar. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 12 After a client has an enteral feeding tube inserted, the most Answers Correct A accurate method for verification of placement is Student's A A) abdominal x-ray B) auscultation C) flushing tube with saline D) aspiration for gastric contents Review Information: The correct answer is A: abdominal x-ray Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby. Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Question 13 Constipation is one of the most frequent complaints of Answers Correct B elders. When assessing this problem, which action should Student's B be the nurse's priority? A) obtain a complete blood count B) obtain a health and dietary history C) refer to a provider for a physical examination D) measure height and weight Review Information: The correct answer is B: obtain a health and dietary history 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. Edelman, C.L. and Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th edition). St. Louis, Missouri: Mosby. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.

Question 14 After a myocardial infarction, a client is placed on a Answers Correct D sodium restricted diet. When the nurse is teaching the Student's D client about the diet, which meal plan would be the most appropriate to suggest? 3 oz. broiled fish, 1 baked potato, ½ cup canned A) beets, 1 orange, and milk 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, B) and 1 apple A bologna sandwich, fresh eggplant, 2 oz fresh fruit, C) tea, and apple juice 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green D) beans, milk, and 1 orange Review Information: The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange 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. Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders. Black, J, Hawk, J, Keene, A. (2001). Medical-Surgical Nursing ( 6th ed). Philadelphia: Saunders.

Question 15 A client in a long term care facility complains of pain. The Answers Correct C nurse collects data about the client’s pain. The first step in Student's C pain assessment is for the nurse to A) have the client identify coping methods get the description of the location and intensity of the B) pain C) accept the client’s report of pain D) determine the client’s status of pain Review Information: The correct answer is C: accept the client’s report of pain 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.”

Price, S.A. and Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th edition). Mosby: St. Louis, Missouri. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 16 What finding of the nursing assessment of a paralyzed Answers Correct B client would indicate the probable presence of a fecal Student's B impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements Review Information: The correct answer is B: Oozing liquid stool 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. Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 17 A client was just taken off the ventilator after surgery and Answers Correct C has a nasogastric tube draining bile-colored liquids. Which Student's C nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs Review Information: The correct answer is C: Perform frequent oral care with a tooth sponge 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. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby. Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed. Albany, NY: Delmar.

Question 18 An 86 year-old nursing home resident who has impaired Answers Correct B mental status is hospitalized with pneumonic infiltrates in Student's A 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? A) Add a thickening agent to the fluids B) Check the client’s gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids Review Information: The correct answer is B: Check the client’s gag reflex 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. Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 19 The nurse is planning care for a client with a cerebral Answers Correct C vascular accident (CVA). Which of the following measures Student's C planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence Review Information: The correct answer is C: Reposition every two hours 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. Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders. Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis, Missouri: Mosby.

Question 20

The nurse is instructing a 65 year-old female client Answers Correct A diagnosed with osteoporosis. The most important Student's A instruction regarding exercise would be to A) exercise doing weight bearing activities B) exercise to reduce weight avoid exercise activities that increase the risk of C) fracture exercise to strengthen muscles and thereby protect D) bones Review Information: The correct answer is A: exercise doing weight bearing activities 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. Ignatavicius, D., and Workman, L. (2002). Medical-Surgical Nursing Critical Thinking for Collaborative Care (4th ed.). Philadelphia: Saunders. Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing: Assessment & management of clinical problems. St. Louis: Mosby.