Vital Signs Nursing: Trivia Quiz!
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Medical professionals monitor and health care providers include four main vital signs: body temperature, pulse rate, respiration rate, and blood pressure. Regarding this quiz, you should be aware of which symptom is closely related to dyspnea: shallow respirations, wheezing, shortness of breath, and coughing up blood. Taking vital signs is an integral part of being a nurse. This quiz will show you this. Good luck.
- 1.
The client's temp at 8:00 am, using an oral thermometer is 36.1° C (97.2° F). If the resp, pulse, and bp are WNL, what would the nurse do next?
- A.
Wait 15 min, retake
- B.
Check what the client's temperature was the last time
- C.
Retake it using a different thermometer
- D.
Chart the temp, it is normal
Correct Answer
B. Check what the client's temperature was the last timeExplanation
Although the temp is slightly lower than expected, it would be best to determine the client's previous temp range next. This may be normal for the client.Rate this question:
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- 2.
Which of the following clients meets the criteria for the selection of an apical site for assessment of the pulse rather than radial pulse?
- A.
A client is in shock
- B.
The pulse changes with body position changes
- C.
A client with an arrhythmia
- D.
It is less than 24 hours since a client's surgical operation
Correct Answer
C. A client with an arrhythmiaExplanation
the apical pulse would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm.Rate this question:
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- 3.
When the nurse enters the room to enter vital signs in preparing the client for a dx test, the client is on the phone. What technique should the nurse use to determine the respiration rate?
- A.
Count the resps during conversational pauses
- B.
Ask the client to tend the phone call now and resume it at a later time.
- C.
Wait at the client's bedside until the phone call is completed, then count resps
- D.
Since there is no evidence of distress or urgency, defer the measurement
Correct Answer
D. Since there is no evidence of distress or urgency, defer the measurementExplanation
Since the client's needs always come first, delay the measurement unless it looks urgent.Rate this question:
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- 4.
For a client with a previous blood pressure of 138/74 and pulse of 64, approx. how long should the nurse take to release the bp cuff in order to obtain an accurate reading?
- A.
10-20 sec
- B.
30-45 sec
- C.
1-1.5 min
- D.
3-3.5 min
Correct Answer
B. 30-45 secExplanation
deflation should occur at 2-3 mm Hg per second, so previous start would have been 168 (30+138) and going down at a rate of 2-3 seconds.Rate this question:
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- 5.
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP?
- A.
A client being prepared for elective facial surgery with a hx of stable hypertension
- B.
A client receiving a blood transfusion with a history of transfusion reactions
- C.
A client recently started on a new antiarrhythmic agent
- D.
A client who is admitted frequently with asthma attacks
Correct Answer
A. A client being prepared for elective facial surgery with a hx of stable hypertensionExplanation
Vital signs may be delegated if they are stable, the findings are expected or the technique requires no modification.Rate this question:
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- 6.
An 85-year-old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing and is unable to move self or maintain position unaided. The nurse determines that which of the following sites is appropriate for taking temp
- A.
Oral, Tympanic, Rectal
- B.
Rectal, Tympanic, Axillary
- C.
Axillary, Typmpanic, Temporal
- D.
Axillary, Temporal, Oral
Correct Answer
C. Axillary, Typmpanic, TemporalExplanation
Ok - oral + stroke + facial dropping = no. Rectal would work but that's wayyy to much extra work when you have other methods.Rate this question:
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- 7.
The nurse reports that the client has dyspnea when ambulating. The nurse is most likely assessed which of the following?
- A.
Shallow respirations
- B.
Wheezing
- C.
Shortness of breath
- D.
Coughing up blood
Correct Answer
C. Shortness of breathExplanation
Dyspnea is related to inadequate oxygenation, meaning the client will most likely experience shortness of breath. Shallow respirations are associated with tachypnea (rapid breathing). Wheezing may or may not occur with dyspnea. Hemoptysis is unrelated to dyspnea.Rate this question:
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- 8.
It is important to remove gloves and gowns in the room if the client is under which of the following precautions?
- A.
Standard
- B.
Airborne
- C.
Contact
- D.
Droplet
Correct Answer
C. ContactExplanation
see K+E pg. 689Rate this question:
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- 9.
Place the following nurse priories in the correct sequence if a fire occurs in a health setting. 1. report the fire 2. extinguish the fire 3. protect the clients 4. contain the fire
- A.
1,4,3,2
- B.
3,1,4,2
- C.
3,2,4,1
- D.
2,3,4,1
Correct Answer
C. 3,2,4,1Explanation
In the event of a fire in a health setting, the first priority should be to protect the clients by ensuring their safety and evacuating them if necessary. Once the clients are safe, the nurse should then report the fire to the appropriate authorities or fire department. After reporting the fire, the nurse should focus on containing the fire to prevent it from spreading further and causing more damage. Finally, if it is safe to do so, the nurse can attempt to extinguish the fire using appropriate fire-fighting equipment. Therefore, the correct sequence of nurse priorities in this situation is 3, 2, 4, 1.Rate this question:
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- 10.
What is the leading cause of accidents in young and middle aged adults?
- A.
Automobile crashes
- B.
Drowning and firearms
- C.
Falls
- D.
Suicide and homicide
Correct Answer
A. Automobile crashesExplanation
Automobile crashes are the leading cause of accidents in young and middle-aged adults. This is because young and middle-aged adults are more likely to be active drivers and spend a significant amount of time on the roads. Factors such as inexperience, distracted driving, speeding, and impaired driving contribute to a higher risk of accidents in this age group. Additionally, the use of mobile devices while driving has become increasingly common among young and middle-aged adults, further increasing the likelihood of automobile crashes.Rate this question:
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- 11.
Because a hospitalized elderly female client, who ambulates with a walker, is receiving diuretics which result in frequent trips to the bathroom at night, the nurse should perform which of the following?
- A.
Leave the bathroom light on
- B.
Withhold the client's diuretic medication
- C.
Provide bedside commode
- D.
Keep the side rails up
Correct Answer
C. Provide bedside commodeExplanation
Rate this question:
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- 12.
Which NADA nursing dx is most applicable for toddlers?
- A.
Risk for suffocation
- B.
Risk for injury
- C.
Risk for poisoning
- D.
Risk for disuse syndrome
Correct Answer
C. Risk for poisoningExplanation
The nursing diagnosis "Risk for poisoning" is the most applicable for toddlers because they are at a stage where they are curious and exploring their environment, which puts them at a higher risk for accidental ingestion of harmful substances. Toddlers have a tendency to put objects in their mouths, and they may not have developed the ability to differentiate between safe and dangerous substances. Therefore, the risk for poisoning is a significant concern for this age group.Rate this question:
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- 13.
A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
- A.
Restrain the client in the bed
- B.
Ask a family member to stay with the client
- C.
Check the client every 15 min
- D.
Use a bed exit safety monitoring device
Correct Answer
D. Use a bed exit safety monitoring deviceExplanation
The most appropriate safety measure for a 75-year-old client who becomes disoriented and tries to get out of bed is to use a bed exit safety monitoring device. This device will help alert the healthcare team if the client attempts to leave the bed without assistance, allowing them to intervene and prevent falls or injuries. Restraints should be avoided whenever possible due to the risk of physical and psychological harm. Asking a family member to stay with the client may not be feasible or available at all times, and checking the client every 15 minutes may not provide immediate intervention if the client attempts to leave the bed.Rate this question:
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- 14.
A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? 1. Place a padded tongue depressor at the head of the bed 2. Pad the bed with blankets 3. Inform the client about the importance of a medical tag 4. Teach the client about epilepsy 5. Test oral suction equipment
- A.
2,4,5
- B.
1,3
- C.
3,4,5
- D.
2,5
- E.
2,3,4,5
Correct Answer
D. 2,5 -
- 15.
Which of the following nursing interventions is the highest in priority for a client at risk for falls in a hospital setting?
- A.
Keep all of the side rails up
- B.
Review medications
- C.
Complete the get up and go test
- D.
Place the bed in the lowest position
Correct Answer
D. Place the bed in the lowest positionExplanation
placing bed in the lowest position makes the fall shorterRate this question:
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- 16.
When planning to teach health care topics to a group of male adolescents, the nurse should consider which of the following topics take priority?
- A.
Sports contribute to self-esteem
- B.
Sunbathing and tanning beds can be dangerous
- C.
Guns are the most frequently used weapon in adolescent suicide
- D.
A river's education course is mandatory for safety
Correct Answer
C. Guns are the most frequently used weapon in adolescent suicideExplanation
When planning to teach health care topics to a group of male adolescents, the nurse should consider that guns are the most frequently used weapon in adolescent suicide. This topic takes priority because it addresses a serious and immediate health concern for this specific population. By providing education and raising awareness about the dangers of guns and the risk of suicide, the nurse can potentially help prevent tragic outcomes and promote the overall well-being of these adolescents.Rate this question:
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- 17.
A client can bathe independently except for the back and feet, walk to and from the bathroom and dress if the clothing is provided. What is the most appropriate functional level for this client?
- A.
Totally dependent (+4)
- B.
Moderately dependent (+3)
- C.
Semidependent (+2)
- D.
Independent (0)
Correct Answer
C. Semidependent (+2)Explanation
The client is able to perform most activities of daily living independently, such as bathing, walking, and dressing. However, they require assistance with bathing their back and feet, indicating a level of dependency in those areas. Therefore, the most appropriate functional level for this client is semidependent (+2).Rate this question:
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- 18.
A client with diabetes has very dry skin on her feet and lower extremities. To maintain intact skin the nurse teaches which of the following?
- A.
Soak feet frequently
- B.
Use of non-perfumed lotion
- C.
Apply foot powder
- D.
Avoid knee high elastic stockings
Correct Answer
B. Use of non-perfumed lotionExplanation
Using a non-perfumed lotion is the correct answer because it helps to moisturize the skin and prevent dryness. Perfumed lotions may contain irritants that can further dry out the skin, so it is important to use a non-perfumed option. Soaking the feet frequently can actually worsen dryness by stripping away natural oils. Applying foot powder may help with odor, but it does not address the issue of dry skin. Avoiding knee high elastic stockings is not directly related to maintaining intact skin on the feet and lower extremities.Rate this question:
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- 19.
The client wears an in-the-ear hearing aid and because of arthritis needs someone to insert the hearing aid. THe nurse teachers the UAP to do which of the following actions before inserting the client's hearing aid?
- A.
Turn the hearing aid off
- B.
Soak the hearing aid in soapy solution to clean it
- C.
Turn the volume all the way up
- D.
Remove the batteries
Correct Answer
A. Turn the hearing aid offExplanation
Before inserting the client's hearing aid, it is important to turn the hearing aid off. This is necessary to prevent any discomfort or potential harm to the client's ear when the hearing aid is being inserted. Turning off the hearing aid ensures that it is not accidentally turned on during the insertion process, which could cause discomfort or loud noises for the client.Rate this question:
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- 20.
The client is in surgery and will be returning to his bed via a stretcher. The nurse plan ahead by making which type of beds and placing the bed in which position?
- A.
An open bed in low position
- B.
An occupied bed in low position
- C.
A closed bed in high position
- D.
A surgical bed in high position
Correct Answer
D. A surgical bed in high positionExplanation
The client is in surgery and will be returning to his bed via a stretcher. In order to accommodate the client's needs and ensure a smooth transition, the nurse plans ahead by making a surgical bed in high position. This allows for easy access and transfer of the client from the stretcher to the bed.Rate this question:
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- 21.
The nurse observed the UAP performing perineal care for a client. WHich of the following actions indicates that further teaching is required?
- A.
Used a clean potion of the wash cloth for each stroke
- B.
Wiped from the pubis to the rectum
- C.
Used clean gloves
- D.
Did not retract foreskin
Correct Answer
D. Did not retract foreskinExplanation
The nurse observed the UAP performing perineal care for a client and noticed that they did not retract the foreskin. This indicates that further teaching is required because retracting the foreskin is an important step in perineal care for male clients. It allows for proper cleaning and inspection of the area, ensuring hygiene and identifying any potential issues or abnormalities. Therefore, the UAP should be educated on the importance of retracting the foreskin during perineal care.Rate this question:
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- 22.
The nurse is discussing foot care with a client who was recently dx with diabetes. Which of the following statements indicates a need for further teaching?
- A.
I am going to use a mirror to check my feet
- B.
I enjoy walking barefoot around the house
- C.
I will file my nails
- D.
I will increase the time that I wear new shoes each day
Correct Answer
B. I enjoy walking barefoot around the houseExplanation
walking barefoot increases the chance for injury and infectionRate this question:
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- 23.
The client is experiencing labored, shortness of breath has a respiratory rate of 28. The bed is currently in the flat position. The best nursing intervention includes putting the bed in which of the following positions?
- A.
Fowler's
- B.
Semi-Folwers
- C.
Trendelenburg
- D.
Reverse Trendelenburg
Correct Answer
A. Fowler'sExplanation
The client is experiencing labored, shortness of breath and has a respiratory rate of 28. Placing the bed in Fowler's position would be the best nursing intervention. Fowler's position is a semi-sitting position with the head of the bed elevated between 45 and 60 degrees. This position helps to improve lung expansion and ease breathing by allowing the diaphragm to descend more easily. It also helps to prevent aspiration and promotes drainage in patients with conditions such as pneumonia or congestive heart failure.Rate this question:
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- 24.
Which of the following nursing dx is most appropriate for a client with a BMI of 35 would likely have?
- A.
Imbalanced nutrition: Less than body requirements
- B.
Imbalanced nutrition: more than body requirements
- C.
Risk for imbalanced nutrition
- D.
Deficient knowledge
Correct Answer
B. Imbalanced nutrition: more than body requirementsExplanation
Imbalanced nutrition: more than body requirements is the most appropriate nursing diagnosis for a client with a BMI of 35. This diagnosis indicates that the client is consuming more calories than their body needs, leading to weight gain and an increased risk for obesity-related health problems. The client's high BMI suggests that they may be overeating or making poor food choices, contributing to the imbalance in their nutrition. By identifying this diagnosis, nurses can develop interventions to help the client make healthier dietary choices and manage their weight effectively.Rate this question:
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- 25.
An adult reports eating, on average, the following each day: 3 cups dairy, 2 cups fruit, 5 ounces grain, and 5 ounces meat. The nurse counsel would be:
- A.
Maintain the diet; servings are adequate
- B.
Increase the number of servings dairy
- C.
Decrease the number of servings of vegetables
- D.
Increase the number of servings of grains
Correct Answer
D. Increase the number of servings of grainsExplanation
The adult's daily intake of dairy, fruit, and meat is within the recommended range. However, the intake of grains is below the recommended amount of 6 ounces per day. Therefore, the nurse would advise increasing the number of servings of grains to ensure a balanced diet.Rate this question:
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- 26.
Which of the following is the best indication of proper placement of nasogastric tube in the stomach?
- A.
Client is unable to speak
- B.
Client gags during insertion
- C.
PH of the aspirate is less than 5
- D.
Fluid is easily instilled into the tube
Correct Answer
C. pH of the aspirate is less than 5Explanation
The pH of the aspirate being less than 5 is the best indication of proper placement of a nasogastric tube in the stomach. A pH of less than 5 indicates that the tube is in the acidic environment of the stomach, confirming correct placement. The other options, such as the client being unable to speak or gagging during insertion, are not reliable indicators of proper placement. Additionally, the ease of fluid instillation into the tube does not necessarily indicate correct placement.Rate this question:
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- 27.
What is the proper technique with gravity tube feeding?
- A.
Feeding bag is hung 1 ft higher than the tube's insertion point into the chest
- B.
Nurse Administers the next feeding only if there is less than 25 mL of residual volume from the previous feeding
- C.
Place the client in the left lateral position
- D.
Feeding is administered directly from the refrigerator
Correct Answer
A. Feeding bag is hung 1 ft higher than the tube's insertion point into the chestExplanation
The proper technique with gravity tube feeding is to hang the feeding bag 1 ft higher than the tube's insertion point into the chest. This ensures a continuous flow of the feeding solution into the patient's stomach or intestines. Gravity helps in the proper flow of the feeding solution and prevents any backflow or blockage in the tube. Hanging the bag higher than the insertion point creates a pressure gradient that facilitates the flow of the solution.Rate this question:
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- 28.
A 55-year-old female is about 20 lb over her desired weight. She has been on a low calroies diet with no improvement. Which of the following statements reflects a health approach to the desired weight loss? "I need to:"
- A.
Increase my exercise at least 30 min each day
- B.
Switch to low carb diet
- C.
Keep a list of my forbidden foods on hand at all times
- D.
Buy more organic and less processed foods
Correct Answer
A. Increase my exercise at least 30 min each dayExplanation
Increasing exercise by at least 30 minutes each day is a healthy approach to desired weight loss. Exercise helps to burn calories and increase metabolism, which can aid in weight loss. It also has numerous other health benefits, such as improving cardiovascular health, increasing muscle strength, and boosting mood. Switching to a low carb diet may be effective for weight loss in some cases, but it is not specified if the individual's current diet is high in carbs. Keeping a list of forbidden foods may lead to a restrictive mindset and potential disordered eating patterns. Buying more organic and less processed foods can be a healthy choice, but it alone may not lead to significant weight loss.Rate this question:
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- 29.
An elderly asian client has mild dysphagia from a recent stroke. The nurse plans the clien's meal based on the need to:
- A.
Have at least 1 serving of thick dairy (pudding, ice cream) per meal
- B.
Eliminate the beer usually ingested every evening
- C.
Include as many of the client's favorite foods as possible
- D.
Increase the calories form lipids to 40%
Correct Answer
C. Include as many of the client's favorite foods as possibleExplanation
The nurse plans the client's meal based on the need to include as many of the client's favorite foods as possible. This is because the client has mild dysphagia from a recent stroke, which may make swallowing difficult. By including the client's favorite foods, the nurse can ensure that the client enjoys their meal and is more likely to eat an adequate amount. This is important for maintaining proper nutrition and preventing malnourishment in elderly clients.Rate this question:
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- 30.
Which of the following meals would the nurse recommend to a client as the highest in calcium, iron and fiber
- A.
3 ounces of cottage cheese with 1/3 cup raisins and 1 banana
- B.
1/2 cup broccoli with 3 ounces chicken and 1/2 cup peanuts
- C.
1/2 cup spaghetti with 2 ounces ground beef and 1/2 cup lima beans plus 1/2 cup ice cream
- D.
3 ounces tuna, +1 ounce cheese sandwich on whole wheat bread plus a pear
Correct Answer
D. 3 ounces tuna, +1 ounce cheese sandwich on whole wheat bread plus a pearExplanation
The meal consisting of 3 ounces of tuna, a 1 ounce cheese sandwich on whole wheat bread, and a pear would be recommended by the nurse as the highest in calcium, iron, and fiber. Tuna is a good source of both calcium and iron, while the cheese sandwich on whole wheat bread provides additional calcium and fiber. The pear adds more fiber to the meal, making it the best choice for all three nutrients. The other meal options do not contain as much calcium, iron, and fiber as this choice.Rate this question:
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- 31.
The nurse recognizes that urinary elimination changes may occur even in health elders because
- A.
The bladder distends and its capacity increase
- B.
Elders ignore the need to void
- C.
Urine becomes more concentrated
- D.
The amount of urine retained after voiding increases
Correct Answer
D. The amount of urine retained after voiding increasesExplanation
As people age, their bladder muscles may weaken, leading to incomplete emptying of the bladder. This can cause a larger amount of urine to be retained after voiding. This is why the nurse recognizes that urinary elimination changes may occur even in healthy elders. The other options are not relevant in explaining this phenomenon.Rate this question:
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- 32.
During assessment of the client with urinary incontinence, the nurse is most likely to assess which of the following? 1. Perineal skin irritation2. Fluid intake < 1,500 ml day3. Hx of Antihistamine intake4. Hx of frequent urinary tract infections
- A.
1,2,3,4
- B.
1,2,3
- C.
1,2,4
- D.
2,4
Correct Answer
C. 1,2,4Explanation
Antihistamines can increase urine outputRate this question:
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- 33.
Which of the following represents the appropriate nursing managemnt of a client wearing a condom catheter?
- A.
Ensure that the tip of the penis fits snugly against the end of the condom
- B.
Check the penis for adequate circulation after 30 min
- C.
Change the condom every 8 hours
- D.
Tape the collecting tubing to the lower abdomen
Correct Answer
B. Check the penis for adequate circulation after 30 minExplanation
The appropriate nursing management of a client wearing a condom catheter includes checking the penis for adequate circulation after 30 minutes. This is important to ensure that the condom catheter is not causing any restriction in blood flow to the penis, which could lead to complications such as tissue damage or necrosis. Regular checks for circulation help to prevent these complications and ensure the client's safety and well-being.Rate this question:
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- 34.
During the straight catheterization of a female client, if the catheter slips into the vagina, the nurse should
- A.
Leave the catheter in place and get a new sterile catheter
- B.
Leave the catheter in place and ask another nurse to attempt the procedure
- C.
Remove the catheter and redirect it to the urinary meatus
- D.
Remove the catheter, wipe it with a sterile gauze and redirect it to the urinary meatus.
Correct Answer
A. Leave the catheter in place and get a new sterile catheterExplanation
the catheter can not be reused. Leaving the old on in place will help differentiate vaginal opening from the urinary meatusRate this question:
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- 35.
Which of the following statements indicates the need for further teaching of home care client with a long-term indwelling catheter?
- A.
I will keep the collecting bags below the level of bladder at all times
- B.
Intake of cranberry juice will decrease the risk of infections
- C.
Soaking in a warm tub bath may decrease irritation associated with the catheter
- D.
I should use sterile technique when emptying the collecting bags
Correct Answer
C. Soaking in a warm tub bath may decrease irritation associated with the catheterExplanation
Soaking increases the possible spreading of infectionRate this question:
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- 36.
The nurse will need to assess the client's performance of client intermittent self-catherization (CISC) for a client with which of the following?
- A.
Ileal conduit
- B.
Kock pouch
- C.
Neobladder
- D.
Vesicostomy
Correct Answer
B. Kock pouchExplanation
A Kock (pronounced coke) pouch creates a conduit to the bladder using a portion of the ileum to form a reservoir for urine. Client needs to place catheter @ home. CISC requires medical aspesis.Rate this question:
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- 37.
Because the client has flaccid bladder, the nurse is most likely to teach which of the following?
- A.
Habit training: attempt voiding at specific times during the day
- B.
Bladder training: delay voiding according to a prescheduled timetable
- C.
Credes Maneuver: apply gentle manual pressure to the lower abdomen
- D.
Kegel exercises: contract the pelvic muscles
Correct Answer
C. Credes Maneuver: apply gentle manual pressure to the lower abdomenExplanation
The client with a flaccid bladder is likely to have difficulty emptying their bladder completely. The Credes Maneuver involves applying gentle manual pressure to the lower abdomen to help promote bladder emptying by manually compressing the bladder. This technique can be taught by the nurse to help the client effectively empty their bladder and prevent complications such as urinary retention or urinary tract infections. Habit training, bladder training, and Kegel exercises may not be as effective in this situation as they do not directly address the issue of bladder emptying.Rate this question:
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- 38.
Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in
- A.
Constipation
- B.
Diarrhea
- C.
Incontinence
- D.
Hemorrhoids
Correct Answer
A. ConstipationExplanation
Repeatedly ignoring the sensation of needing to defecate can lead to constipation. When individuals consistently ignore the urge to have a bowel movement, the stool can become dry and hard, making it difficult to pass. This can result in infrequent or incomplete bowel movements, causing discomfort and bloating. Therefore, it is important for clients to be aware of the importance of responding to the body's natural signals and not ignoring the need to defecate.Rate this question:
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- 39.
Which of the following statements provide evidence that an older adult who is prone to constipation needs more education?
- A.
I need to drink one and half to two quarts of liquids ech day
- B.
I need to take a laxative such as milk of magnesia if I don't have a BM each day.
- C.
If my bowel pattern changes on its own, I should call you
- D.
Eating my meals at regular times is likely to result in regular bowel movements
Correct Answer
B. I need to take a laxative such as milk of magnesia if I don't have a BM each day.Explanation
The statement "I need to take a laxative such as milk of magnesia if I don't have a BM each day" provides evidence that the older adult may need more education on managing constipation. This statement suggests that the individual believes that taking a laxative is necessary for daily bowel movements, which may indicate a lack of understanding about natural bowel patterns and the importance of dietary and lifestyle changes in promoting regular bowel movements.Rate this question:
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- 40.
Because a client is scheduled for a colonscopy, the nurse will instruct the client to perform which of the following?
- A.
Oil retention enema
- B.
Return flow enema
- C.
High, large volume enema
- D.
Low, small volume enema
Correct Answer
D. Low, small volume enemaExplanation
high volume enema could result in electrolyte imbalance that makes it less than ideal.Rate this question:
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- 41.
The nurse is most likely to report which of the following findings to the PCP for a client who has an established colostomy?
- A.
The stoma extends 1/2 inch above the abdomen
- B.
The skin under the appliance looks red briefly after removing the appliance
- C.
The stoma color is deep purple
- D.
The ascending colostomy delivers liquid feces
Correct Answer
C. The stoma color is deep purpleExplanation
The nurse is most likely to report that the stoma color is deep purple because this could indicate a lack of blood supply to the stoma, which is a serious concern. A healthy stoma should be pink or red, so a deep purple color suggests ischemia or necrosis. This finding should be reported to the primary care physician immediately for further evaluation and intervention.Rate this question:
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- 42.
A client with a new stoma who has not had a bowl movement since surgery last week reports feeling nauseous. What is the appropriate action?
- A.
Prepare to irrigate the colostomy
- B.
After assessing the stoma and surrounding skin, call the surgeon.
- C.
Assess bowel sounds and administer antiemetic
- D.
Administer a bulk-forming laxative and encourage increased fluids and exercise
Correct Answer
B. After assessing the stoma and surrounding skin, call the surgeon.Explanation
Don't give meds or interventions without an order. Right?Rate this question:
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- 43.
The nurse assess a client's abdomen several days after abdominal surgery. It is firm, distended and painful to palpate. The client reports feeling bloated. The nurses consults with the surgeon who orders an enema. The nurse prepares to give what kind of enema?
- A.
Soapsuds enema
- B.
Retention enema
- C.
Return flow enema
- D.
Oil retention enema
Correct Answer
C. Return flow enemaExplanation
The given answer, "return flow enema," is correct because the client's symptoms of a firm, distended abdomen, pain on palpation, and feeling bloated indicate the presence of gas or fecal impaction. A return flow enema is designed to help relieve these symptoms by introducing fluid into the rectum and then allowing it to flow back out, carrying any gas or fecal matter with it. This type of enema helps to relieve discomfort and promote bowel movement.Rate this question:
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- 44.
Which of the following is most likely to validate that a client is experiencing intestinal bleeding?
- A.
Large quantities of fat mixed with pale yellow liquid stool
- B.
Brown, formed stools
- C.
Semisoft tar-colored stools
- D.
Narrow, pencil shaped stools
Correct Answer
C. Semisoft tar-colored stoolsExplanation
Semisoft tar-colored stools are most likely to validate that a client is experiencing intestinal bleeding. Intestinal bleeding can cause the stool to appear black and tarry, indicating the presence of digested blood. This stool color is often associated with bleeding in the upper gastrointestinal tract, such as the stomach or small intestine. It is important to note that the other options do not typically indicate intestinal bleeding. Large quantities of fat mixed with pale yellow liquid stool may suggest malabsorption or pancreatic issues, brown, formed stools are considered normal, and narrow, pencil-shaped stools may indicate a potential obstruction in the colon.Rate this question:
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Mar 21, 2023Quiz Edited by
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Jul 18, 2009Quiz Created by
Mbastide
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