Fundamentals Of Nursing NCLEX Quiz 16

1. A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client's condition?

Hypoxia

Hypoxemia

Dyspnea

Cyanosis

A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes. The nurse can only observe signs/symptoms of hypoxia. More information is needed to validate this conclusion. Hypoxemia requires blood oxygenation saturation data to be confirmed and dyspnea is difficulty breathing.

Explanation

A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes. The nurse can only observe signs/symptoms of hypoxia. More information is needed to validate this conclusion. Hypoxemia requires blood oxygenation saturation data to be confirmed and dyspnea is difficulty breathing.

2. A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation. which of the following foods should the nurse recommend?

Macaroni and cheese

Fresh food and whole wheat toast

Rice pudding and ripe bananas

Roast chicken and white rice

A high fiber diet promotes normal bowel elimination. The choice of fruit and toast is the highest fiber option. Macaroni and cheese is a low residue option that could actually worse and constipation. Rice pudding and ripe bananas are low residue options that could actually worsen constipation. Roast chicken and white rice or low residue options that could actually worsen constipation.

Explanation

A high fiber diet promotes normal bowel elimination. The choice of fruit and toast is the highest fiber option. Macaroni and cheese is a low residue option that could actually worse and constipation. Rice pudding and ripe bananas are low residue options that could actually worsen constipation. Roast chicken and white rice or low residue options that could actually worsen constipation.

3. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?

Eating more protein is optimal prior to testing.

One stool specimen is sufficient for testing.

A red color changes indicates a positive test.

The specimen cannot be contaminated with urine.

For fecal occult blood testing at home. the stool specimens cannot be contaminated with water or urine. Some proteins such as red meat. fish. and poultry can alter the test results. Three specimens from three different bowel movements are required. A blue color indicates blood in the stool.

Explanation

For fecal occult blood testing at home. the stool specimens cannot be contaminated with water or urine. Some proteins such as red meat. fish. and poultry can alter the test results. Three specimens from three different bowel movements are required. A blue color indicates blood in the stool.

4. Which statement by a patient with an ileostomy alert the nurse to the need for further education?

“I don’t expect to have much of a problem with fecal odor.”

“I will have to take special precaution to protect my skin around the stoma.”

“I’m going to have to irrigate my stoma so I have a bowel movement every morning.”

“I should avoid gas forming foods like beans to limit funny noises from the stoma.”

This statement is inaccurate in relation to an ileostomy and indicates that the patient needs more teaching. And ileostomy produces liquid fecal drainage that is constant and cannot be regulated. The odor from drainage is minimal because fewer bacteria are present in the ileum compared with the large intestine. And ileostomy is an opening into the ileum (distal small intestine from the jejunum to the cecum). Cleansing the skin. skin barriers. and a well fitted appliance are precautions to protect the skin around the ileostomy stoma. The drainage from ileostomy contains enzymes that can damage the skin. An ileostomy stoma does not have a sphincter that can control the flow of flatus or drainage. resulting in noise.

Explanation

This statement is inaccurate in relation to an ileostomy and indicates that the patient needs more teaching. And ileostomy produces liquid fecal drainage that is constant and cannot be regulated. The odor from drainage is minimal because fewer bacteria are present in the ileum compared with the large intestine. And ileostomy is an opening into the ileum (distal small intestine from the jejunum to the cecum). Cleansing the skin. skin barriers. and a well fitted appliance are precautions to protect the skin around the ileostomy stoma. The drainage from ileostomy contains enzymes that can damage the skin. An ileostomy stoma does not have a sphincter that can control the flow of flatus or drainage. resulting in noise.

5. A practitioner orders a return flow enema (Harris flush drip) for an adult patient with flatulence. When preparing to administer this enema The nurse compares the steps of a return flow enema with cleansing enemas. What should the nurse do that is unique to a return flow enema?

Lubricate the last 2 inches of the rectal tube.

Insert the rectal tube about 4 inches into the anus.

Raise the solution container about 12 inches above the anus.

Lower the solution container after instilling about 150 mL of solution.

Lowering the container of solution create a siphon effect that pulls the instilled fluid back out through the rectal tube into the solution container. The return flow promotes the evacuation of gas from the intestines. This technique is used only with a return flow enema. All rectal tube should be lubricated to facilitate entry of the tube into the anus and rectum and prevent mucosal trauma.The anal canal is 1 to 2 inches long. Inserting the rectal tube 3 to 4 inches ensures that the tip of the tube is beyond the anal Sphincter. This action is appropriate for all types of enemas. The solution container should be raised no higher than 12 inches for all enemas; this allows the solution to instill slowly. which limits discomfort and intestinal spasms.

Explanation

Lowering the container of solution create a siphon effect that pulls the instilled fluid back out through the rectal tube into the solution container. The return flow promotes the evacuation of gas from the intestines. This technique is used only with a return flow enema. All rectal tube should be lubricated to facilitate entry of the tube into the anus and rectum and prevent mucosal trauma.The anal canal is 1 to 2 inches long. Inserting the rectal tube 3 to 4 inches ensures that the tip of the tube is beyond the anal Sphincter. This action is appropriate for all types of enemas. The solution container should be raised no higher than 12 inches for all enemas; this allows the solution to instill slowly. which limits discomfort and intestinal spasms.

6. A patient with the diagnosis of diverticulosis is advised to eat a diet high in fiber. What should the nurse recommend that the patient eat to best increase the bulk and fecal material?

Whole wheat bread

White rice

Pasta

Kale

Kayle is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale contain 6.6 g of dietary fiber. One slice of whole wheat bread contains only 1.5 g of dietary fiber. A serving of a 1/2 cup of white rice contains only 0.8 g of dietary fiber. A serving of 3 1/2 ounces of cooked pasta contains only 1.6 g of dietary fiber.

Explanation

Kayle is an excellent source of dietary fiber. A serving of 3 1/2 ounces of kale contain 6.6 g of dietary fiber. One slice of whole wheat bread contains only 1.5 g of dietary fiber. A serving of a 1/2 cup of white rice contains only 0.8 g of dietary fiber. A serving of 3 1/2 ounces of cooked pasta contains only 1.6 g of dietary fiber.

7. While a nurse is administering a cleansing enema. the client reports abdominal cramping. Which of the following is the appropriate intervention?

Have a client hold his breath briefly.

Discontinue the fluid installation.

Remind the client that cramping is common at this time.

Lower the enema fluid container.

To relieve the client’s discomfort. the nurse should slow the rate of installation by reducing the height of the enema solution container. Taking slow. deep breaths is more therapeutic for easing discomfort than holding the breath. The nurse should stop the installation if the client’s abdomen becomes a rigid and distended or if the nurse notes bleeding from the rectum.Option C is not therapeutic as it implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it.

Explanation

To relieve the client’s discomfort. the nurse should slow the rate of installation by reducing the height of the enema solution container. Taking slow. deep breaths is more therapeutic for easing discomfort than holding the breath. The nurse should stop the installation if the client’s abdomen becomes a rigid and distended or if the nurse notes bleeding from the rectum.Option C is not therapeutic as it implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it.

8. A nurse discourages a patient from straining excessively when attempting to have a bowel movement. What physiological response primarily may be prevented by avoiding straining on defecation?

Incontinence

Dysrhythmias

Fecal impaction

Rectal hemorrhoids

Straining on defecation requires the person to hold the breath while bearing down. This maneuver increases the intrathoracic and intracranial pressures. which can precipitate dysrhythmias. brain attack. and respiratory difficulties; all of these can be life threatening. The loss of the voluntary ability to control the passage of fecal or gaseous discharges through the anus is caused by impaired functioning of the anal sphincter or it’s nerve supply. not straining on defecation. Fecal impaction is caused by prolonged retention and the accumulation of fecal material in the large intestine. not straining on defecation. Although straining on defecation can contribute to the formation of hemorrhoids. this is not the primary reason straining on defecation is discouraged. Hemorrhoids. although painful. are not life-threatening.

Explanation

Straining on defecation requires the person to hold the breath while bearing down. This maneuver increases the intrathoracic and intracranial pressures. which can precipitate dysrhythmias. brain attack. and respiratory difficulties; all of these can be life threatening. The loss of the voluntary ability to control the passage of fecal or gaseous discharges through the anus is caused by impaired functioning of the anal sphincter or it’s nerve supply. not straining on defecation. Fecal impaction is caused by prolonged retention and the accumulation of fecal material in the large intestine. not straining on defecation. Although straining on defecation can contribute to the formation of hemorrhoids. this is not the primary reason straining on defecation is discouraged. Hemorrhoids. although painful. are not life-threatening.

9. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all that apply.

Warm the enema solution prior to installation.

Position the client on the left side with the right leg flexed forward.

Lubricate the rectal tube or nozzle.

Slowly insert the rectal tube about 2 inches.

Hang the enema container 24 inches above the clients anus

The nurse should warm the enema solution because cold fluid can cause abdominal cramping and hot fluid can injure the intestinal mucosa. Option B allows a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon. Lubrication prevents trauma or irritation to the rectal mucosa. Option D is an appropriate length of insertion for a child. For an adult client. the nurse should insert a tube 3 to 4 inches. The height of the fluid container affects the speed of installation. The maximum recommended height is 18 inches. Hanging the container higher than that could cause rapid installation and possibly painful distention of the colon.

Explanation

The nurse should warm the enema solution because cold fluid can cause abdominal cramping and hot fluid can injure the intestinal mucosa. Option B allows a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon. Lubrication prevents trauma or irritation to the rectal mucosa. Option D is an appropriate length of insertion for a child. For an adult client. the nurse should insert a tube 3 to 4 inches. The height of the fluid container affects the speed of installation. The maximum recommended height is 18 inches. Hanging the container higher than that could cause rapid installation and possibly painful distention of the colon.

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10. A nurse is caring for a client who has diarrhea for the past four days. When assessing a client. the nurse should expect which of the following findings? Select all that apply.

Bradycardia

Hypotension

Fever

Poor skin turgor

Peripheral edema

Prolonged diarrhea lead to dehydration. which causes a decrease in blood pressure. Prolonged diarrhea leads to dehydration. which causes fever. Prolonged diarrhea is more likely to cause take a tachycardia than bradycardia. Peripheral edema results from a fluid overload. Prolonged diarrhea is more likely to cause a fluid deficit.

Explanation

Prolonged diarrhea lead to dehydration. which causes a decrease in blood pressure. Prolonged diarrhea leads to dehydration. which causes fever. Prolonged diarrhea is more likely to cause take a tachycardia than bradycardia. Peripheral edema results from a fluid overload. Prolonged diarrhea is more likely to cause a fluid deficit.

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