Question 1

The nurse has a prescription to give ear drops to a 2-year-old child. The nurse positions the child's ear properly by pulling the pinna of the ear:

Accepted Answer

For a child under 3 years old, the correct technique to straighten the ear canal and facilitate the administration of ear drops is to pull the pinna downward and backward. This helps in aligning the ear canal for easier application of the medication.

Question 2

A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. When the client expresses concern about his or her ability to perform this procedure at home, the nurse would best respond with which of the following?

Accepted Answer

"Tell me more about your concerns about going home." is the best response as it encourages the client to express feelings and concerns, allowing the nurse to assess the client's understanding and readiness for discharge while providing emotional support.

Question 3

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should do which of the following when caring for this client to maintain client safety?

Accepted Answer

Checking for tube placement and residual amount at least every 4 hours is essential for ensuring the NG tube is properly positioned and to assess for potential complications such as aspiration or feeding intolerance.

Question 4

The client with pancreatitis is being weaned from parenteral nutrition (PN). The client asks the nurse why the PN cannot just be stopped. The nurse includes in a response to the client that which of the following complications could occur with sudden termination of PN formula?

Accepted Answer

Rebound hypoglycemia can occur if parenteral nutrition (PN) is stopped suddenly because the body has adapted to the high glucose levels provided by the PN. When the PN is abruptly discontinued, insulin levels may still be high, leading to a rapid decrease in blood glucose levels.

Question 5

The nurse hears in intershift report that a client receiving parenteral nutrition (PN) at 100 mL/hr has bilateral crackles and 1+ pedal edema. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lb in 2 days. Which of the following nursing actions should the nurse take first?

Accepted Answer

Comparing the intake and output records of the last 2 days is the first step in assessing fluid balance, which is crucial given the signs of fluid overload (bilateral crackles, pedal edema, and rapid weight gain). This will help determine the cause of the symptoms and guide further interventions.

Question 6

The nurse is caring for a client receiving parenteral nutrition (PN) via a central line. The nurse should monitor which of the following to detect the development of the most common complication of PN?

Accepted Answer

The most common complication of parenteral nutrition is infection, particularly due to the central line. Monitoring the client's temperature can help detect signs of infection early.

Question 7

The nurse is providing care to a client with continuous tube feedings through a nasogastric (NG) tube. The nurse should avoid doing which of the following, which is not part of the standard care for a client receiving enteral nutrition?

Accepted Answer

Feeding bags should be changed every 24 hours to prevent bacterial contamination, not every 72 hours.

Question 8

The nurse is monitoring the nutritional status of the client receiving enteral nutrition. The nurse monitors which of the following to determine the effectiveness of the tube feedings for this client?

Accepted Answer

Daily weight is a direct indicator of nutritional status and can help determine the effectiveness of tube feedings by showing changes in body weight over time.

Question 9

A client is scheduled for insertion of a peripherally inserted central catheter (PICC) and the nurse explains the advantages of this catheter. The nurse determines that the client needs additional information about the catheter if the client makes which statement?

Accepted Answer

PICC lines are designed for long-term use, typically weeks to months, not short-term use.

Question 10

A nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse interprets that which of the following complications has been experienced by the client?

Accepted Answer

Infiltration occurs when IV fluid leaks into the surrounding tissue, causing the site to become cool, pale, and swollen, and the solution to stop infusing properly.

Question 11

The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which of the following frequencies?

Accepted Answer

IV sites should be checked every hour to ensure there are no complications such as infiltration, phlebitis, or infection, and to ensure the IV is functioning properly.

Question 12

The client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first?

Accepted Answer

Shutting off the infusion is the first action the nurse should take in response to signs of fluid overload or a possible allergic reaction to the IV solution. This action helps prevent further complications by stopping the infusion of the substance causing the adverse effects.

Question 13

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced:

Accepted Answer

The symptoms described (redness, warmth, pain, and slight edema proximal to the insertion point) are indicative of phlebitis, which is inflammation of a vein. These symptoms do not align with infiltration (which involves fluid leaking into the surrounding tissue), hypersensitivity to the IV solution, or an allergic reaction to the catheter material, which would likely present differently.

Question 14

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which of the following supplies from the unit supply area for use in applying pressure to the site after removing the IV catheter?

Accepted Answer

Sterile 2 * 2 gauze is used to apply pressure to the site after removing an IV catheter to help stop bleeding and prevent infection, ensuring a clean and safe procedure.

Question 15

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?

Accepted Answer

The appropriate action is to change the IV tubing because it has been contaminated by touching a non-sterile surface, which could lead to infection if used.

Question 16

The nurse is collecting data from an African-American client scheduled for surgery. Which of the following questions would be of least priority for the nurse to ask on initial assessment?

Accepted Answer

The question about family relationships is of least priority in the context of a pre-surgical assessment, where the focus should be on identifying any immediate health concerns that could affect the surgery or anesthesia.

Question 17

The nurse is providing discharge instructions to an Asian-American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which of the following nursing actions is most appropriate?

Accepted Answer

In some Asian cultures, direct eye contact or facing someone directly can be considered disrespectful. The client turning away may be a cultural norm rather than a sign of disinterest. Continuing with the instructions while verifying understanding respects cultural differences.

Question 18

The nurse is planning to instruct the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware that this ethnic group:

Accepted Answer

Hispanic-American culture often views food as a primary form of socialization, where meals are shared with family and friends, and food plays a central role in gatherings and celebrations.

Question 19

The nurse is preparing to assist a Jewish-American client with eating lunch. A kosher meal is delivered to the client. Which of the following nursing actions is most appropriate in assisting the client with the meal?

Accepted Answer

Jewish dietary laws require that kosher meals remain sealed until the client opens them to ensure they have not been tampered with. Allowing the client to unwrap and prepare the meal respects these religious practices.

Question 20

The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. When meeting the client, the nurse should plan to do which of the following?

Accepted Answer

Hispanic-American culture often values personal relationships and a handshake is a common and respectful way to greet someone in a professional setting.

Quiz 3: Fundamentals and Issues of Nursing