Q & A Random -17

Question Number 1 of 13
After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a
ritual bath on the deceased prior to moving the body. The appropriate response by the nurse is
".
A) I will have to check on hospital regulations and policies.
B) These procedures have to be carried out by our staff.
C) Is there anything you need from me to perform the ritual bath?
D) A ritual bath will have to wait until after post-mortem care
Your response was "A".

The correct answer is C: Is there anything you need from me to perform the ritual bath?

Rationale: In some religious traditions, a ritual bath is performed by a family member or a ritual burial society. Nurses
should inquire about rituals or observances following death and respect these. Options 1, 2 and 4 are inappropriate and
insensitive.

Question Number 2 of 13
An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is
appropriate?

A) Spray the oropharynx with saline

B) Ask the client to drink a warm liquid
C) Force fluids for the next 8 hours
D) Raise the head of the bed to at least 45 degrees
Your response was "A".

The correct answer is D: Raise the head of the bed to at least 45 degrees

Placing the client in semi or high fowler’s position will promote lung expansion and effective coughing. While drinking
liquids helps to loosen secretions over time, they should not be given when collecting a specimen. Spraying the throat
with saline may cause irritation and coughing and reduce oxygenation.

Question Number 3 of 13
A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When
initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Which first nursing action is
appropriate?

A) Continue to monitor the vital signs as indicated

B) Apply a warm blanket and check the temperature in 10 minutes
C) Ask the PACU nurse more details of what happened in PACU
D) Call the health care provider and obtain further orders for warming
Your response was "A". The correct answer is B: Apply a warm blanket and check the temperature in ten minutes

A client’s post-operative temperature should be at least 95 degrees. If the temperature does not increase, the nurse
should call the provider for orders for an electric warming blanket or other measures. It is not sufficient to continue
monitoring without taking action.

Question Number 4 of 13
The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before
flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next
appropriate nursing action?

A) Administer the feeding as ordered

B) Hold the next feeding
C) Flush with sterile water
D) Discard the undigested feeding
Your response was "A". The correct answer is B: Hold the next feeding
If residual is greater than 150 ml, then the next feeding should be held. Administering water or the next feeding does not
help with the digestion of this feeding. Discarding the feeding that was aspirated depletes the body of enzymes and
electrolytes that have been mixed with the feeding

Question Number 5 of 13
The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember that

A) the procedure be done prior to the bath

B) family members should be taught the procedure
C) cardiac dysrhythmias can result during the process
D) increased dietary fiber can minimize such problems
Your response was "A". The correct answer is C: cardiac dysrhythmias can result during the process

Cardiac dysrhythmias such as severe bradycardia can result from vagal nerve stimulation during fecal impaction removal
in the elderly or in cardiac patients. Options 1, 2 and 4 are appropriate though are not the most important considerations.

Question Number 6 of 13
A client is being discharged home today, and will be taking K-dur 20mEq per day by mouth. The nurse should reinforce
that potassium levels will be decreased by

A) foods seasoned with salt substitute

B) frequent daily snacks of black licorice
C) prescribed potassium-sparing diuretics
D) occasional use of a nonsteroidal anti-inflammatory drug (NSAID)
Your response was "A". The correct answer is B: frequent daily snacks of black licorice

Excessive intake of black licorice can lead to decreased K+ levels due to the effect of glyceric acid (aldosterone effect).
The excessive intake of salt substitutes, K+ sparing diuretics and NSAIDs all have the potential for raising the K+ level.

Question Number 7 of 13
When taking the client’s blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action
should the nurse take first?

A) take the BP again in 2 minutes in the same arm

B) retake the BP again immediately in the same arm
C) use an electronic BP cuff on the other arm
D) check to see if the stethoscope is plugged
Your response was "A". The correct answer is A: take the BP again in 2 minutes in the same arm

It is best to wait 2 minutes between readings of a BP in the same arm to allow the vessels to recover from being
squeezed. The electronic cuff would also require a 2 minute wait and may not read a very low pressure

Question Number 8 of 13
On admission to the ambulatory surgery unit, the nurse notices the client's painted finger nails. On reviewing the pre-op
orders, the nurse notes that pulse oximetry has been ordered. Which statement by the nurse is appropriate?

A) "In order to measure your oxygen level, please remove the polish from at least 2 nails."
B) "If you do not remove all your polish, I will request a needlestick to test oxygen levels."
C) "I am sorry. All your nail polish must go off."
D) "I will ask your provider if we must ruin those beautiful nails."
Your response was "A". The correct answer is A: "In order to measure your oxygen level, please remove the polish from at
least 2 nails."

In order to effectively measure pulse oximetry, there can be no nail polish on the finger with the reading device. The client
should be approached using therapeutic communication skills. The other options are not appropriate

Question Number 9 of 13
The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube,
the nurse should

A) ask the client to hold a breath

B) offer sips of water
C) bring the code cart to the bedside
D) empty the tube of all drainage
Your response was "A". The correct answer is A: ask the client to hold a breath

Holding the breath closes the epiglottis to help prevent aspiration. Occasionally passing a NG tube is easier if the client
swallows during the process. Emptying the tube does not prevent aspiration. There should be no need for the code cart.

Question Number 10 of 13
The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the
appropriate response by the nurse?

A) The radiation from a mammography is equivalent to 1 hour of sun exposure.

B) You have nothing to worry about; it is less than tanning in the nude.
C) A chest x-ray gives you more radiation exposure.
D) Exposure to mammography every 2 years is not dangerous.

Your response was "A". The correct answer is A: The radiation from a mammography is equivalent to one hour of sun
exposure. The exposure of radiation from a mammography is equivalent to 1 hour of sun exposure; a client would have to
have several in a year’s time to be at risk for cancer. This answer is concise and gives the client a point of reference.
Option 2 is judgmental and non-therapeutic. Option 3 is not accurate and can cause further concern about radiation
exposure. Option 4 does not clearly address the client’s question.

Question Number 11 of 13
A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only
minor injuries. The nurse knows that the most important initial intervention would be to:

A) Suggest the client rent an apartment with a sprinkler system

B) Provide a brochure on methods to promote relaxation.
C) Determine available community and personal resources
D) Explore the feelings of grief associated with the loss
Your response was "A".

The correct answer is C: Determine available community and personal resources

The client has experienced a sudden event that has resulted in disequilibrium. The most important initial intervention
focuses on identifying resources and obtaining assistance for housing and other immediate needs. Information on home
safety, relaxation exercises, and grief counseling are of value after meeting initial needs for shelter.

Question Number 12 of 13
The nurse is inserting a Foley catheter into the bladder of a female adult client. The nurse slips the catheter into an
opening for four-5 inches and no urine is obtained. The most probable reason for this is that

A) there is no urine present in the bladder

B) the catheter is in the vagina
C) the catheter is not inserted in far enough
D) the bladder is over distended
Your response was "A". The correct answer is B: the catheter is in the vagina

The urinary catheter is inserted about 2 to 3 inches in the urinary meatus until the urine flow is visualized. If urine does not
flow, the catheter is rotated gently and carefully inserted another inch farther. A catheter inserted 4 to 5 inches with no
urine return is probably in the vagina

Question Number 13 of 13
The nurse is caring for a 16 year-old client with femur fracture14 hours after surgery. Assessment findings include
tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious,
and oxygen saturation level of 88%. In immediately notifying the provider of these findings, the nurse recognizes the client
is at risk for

A) compartment syndrome
B) atelectasis
C) myocardial infarction
D) fatty embolism
Your response was "A".

The correct answer is D: fatty embolism

The findings are cardinal signs of a fatty embolism. Compartment syndrome does not cause increased shortness of
breath or feelings of anxiousness. Atelectasis occurs when ventilation is decreased and secretions accumulate.
Myocardial infarction is characterized with chest pain and generally does not occur in 16 year olds unless there is a
cardiac history