1. A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate...
ATI PN PHARMACOLOGY PROCTORED TEST BANK |
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1. A nurse is planning to collect a stool specimen for ova and parasites from a client
who has diarrhea. Which of the following actions should the nurse take when collecting
the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container
for stoolcollection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a
tonguedepressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the
laboratory after labeling the specimen properly to prevent contamination with
microorganisms and keep thespecimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with the
client label on the container and the bag for easy identification. This will also prevent
contaminationwith microorganisms.
2. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which
of thefollowing actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for
severalminutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage
to thetracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
3. A nurse is providing teaching to a client regarding protein intake. Which of the
followingfoods should the nurse include as an example of an incomplete protein?
A. Eggs
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for thesynthesis of protein in the body.
B. Soybeans
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for thesynthesis of protein in the body.
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C. Lentils
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for
the synthesis of protein in the body. Examples of incomplete proteins include lentils,
vegetables,grains, nuts, and seeds.
D. Yogurt
-incorrect: this is a complete protein, contains all of the essential amino acids necessary
for thesynthesis of protein in the body.
4. A nurse is caring for a client who was admitted to a long-term care facility for
rehabilitationafter a total hip arthroplasty. At which of the following times should the
nurse begin discharge planning?
A. One week prior to the client‟s discharge
-incorrect: Beginning to plan for the client‟s discharge a week prior to the event might not
allowsufficient time for planning. The nurse should begin discharge planning at the time of
admission.B. Upon the client‟s admission to the care facility
-The nurse should begin discharge planning at the time that the client is admitted to the facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client‟s discharge once the discharge date is identified
mightnot allow sufficient time for planning. The nurse should begin discharge planning at
the time of admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client‟s discharge once the discharge date is identified
mightnot allow sufficient time for planning. The nurse should begin discharge planning at
the time of admission.
5. A nurse is preparing to administer a cleansing enema to a client. Which of the
followingactions should the nurse plan to take?
A. Insert the rectal tube 15.2 cm (6 in)
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)
B. Wear sterile gloves to insert the tubing
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent contamination.
C. Position the client on his left side
-Positioning is an important aspect of administering an enema. Having the client lie on
his leftside facilitates the flow of the enema solution into the sigmoid and descending
colon.
D. Hold the solution bag 91 cm (36 inch) above the client‟s rectum
-incorrect: The nurse should hold the solution bag 30 cm (12 in) above the client‟s rectum
for alow enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag
too high, thesolution might run in too fast, causing discomfort and spasms that make
retaining the enema more difficult.
5. A nurse is caring for a client who has bilateral cats on her hands. Which of the
followingactions should the nurse take when assisting the client with feeding?
A. Sit at the bedside when feeding the client
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the
client withthe nurse‟s full attention during the feeding
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B. Order pureed foods
-incorrect: Without any mouth or throat injuries that make chewing or swallowing
difficult, the client should be served foods of an appropriate variety of textures. Pureed
foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth.
C. Make sure feedings are provided at room temperature
-incorrect: The nurse should ask the client if the food is the correct temperature
D. Offer the client a drink of fluid after every bite
-incorrect: If the client is unable to communicate, the nurse should offer the client fluids
after every 3 or 4 mouthfuls. However, there is no indication that this client is unable to
communicate.Therefore, the client should tell the nurse when she would like a drink.
6. A nurse is administering an IM injection to a 5-month-old infant. Which of the
followinginjection sites should the nurse use?
A. Deltoid
-incorrect: The nurse can use the deltoid muscle for injecting small volumes of
medication forchildren 18 months of age or older, but its proximity to several nerves
and arteries make it a riskier choice.
B. Ventrogluteal
-incorrect: This is a safe site for IM injections for clients older than 7 months.
C. Vastus lateralis
-The nurse should use the vastus lateralis site over the anterior thigh for IM injections for
infantsand children.
D. Dorsogluteal
-incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the
superiorgluteal nerve and artery.
7. A nurse is caring for a client who has major fecal incontinence and reports irritation
in theperianal area. Which of the following actions should the nurse take first?
A. Apply a fecal collection system
-incorrect: The nurse should apply a fecal collection system to divert the feces away
from thearea of skin irritation; however, there is another action the nurse should take
first.
B. Apply a barrier cream
-incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the
perianalarea from the feces; however, there is another action the nurse should take
first.
C. Cleanse and dry the area
-incorrect: The nurse should cleanse and dry the perianal area to decrease skin
irritation;however, there is another action the nurse should take first.
D. Check the client‟s perineum
-The nurse should apply the nursing process priority-setting framework to plan care and
prioritize nursing actions. Each step of the nursing process builds on the previous step,
beginningwith an assessment or data collection. Before the nurse can formulate a plan of
action, implementa nursing intervention, or notify a provider of a change in the client‟s
status, the nurse must first collect adequate data from the client. Assessing or collecting
additional data will provide the nurse with knowledge to make an appropriate decision.
The priority nursing action is for the nurse to collect more data by assessing the area of
irritation.
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