Student Exam Results

Student Information
Last Name: lazaro Reference:
First Name: briselda
Exam: RN Lesson 5 Posttest Total Attempts: 1 Total Submitted Attempts : 1 Mark: 45 %

Objective: RN Lesson 5 Posttest - Physiological Integrity: Basic Care and Comfort Student Mark for this Objective: 45% Correct Responses: 9 / 20
Incorrect (Ref: )A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort?
Learner Response: A) Increase oral fluid intake
Correct Response: C) Keep conversations short
Feedback: Keeping conversations short will promote the client's comfort by decreasing demands on the client's
breathing and energy. Increased intake is not related to comfort. While the presence of family is supportive,
demands on the client to interact with the visitors may interfere with the client's rest. Monitoring vital signs is
an important assessment but not related to promoting the client's comfort.
Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar.
Daniels, R. (2003). Delmar's manual of laboratory and diagnostic tests. USA: Thompson Delmar Learning.

Incorrect (Ref: )What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal
impaction?
Learner Response: D) Absence of bowel movements
Correct Response: B) Oozing liquid stool
Feedback: When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the
obstruction. This is often mistaken for uncontrolled diarrhea.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care.
(4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
Learner Response: D) Aspiration for gastric contents
Correct Response: A) Abdominal x-ray
Feedback: Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather
than in the airways.
Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment &
management of clinical problems. St. Louis: Elsevier.

Incorrect (Ref: )When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
Learner Response: A) Every four to six hours
Correct Response: B) Continuously
Feedback: Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption.
However, initial feedings may be given by bolus to assess the client's tolerance to formula.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment &
management of clinical problems. St. Louis: Elsevier.

Incorrect (Ref: )The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice
indicates the client understands dietary needs?
Learner Response: B) Medium banana
Correct Response: D) Baked potato
Feedback: A baked potato contains 610 milligrams of potassium.
Lutz, C.A., & Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd ed.). Philadelphia: F.A. Davis Company.
Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier.

Correct (Ref: )Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be
the nurse's priority?
Learner Response: B) Obtain a health and dietary history
Correct Response: B) Obtain a health and dietary history

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 Student Exam Results

Feedback: Initially, the nurse should obtain information about the chronicity of and details about constipation, recent
changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid
history. This information may suggest causes as well as an appropriate, safe treatment plan.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment &
management of clinical problems. St. Louis: Elsevier.
Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis:
Elsevier.

Incorrect (Ref: )The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would
caution the client to avoid
Learner Response:
Correct Response:
Feedback:
A) glycerine suppositories
C) laxatives
Some elders are constipated because they have used over-the-counter laxatives for a long time. In addition,
many people do not eat enough fiber, drink enough water, or exercise adequately. Certain medications,
including opioid analgesics, are constipating. Elders are rarely constipated because of organic or
pathological reasons.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Edelman, C.L., & Mandle, C.M. (2002). Health promotion throughout the lifespan. (5th ed.). St. Louis:
Elsevier.

Correct (Ref: )The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch
selections indicates the client has learned about sodium restriction?
Learner Response: B) Sliced turkey sandwich and canned pineapple
Correct Response: B) Sliced turkey sandwich and canned pineapple
Feedback: Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in
sodium. All of the other choices contain one or more high-sodium foods.
Lutz, C.A., & Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd ed.). Philadelphia: F.A. Davis Company.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and
oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
Learner Response: B) Decreased sodium and potassium
Correct Response: B) Decreased sodium and potassium
Feedback: Children with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions limiting
sodium, potassium, fluids, and protein.
Potts, N.L., & Mandleco, B.L. (2002). Pediatric nursing, caring for children and their families. USA:
Thompson Delmar Learning.
McCampbell, L.S., & Renfro, A.R. (2002). Wong's nursing care of infants and children. (7th ed.). St. Louis:
Elsevier.

Incorrect (Ref: )A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development
of decubitus ulcers?
Learner Response:
Correct Response:
Feedback:
B) An obese client who uses a wheelchair
A) A 79 year-old malnourished client on bed rest
Weighing significantly less than ideal body weight increases the number and surface area of bony
prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti,
due in part to poor hydration and inadequate protein intake.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care.
(4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )Which statement best describes the effects of immobility in children?
Learner Response: A) Immobility prevents the progression of language and fine motor development
Correct Response: B) Immobility in children has similar physical effects to those found in adults
Feedback: Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin
breakdown, decreased metabolism and bone demineralization. Secondary alterations also occur in the
cardiovascular, respiratory and renal systems. Similar effects and alterations occur in adults.
Wong, D.L., Perry, S.E. & Hockenberry, M.J. (2002). Maternal child nursing. (2nd ed.). St. Louis: Elsevier.
Ashwill, J., Droske, S., & James, S. (2002). Nursing care of children: principles and practice. (2nd ed.).
Philadelphia: Elsevier.

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 Student Exam Results

Correct (Ref: )After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about
the diet, which meal plan would be the most appropriate to suggest?
Learner Response: D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Response: D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Feedback: Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned
fish and/or vegetables or cured meats.
Black, J., Hawk, J., & Keene, A. (2001). Medical-surgical nursing. (6th ed). Philadelphia: Elsevier.
Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care.
(4th ed.). Philadelphia: Elsevier.

Correct (Ref: )A client with diarrhea should avoid which of the following?
Learner Response: A) Orange juice
Correct Response: A) Orange juice
Feedback: Orange juice is contraindicated for a client with diarrhea because it increases the motility of the
gastrointestinal tract.
Lutz, C.A., & Prytulski, K.R. (2001). Nutrition and diet therapy. (3rd ed.). Philadelphia: F.A. Davis Company.
Beare, P., & Myers, J. (1998). Adult health nursing. (3rd ed.). St. Louis: Elsevier.

Incorrect (Ref: )An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be
Learner Response: D) Encourage him to increase his activity
Correct Response: A) Assess the severity and location of the pain
Feedback: Most older adults have 1 or more chronic painful illnesses, and in fact, they often must be asked about
discomfort (rather than "pain") to reveal the presence of pain. There is no evidence that pain of older adults
is less intense than younger adults. It is important for the nurse to assess the pain thoroughly before
implementing pain relief measures.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Estes, M.E.Z. (2002). Health assessment and physical examination. (2nd ed). Albany, NY: Delmar.

Correct (Ref: )An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in the
right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should
the nurse do next?
Learner Response: B) Check the client's gag reflex
Correct Response: B) Check the client's gag reflex
Feedback: When a new problem emerges, the nurse should perform appropriate assessment so that suitable nursing
interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the
trachea and finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care.
(4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction
regarding exercise would be to
Learner Response: C) avoid exercise activities that increase the risk of fracture
Correct Response: A) exercise doing weight bearing activities
Feedback: Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be
substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises
along with estrogen replacement and calcium supplements in their treatment protocol.
Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-surgical nursing: assessment &
management of clinical problems. St. Louis: Elsevier.
Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care.
(4th ed.). Philadelphia: Elsevier.

Correct (Ref: )The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures
planned by the nurse would be most effective in preventing skin breakdown?
Learner Response: C) Reposition every two hours
Correct Response: C) Reposition every two hours

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 Student Exam Results

Feedback: Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours.
By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of
potential injury is maintained.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Ignatavicius, D., & Workman, L. (2002). Medical-surgical nursing critical thinking for collaborative care.
(4th ed.). Philadelphia: Elsevier.

Incorrect (Ref: )A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in
pain assessment is for the nurse to
Learner Response: B) get the description of the location and intensity of the pain
Correct Response: C) accept the client's report of pain
Feedback: Although all of the options above are correct, the first and most important piece of information in this client's
pain assessment is what the client is telling you about the pain --"the client's report."
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.
Price, S.A. & Wilson, L.M. (2003). Pathophysiology clinical concepts of disease processes. (6th ed.). St.
Louis: Elsevier.

Correct (Ref: )A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk
for falls, as part of a prevention protocol?
Learner Response: D) Bed in lowest position, wheels locked, place bed against wall
Correct Response: D) Bed in lowest position, wheels locked, place bed against wall
Feedback: It is no longer advisable to use only the lower side rails. Using all 4 side rails (upper and lower siderails at
the top and bottom of the bed) is an inappropriate use of restraint without an order. If all 4 are pulled up, an
order for protective restraints is needed that usually has to be renewed in 48 to 72 hours along with more
frequent documentation. Having all 4 side rails raised limits the client's autonomy and freedom of movement.
Using 3 of the 4 side rails pulled up is acceptable, because clients can safely exit the bed on their own
initiative. Placing the bed against the wall permits getting out of bed on only 1 side. Locking the wheels
keeps the bed from sliding. Keeping the bed in the lowest position (without bending limbs to restrict
movement) provides a shorter distance to the ground if the client chooses to get out of bed.
Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

Correct (Ref: )A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which
nursing measure will provide the most comfort to the client?
Learner Response: C) Perform frequent oral care with a tooth sponge
Correct Response: C) Perform frequent oral care with a tooth sponge
Feedback: Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube
to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and
do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.
Altman, G. (2004). Delmar's fundamental and advanced nursing skills. (2nd ed.). Albany, NY: Delmar.
Potter P., & Perry, A. (2005). Fundamentals of nursing. (6th ed.). St. Louis: Elsevier.

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