Nursing Fundamentals Test (Questions 31-35)

31. When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

a. "I will administer the enema while sitting on the toilet."
b. "I will administer the enema while lying on my left side with my right knee flexed."
c. "I will administer the enema while lying on my right side with my left knee flexed."
d. "I will administer the enema while lying on my back with both knees flexed."

32. A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, the nurse will:

a. be unable to palpate the bladder.
b. feel that the bladder is smooth.
c. palpate the bladder above the symphysis pubis.
d. palpate the bladder at the umbilicus.

33. After assessing a client, the nurse formulates relevant nursing diagnoses. Which of the following is a complete nursing diagnosis statement?

a. Ineffective airway clearance related to mucus plugs and nonproductive cough
b. Hyperventilation related to anxiety
c. Tachycardia
d. Shortness of breath related to anxiety

34. The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include?

a. Encourage a high-calorie, high-protein diet.
b. Restrict fluids to 1,500 ml per day.
c. Limit salt intake to 2 g per day.
d. Encourage foods high in vitamin B.

35. To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should:

a. have the client lie down while taking his blood pressure.
b. inflate the cuff to at least 200 mm Hg.
c. take blood pressure readings in both arms.
d. inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.

---> Nursing Fundamentals Test (36-40)

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