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61問 • 1年前

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The nurse caring for a severely dehydrated patient who has a Foley catheter in place assesses the patient to confirm adequate urine perfusion by the urine output of: The nurse caring for a severely dehydrated patient who has a Foley catheter in place assesses the patient to confirm adequate urine perfusion by the urine output of:

30 mL.

To help reduce a patient‘s risk of recurrent cystitis, the nurse teaches the patient to:

wear cotton underwear and avoid nylon or constrictive clothing.

The nurse is aware that in the older adult, a urinary infection may cause the patient to:

become disoriented and confused.

To prevent changes in the chemical characteristics of urine, a nurse sends a sample of fresh urine to the laboratory for urinalysis within at least:

5 to 10 minutes.

A patient has been ordered to have a 24-hour urine collection as part of a diagnostic workup. The action taken to perform this procedure correctly is to:

have the patient void at the beginning of the collection and throw it away.

A nurse would modify the urine collection technique when a urine sample is needed from an infant by:

attaching a bag with adhesive backing to the skin surrounding the genitals.

The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing intervention in the care of such a patient would be to:

place a sieve over the commode.

When the patient who has an order to be out of bed complains of feeling too weak to walk to the bathroom, the nurse assists the patient with urination elimination by:

placing a commode at the bedside.

A nurse is observing a nursing assistant offering a bedpan to a patient. The nurse will intervene if the nursing assistant:

keeps the head of the bed flat after placing the bedpan.

The nurse can assist a patient who needs to void but cannot begin the urinary stream by:

running water in a nearby sink.

An adult male patient who cannot void has an order to have a urinary catheter inserted. Which size catheter would be most appropriate to use?

18 French

An older adult male patient needs to have a condom catheter applied. An appropriate technique is to:

leave 1 to 2 inches between the tip of the penis and the drainage part of the catheter.

A patient who underwent prostate surgery is admitted to the surgical unit with a catheter that is used to provide continuous irrigation. The nurse recognizes this catheter is a(n):

Alcock.

A nurse is cleansing the perineal area of a female patient who is having a urinary catheter inserted. The nurse should use the last povidone iodine–soaked cotton ball to cleanse downward over the:

urinary meatus.

When attempting to catheterize a male patient, there is resistance to catheter insertion. The nurse‘s initial intervention should be to:

ask the patient to take a deep breath.

A patient has just had a urinary drainage catheter removed. The nurse plans to measure intake and output for this patient for another:

12 to 24 hours.

A male patient who suffered a spinal cord injury is learning to perform self-urinary catheterization before being discharged to home. The statement made by the patient that indicates more instruction is needed is:

―It is a sterile procedure.

An adult patient has an order to have his urinary catheter irrigated with normal saline. The nurse plans to draw up how much solution into the sterile irrigation syringe?

30 to 40 mL

A nurse irrigating a patient‘s indwelling urinary catheter should instill normal saline as ordered, and then:

unclamp the tubing and lower the collection bag.

A nurse is reinforcing instructions about Kegel exercises with a female patient. An appropriate instruction is to:

tighten the pelvic muscles.

A nurse is documenting the removal of a urinary drainage catheter from an assigned patient. If the catheter is removed at 9:00 AM, the nurse recognizes that the patient is due to void by:

5:00 PM.

A patient with a history of cystitis had surgery 24 hours ago and is now unable to void. A bladder scan indicates that he has approximately 400 mL of retained urine. The nurse anticipates that the least invasive intervention the primary care provider will order would be:

applying Credé maneuver to the bladder.

A nurse is caring for a patient with prostate enlargement who has an indwelling catheter. As the nurse is attaching a portion of the catheter to the patient‘s abdomen, the patient asks why this is being done. The correct response is:

―Taping the catheter to your abdomen will prevent pulling on the meatus.

A nurse instructing a female patient on obtaining a clean catch urine specimen should stress:

to catch the middle portion of urine after voiding a small amount into the toilet.

A patient is being assessed for a possible urinary tract infection in the outpatient clinic. Before sending a urinalysis specimen to the laboratory, the nurse collects a small amount of urine in order to perform a dipstick test in order to detect:

leukocytes

Nurses in a long-term care facility are developing a prevention program to eliminate catheter acquired infections (CAUTI). The rationale for this program includes which of the following?

Medicaid will no longer reimburse for this complication.

A nurse instructing a patient about how to prevent recurrent cystitis would include the need to: (Select all that apply.)

increasing fluid intake to 2500 to 3000 mL/day., wearing cotton underwear., wiping the rectal area from front to back after a bowel movement., avoiding sitting in a wet bathing suit for extended periods., emptying the bladder every 2 to 3 hours.

A patient‘s urinalysis results are available. Which of the following are considered normal characteristics? (Select all that apply.)

Straw colored, Specific gravity (SpG), 1.015, pH, 6.0

The nurse should provide enough hydration for the patient so that the patient can void at least every hours.

The nurse has assessed that a patient‘s stool has changed from brown to dark black and sticky. The nurse suspects:

presence of occult blood.

The nurse has documented that a patient has had two episodes of steatorrhea, which means that the character of the stool is:

frothy and foul smelling.

The nurse should plan interventions to combat constipation in a patient:

who just completed barium studies of the bowel.

An older adult patient who routinely takes the bulk forming laxative psyllium (Metamucil) is counseled by the home health nurse that in order to prevent constipation and possible fecal impaction, this patient should be sure to take:

the medication with a large amount of fluid.

A patient calls the nurse at the health clinic and reports that since his trip to Mexico, he has been experiencing diarrhea. The nurse suggests he try the antidiarrheal drug:

loperamide (Imodium).

An older adult resident in a long-term care facility has experienced constant diarrhea for 3 days and is now exhibiting signs and symptoms of dehydration. The nurse initiates an intervention to offer small amounts of _______frequently.

Gatorade

A patient who has started antibiotic therapy is having diarrhea as a side effect of the medication. The nurse should encourage the patient to eat:

yogurt

The nurse caring for a patient with lactose intolerance would anticipate the need to offer interventions for:

diarrhea

A nurse has performed abdominal assessments on four patients. After reviewing the findings, the nurse is least concerned about problems with bowel elimination for the patient with:

abdomen nondistended, soft, with active bowel sounds in all four quadrants.

A nurse is monitoring bowel elimination of a patient who has a history of constipation. The nurse implements measures to assist with bowel elimination if the patient has not had a bowel movement within how many days?

A patient has just completed a series of upper gastrointestinal tract radiographs that involved the use of barium as a contrast agent. Which measure will this patient need to help excrete the barium?

Laxatives and fluid intake increased to 3.5 L

An ambulatory clinic patient telephones to report diarrhea and to ask for advice on medication to manage it. The best response by the nurse is, ―Do not use antidiarrheal medication for longer than:

48 hours without calling back for an appointment.

There is an order to administer a cleansing enema to an adult patient before bowel surgery. The nurse will fill the enema bag with how many milliliters of fluid for this procedure?

500 to 1000 mL

A patient who is badly constipated has just received an oil retention enema. The nurse encourages this patient to try to hold the enema for at least how long before trying to have a bowel movement?

20 minutes

A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should:

warm the solution to 105° F.

A patient scheduled for bowel surgery has an order to receive enemas until clear. The nurse is aware that no more than three enemas should be given because:

repeated enemas may cause electrolyte imbalance.

A nurse is digitally removing a fecal impaction from a patient. The nurse should stop the procedure immediately and take corrective action if the patient‘s:

pulse rate decreases from 78 to 52 beats/min.

A nurse is reinforcing education with a patient who will begin a bowel training program. An intervention this program does not include is:

use of an enema.

A nurse is assisting a patient with a new continent ileostomy to catheterize the internal reservoir to drain the ileostomy. When the catheter meets resistance from the internal valve, the nurse should:

have the patient take a deep breath and apply gentle pressure over the area.

A patient with a new colostomy should have the hole in the faceplate cut to allow _____ inch around the stoma.

1/4

A nurse is caring for a patient who had bowel surgery 3 days ago and is now beginning to have a well-functioning ostomy. The ostomy drainage bag should be emptied whenever it is:

one half full.

A patient with a colostomy asks about foods that can be eaten that will reduce odor in the ostomy drainage bag. The most informative response by the nurse is to say that ostomy odor can be decreased with the intake of:

buttermilk.

The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, ―I am so scared.‖ The nurse‘s most supportive response would be:

―What about your colostomy scares you?

The nurse reminds the patient that digestion of food is a complex process with much of the food breaking down in intestines. The small intestine functions to:

absorb food substances from the bloodstream.

The nurse caring for a patient who had a colostomy 2 days ago assesses slight bleeding around the stoma when the area is cleansed, colostomy bag filled with gas, pale stoma, and a reddened area under the adhesive of the appliance. The assessment that should be reported immediately is the assessment pertaining to the:

pale stoma.

The patient asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that:

a colostomy is an opening into the colon, whereas an ileostomy is an opening at the ileum.

The patient with the new colostomy is concerned about how to control diarrhea of the effluent. The nurse suggests that diarrhea can be controlled by the intake of:

cheese.

The nurse instructs the patient who has had an ileostomy to modify the diet to include: (Select all that apply.)

increase the protein intake., choose foods that are high in calories.

The nurse points out that age-related changes in the intestinal tract are relatively insignificant. The changes include: (Select all that apply.)

atrophy of the villi in the small intestine., decreased absorption of fats and vitamin B12., creation of excessive flatus.

The nurse instructs a patient with a new colostomy against eating food that may cause an obstruction. These foods include: (Select all that apply.)

whole kernel corn., tomatoes., shrimp.

The gastrocolic reflex initiates ______.

peristalsis

The nurse assesses a pale, light gray stool and recognizes that the cause of this abnormal color is due to an obstruction in the ______ duct.

bile