Exam 1 Holistic Health Illness Concepts

The nurse prepares a patient for discharge after a cystoscopy. It is most important for the nurse to provide additional information in response to which patient statement?

"Bright red bleeding is normal for a few days after the procedure." Bright red bleeding after a cystoscopy is not normal and should be reported immediately. Other complications include urinary retention, bladder infection, and perforation of the bladder. Patients should drink plenty of fluids and expect burning on urination, pink-tinged urine, and urinary frequency. Warm sitz baths, heat, and mild analgesics may be used to relieve discomfort.

A 5-year-old kindergartner asks to go to the bathroom almost every hour. What is the most important question to ask when the school nurse calls the mother to inquire about this problem?

"Has your child been going to the bathroom often at home?"

The nurse is preparing to administer a dose of bisacodyl to a patient with constipation and the patient asks how it will work. What is the best response by the nurse?

"It will increase peristalsis by stimulating nerves in the colon wall." Bisacodyl is a stimulant laxative that aids in producing a bowel movement by irritating the colon wall and stimulating enteric nerves. Fiber and bulk- forming drugs increase bulk in the stool. Water and stool softeners soften feces, and saline and osmotic solutions cause fluid retention in the intestinal tract.

The nurse is caring for a 62-yr-old woman taking tolterodine (Detrol) to treat urinary urgency and incontinence. Which instruction should be included in the discharge plan?

"Suck on sugarless candy or chew sugarless gum if you develop a dry mouth." Dry mouth is a common side effect of tolterodine. Patients can suck on hard candy or ice chips or chew gum if dry mouth occurs. Tobacco use does not affect the initiation of this medication. Visual changes (but not cataracts) can occur while taking this medication. Constipation may occur as a side effect of this medication.

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing?

0.9% sodium chloride

A patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the change. The available syrup contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer._______________ mL

10 The concentration of the syrup is 10 mg/mL (150 mg÷15 mL=10 mg/mL). Therefore, a 100-mg dose necessitates 10 mL (100 mg÷10 mg/mL=10 mL).

The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time?

12:00 noon

When planning the care of a patient with dehydration, what urine output would the nurse instruct the unlicensed assistive personnel to report?

20 mL for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours?

3.1 mEq/L The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.

The healthcare provider prescribes 1 liter of intravenous (IV) fluid to infuse over 4 hours for a client admitted for a urinary tract infection and hyponatremia. The tubing drop factor is 10 drops/mL. At what rate will the nurse infuse the medications?

42 drops/minute

The nurse is teaching resident at the retirement village about prevention of UTIs. One person asks how much fluid she should drink each day. The nurse determines that she weighs 140 lb. Calculate how many ounces of fluid this person should drink each day.

56 Divide the weight in pounds by 2; then multiply this number by 80% because 20% of a person's fluid is obtained from food. So 140/2 = 70, 70 × 0.80 = 56 oz to be drunk each day, or seven 8-oz gl

A patient with suspected bowel obstruction had a nasogastric tube inserted at 4:00 AM. The nurse shares in the morning report that the day shift staff should check the tube for patency at what times?

8:00 AM, 12:00 PM, and 4:00 PM A nasogastric tube should be checked for patency routinely at 4-hour intervals. Thus if the tube were inserted at 4:00 AM, it would be due to be checked at 8:00 AM, 12:00 PM, and 4:00 PM.

Which nursing diagnosis is priority when caring for a patient with renal calculi?

Acute pain Urinary stones are associated with severe abdominal or flank pain. Whereas deficient fluid volume is unlikely to result from urinary stones, constipation is more likely to be an indirect consequence rather than a primary clinical manifestation of the problem. The presence of pain supersedes powerlessness as an immediate focus of nursing care.

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F (39° C). The temperature was 99.2° F (37.3° C) when it was taken 6 hours ago. What is a priority nursing intervention in this case?

Administer the prescribed antipyretic and notify the primary health care provider.

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient?

Administration of oral or IV corticosteroids

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas?

Ammonia level

A patient has been diagnosed with acute myelogenous leukemia (AML). What should the nurse educate the patient that care will focus on?

Attaining remission

An older male patient visits his primary care provider because of burning on urination and production of foul-smelling urine. What contributing factor should the health care provider consider?

Benign prostatic hyperplasia (BPH) BPH causes urinary stasis, which is a predisposing factor for UTIs. A sedentary lifestyle and recent antibiotic use are unlikely to contribute to UTIs, but a diet high in purines is associated with renal calculi.

A nurse explains to a client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing. Why is blood glucose monitoring preferred?

Blood glucose monitoring is more accurate.

After identifying that a patient has possible nutritional deficits, which action will the nurse perform next?

Complete a full nutritional assessment. A full nutritional assessment includes history and physical examination and laboratory data. The nutritional assessment will need to be done to provide the basis for nutrition intervention. The interventions may include supplements if ordered, family bringing food from home, and socializing with meals.

Which instruction should the nurse provide when teaching a patient to exercise the pelvic floor?

Contract muscles around rectum. To teach pelvic floor exercises (Kegel exercise), the nurse should instruct the patient (without contracting the legs, buttocks, or abdomen) to contract the muscles around the rectum (pelvic floor muscles) as if stopping a stool, which should result in a pelvic lifting sensation.

When teaching the patient about the diet for diverticular disease, which foods should the nurse recommend?

Dried beans, All Bran (100%) cereal, and raspberries A high-fiber diet is recommended for diverticular disease. Dried beans, All Bran (100%) cereal, and raspberries all have higher amounts of fiber than white bread, cheese, green beans, fresh tomatoes, pears, corn flakes, oranges, baked potatoes, and raw carrots.

Which action is most important for the nurse to take when caring for a patient with a subclavian triple-lumen catheter?

During removal of the catheter, have the patient perform the Valsalva maneuver. The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find?

Elevated D-dimers

A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for?

Elevated U and flattened T waves

A client has surgery for an abdominal cholecystectomy and returns from surgery with a nasogastric tube to low continuous suction, a T-tube, and an indwelling catheter. Which intervention should the nurse perform first?

Ensure that all tubes are attached to collection devices All tubes should be attached to appropriate collection devices to permit drainage. A T-tube should not be fastened to the bedsheets; a T-tube is positioned surgically in the common bile duct, and tension on the tube must be avoided to prevent accidental removal. A T-tube drains by gravity and is not irrigated. Measuring the drainage in the collection devices is not the priority at this time; this will be done later at the change of shift or when the collection devices are full.

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing?

Fatigue

A patient is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority?

Firmly distended abdomen Clinical manifestations of abdominal trauma are guarding and splinting of the abdominal wall; a hard, distended abdomen (indicating possible intraabdominal bleeding); decreased or absent bowel sounds; contusions, abrasions, or bruising over the abdomen; abdominal pain; pain over the scapula; hematemesis or hematuria; and signs of hypovolemic shock (tachycardia and decreased blood pressure).

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?

Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

A patient was admitted 2 weeks ago after multiple traumatic injuries in a motor vehicle collision. The patient now has a serum creatinine at 3.9 mg/dL and blood urea nitrogen (BUN) of 100 mg/dL. Which medication, if ordered by the health care provider, should the nurse question?

Gentamicin Elevated serum creatinine and BUN indicate renal insufficiency or acute kidney injury. Medications (e.g., prescribed, over-the-counter, and herbs) should be evaluated for nephrotoxic potential. Many drugs are known to be nephrotoxic (see Table 44-3); gentamicin is a potential nephrotoxic agent.

A patient is being admitted with anorexia nervosa. Which clinical manifestations should the nurse anticipate?

Hair loss; dry, yellowish skin; and constipation The patient with anorexia nervosa, along with abnormal weight loss, is likely to have hair loss; dry, yellow skin; constipation; sensitivity to cold, and absent or irregular menstruation. Other signs of malnutrition may also be noted during physical examination.

A client is receiving furosemide to relieve edema. The nurse should monitor the client for which response to the medication?

Hypokalemia

Two days after a colectomy for an abdominal mass, a patient reports gas pains and abdominal distention. The nurse plans care for the patient based on the knowledge that the symptoms are occurring as a result what event?

Impaired peristalsis Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastrointestinal motility, leading to gas pains and abdominal distention. Irritation of the bowel, nasogastric suctioning, and inflammation of the surgical site do not cause gas pains or abdominal distention.

What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea?

Improvement of fluid balance

A nurse teaches a client about the dangers of using sodium bicarbonate regularly. What effect of sodium bicarbonate is the nurse trying to prevent?

Metabolic alkalosis

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient?

Metabolic alkalosis Because gastric secretions are rich in HCl acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.

A client admitted with a myocardial infarction is prescribed docusate and morphine and takes digoxin and fluoxetine at home. Which drug should the nurse recognize as a risk factor for straining due to constipation?

Morphine

A frail older adult with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. Which foods would the nurse suggest for breakfast?

Oatmeal with butter and cream Oatmeal, butter, and cream are all examples of breakfast items that would be appropriate to include for a patient on a high-protein, high-calorie diet.

The nurse is educating student nurses about the anatomy and physiology of the kidneys. What term does the nurse explain is used for the tip of the pyramid of a kidney?

Papilla Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid. The renal calices join together to form the renal pelvis. A renal column is a cortical tissue that separates the pyramids.

The nurse recognizes that the majority of patients' caloric needs should come from which source?

Polysaccharides Carbohydrates should constitute between 45% and 65% of caloric needs compared with 20% to 35% from fats and 10% to 35% from proteins. Polysaccharides are the complex carbohydrates that are contained in breads and grains. Monosaccharides are simple sugars.

A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider?

Potassium 3.0 mEq/L (3.0 mmol/L)

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant?

Prevent patient infection.

In addition to urine function, the nurse recognizes that the kidneys perform numerous other functions important to the maintenance of homeostasis. Which physiologic processes are performed by the kidneys (select all that apply.)?

Production of renin Activation of vitamin D Erythropoietin production In addition to urine formation, the kidneys release renin to maintain blood pressure, activate vitamin D to maintain calcium levels, and produce erythropoietin to stimulate RBC production. Carbohydrate metabolism and hemolysis of old RBCs are not physiologic functions that are performed by the kidneys.

A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth?

Putting the naked newborn on the mother's skin and covering the infant with a blanket

Which diagnostic tests are used to measure the kidney size of a client with kidney dysfunction? Select all that apply.

Radiography Computed tomography (CT)

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in the left knee joint. What should be the emergency nurse's immediate action?

Resting the patient's knee to prevent hemarthroses

When assessing a patient admitted with nausea and vomiting, which finding best supports the nursing diagnosis of deficient fluid volume?

Restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.

A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first?

Start the time of the test after discarding the first voiding.

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide that would be beneficial to the patient?

Take the iron with orange juice one hour before meals.

A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion?

The client's fever spikes and falls without a return to normal temperature levels

A client presenting to the emergency department with chest pain and dizziness is found to be having a myocardial infarction and subsequently suffers cardiac arrest. The healthcare team is able to successfully resuscitate the client. Lab work shows that the client now is acidotic. How does the nurse interpret the cause of the acidosis?

The decreased tissue perfusion caused lactic acid production.

A registered nurse teaches a nursing student about the physiologic changes that occur during pregnancy and their impact on drug disposition and dosing. Which statement of the nursing student indicates the need for further education?

The hepatic metabolism of a drug is decreased. The hepatic metabolism of the drugs is increased in pregnancy, which increases the drug response. Elimination of the drugs is increased because the renal blood flow doubles in the third trimester. The intestinal transit time of drugs increases because the motility of the bowel decreases in pregnancy. This action also leads to an increase in the drug's gastrointestinal absorption.

When a patient reports acute, severe, renal colic pain in the lower abdomen, the nurse suspects that the patient is most likely to have an obstruction at which area?

Ureterovesical junction The ureterovesical junction is the narrowest part of the urethra and easily obstructed by urinary calculi. With a stone in the kidney or at the ureteropelvic junction, the pain may be dull costovertebral flank pain. Stones in the bladder do not cause obstruction or symptoms unless they are staghorn stones. The urethra seldom has obstruction related to stones.

The nurse is caring for a patient with a nephrostomy tube. The tube has stopped draining. After receiving orders, what should the nurse do?

Use 5 mL of sterile saline to irrigate. With a nephrostomy tube, if the tube is occluded and irrigation is ordered, the nurse should use 5 mL or less of sterile saline to gently irrigate it. The patient with a ureteral catheter may be kept on bed rest after insertion, but this is unrelated to obstruction. Only sterile solutions are used to irrigate any type of urinary catheter. With a suprapubic catheter, the patient should be instructed to turn from side to side to ensure patency.

A school-aged child with newly diagnosed acute lymphocytic leukemia (ALL) is to undergo induction therapy with prednisone, vincristine, and asparaginase. After several days the child becomes constipated. What does the nurse suspect as the cause?

Vincristine, which decreases peristalsis

The nurse obtained a urine specimen from a patient. What result should the nurse recognize as an abnormal finding?

White blood cells (WBCs) 9/hpf Normal WBC levels in urine are below 5/hpf, with levels exceeding this indicative of inflammation or urinary tract infection. A urine pH of 6.0 is average; amber yellow is normal coloration, and the reference range for specific gravity is 1.003 to 1.030.

A patient informs the nurse that they are having burning on urination, dysuria, and frequency. What is the best response by the nurse?

"Come in so we can check a clean-catch urine specimen." The patient's symptoms are typical of a urinary tract infection. To verify this, a clean-catch urine specimen must be obtained for a specimen of urine to culture. Drinking less fluid will not improve the symptoms. Acetaminophen would not decrease the discomfort; an antibiotic would be needed. Avoiding caffeine and spicy food may decrease bladder inflammation but will not affect these symptoms.

When evaluating the patient's understanding about the care of the ileostomy, which statement by the patient indicates the patient needs more teaching?

"I will be able to regulate when I have stools." An ileostomy is in the ileum and drains liquid stool frequently, unlike a colostomy, which has more formed stool the farther distal the ostomy is in the colon. The ileostomy pouch is usually worn for 4 to 7 days or until it leaks. It must be changed immediately if it leaks because the drainage is very irritating to the skin. To avoid obstruction, popcorn, dried fruit, coconut, mushrooms, olives, stringy vegetables, food with skin, and meats with casings must be chewed extremely well before swallowing because of the narrow diameter of the ileostomy lumen.

A 21-yr-old female patient came to the clinic for instruction to prevent recurrence of urinary tract infections. Which patient statement indicates that teaching was effective?

"I will urinate before and after having intercourse." The woman should empty her bladder before and after sexual intercourse. She should avoid vaginal douches and maintain adequate oral fluid intake (15 mL per pound of body weight). All of the antibiotics should be taken as prescribed even if symptoms are no longer present.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?

"It is performed routinely starting at your age as part of an assessment for colon cancer."

An older client with diarrhea is admitted to the hospital from a nursing home. A stool specimen confirms a diagnosis of a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse making room assignments asks if it is possible to place the new client with another client that also has MRSA in the same isolation room. How should the nurse respond?

"It is safe to place people with the same infection in one room."

The nurse is preparing to administer famotidine to a postoperative patient with a colostomy. The patient states they do not have heartburn. What response by the nurse would be the most appropriate?

"It will reduce the amount of acid in the stomach." Famotidine is an H2-receptor antagonist that inhibits gastric HCl secretion and thus minimizes damage to gastric mucosa while the patient is not eating a regular diet after surgery. Famotidine does not prevent air from accumulating in the stomach or stop the stomach from bleeding. Heartburn is not a side effect of general anesthesia.

In order to ensure a quality specimen and an accurate test result, which instruction should the nurse give a client who is scheduled to undergo urine endocrine testing?

"Store the urine specimen in a cooler with ice."

The nurse is preparing to insert a nasogastric (NG) tube into a patient with a suspected small intestinal obstruction that is vomiting. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate?

"The tube will help to drain the stomach contents and prevent further vomiting." The NG tube is used to decompress the stomach by draining stomach contents and thereby prevent further vomiting. The NG tube will not push past the blocked area. Potential surgery is not currently indicated. The location of the obstruction will determine the type of fluid to use, not measure the amount of stomach contents.

The nurse instructs an African American man who has sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement?

"When my vision is blurred, I will close my eyes and rest for an hour."

A patient with a history of recurrent urinary tract infections has been scheduled for a cystoscopy. What teaching point should the nurse emphasize before the procedure?

"You might have pink-tinged urine and burning after your cystoscopy." Pink-tinged urine, burning, and frequency are common after a cystoscopy. The patient does not need to be NPO before the test, and contrast media is not needed. A cystoscopy does not always necessitate catheterization before or after the procedure.

Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion?

15

A patient is given a bisacodyl suppository and asks the nurse how long it will take to work. What is the best response by the nurse?

15 to 60 minutes Bisacodyl suppositories usually are effective within 15 to 60 minutes of administration, so the nurse should plan accordingly to assist the patient to use the bedpan or commode.

When planning care for stable adult patients, the oral intake that is adequate to meet daily fluid needs is

2000 to 3000 mL. Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.

A patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. Which IV solution may be used to pull fluid into the intravascular space after the paracentesis?

25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's solution, and 5% dextrose in 0.45% saline will not be effective for this action.

Which degree of edema will result in a 6-mm deep indentation upon pressure application?

3+ The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

You are caring for a patient receiving D5W at a rate of 125 mL/hr. During the 4:00 PM assessment of the patient, you determine that 500 mL is left in the present IV bag. At what time should the nurse anticipate hanging the next bag of D5W?

8:00 PM Divide the 500 mL left in the IV bag by the hourly rate of 125 mL to calculate that the present solution will remain infusing for another 4 hours. If you made this notation at 4:00 PM, the bag is due to be changed at 8:00 PM.

Which patient is most likely to experience anemia related to an increased destruction of red blood cells?

A 23-yr-old African American man who has a diagnosis of sickle cell disease

The nurse identifies that which patient is at highest risk for developing colon cancer?

A 32-yr-old woman with a 12-year history of ulcerative colitis Risk for colon cancer includes personal history of inflammatory bowel disease (especially ulcerative colitis for longer than 10 years); obesity (body mass index ?5= 30 kg/m2); family (first-degree relative) or personal history of colorectal cancer, adenomatous polyposis, or hereditary nonpolyposis colorectal cancer syndrome; eating red meat (?5=7 servings/week); cigarette use; and drinking alcohol (?5=4 drinks/week).

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse check on first?

A 40-yr-old patient with a temperature of 100.8oF (38.2oC) and a neutrophil count of 256/µL

The nurse on a medical-surgical unit identifies which patient as having the highest risk for metabolic alkalosis?

A patient with nasogastric tube suction Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.

A patient is planned for discharge home today after ostomy surgery for colon cancer. The nurse should assign the patient to which staff member?

A registered nurse with 6 months of experience on the surgical unit The patient needs ostomy care directions and reinforcement at discharge and should be assigned to a registered nurse with experience in providing discharge teaching for ostomy care. Teaching should not be delegated to a licensed practical/vocational nurse or unlicensed assistive personnel.

The nurse is preparing a patient for an intravenous pyelogram (IVP). What is a priority action by the nurse?

Administer a cathartic or enema. Nursing responsibilities in caring for a patient undergoing an IVP include administration of a cathartic or enema to empty the colon of feces and gas. The nurse will also assess the patient for iodine sensitivity; keep the patient NPO for 8 hours before the procedure; and advise the patient that warmth, a flushed face, and a salty taste during injection of contrast material may occur.

The stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply.)?

Administer bolus or continuous feedings. Administer medications through the gastrostomy tube. For the stable patient, the LPN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutritional status of the patient, monitor for complications related to the tube and the enteral feeding, and teach the caregiver about feeding via the gastrostomy tube at home.

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action?

Administer oxygen The cap off the central line could allow entry of air into the circulation, causing an air embolus. To manage an air embolus, oxygen is administered; the catheter is clamped, and the patient is positioned on the left side with the head down. Then the health care provider is notified.

A client with cancer of the colon is admitted to the hospital for a hemicolectomy. What does the nurse expect the preoperative plan of care to include?

Administering cleansing enemas and then neomycin

A colectomy is scheduled for a patient with ulcerative colitis. The nurse should plan to include which prescribed measure in the preoperative preparation of this patient?

Administration of a cleansing enema Preoperative preparation for bowel surgery typically includes bowel cleansing with antibiotics, such as oral neomycin and cleansing enemas, including Fleet enemas. Instructions to irrigate the colostomy will be done postoperatively. Oral antibiotics are given preoperatively and an IV antibiotic may be used in the operating room. A clear liquid diet will be used the day before surgery with the bowel cleansing.

The nurse is reviewing the laboratory test results for a patient with metastatic lung cancer who was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. How will the nurse interpret these results?

Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status. Prealbumin has a half-life of 2 days and is a better indicator of recent or current nutritional status. Serum albumin has a half-life of approximately 20 to 22 days. The serum level may lag behind actual protein changes by more than 2 weeks and is therefore not the best indicator of acute changes in nutritional status.

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration?

Another registered nurse

A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce?

Antacids commonly interfere with the absorption of other drugs.

Which hormonal deficiency causes diabetes insipidus in a client?

Antidiuretic hormone (ADH)

The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate?

Assist with or perform phlebotomy at the bedside. Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.

A patient underwent a surgical procedure has a urinary catheter. Eight hours after catheter removal and drinking fluids, the patient has not been able to void. What is the nurse's first action to assess for urinary retention?

Bladder scan If the patient is unable to void, the bladder may be palpated for distention or percussed for dullness if it is full, or a bladder scan may be done to determine the approximate amount of urine in the bladder. A cystometrogram visualizes the bladder and evaluates vesicoureteral reflux. A KUB x-ray delineates size, shape, and positions of kidneys and possibly a full bladder. Neither of these would be useful in this situation. A residual urine test requires urination before catheterizing the patient to determine the amount of urine left in the bladder, so this assessment would not be helpful for this patient.

Which clinical manifestations of inflammatory bowel disease does the nurse determine are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply.)?

Bloody, diarrhea stools Cramping abdominal pain Clinical manifestations of UC and Crohn's disease include bloody diarrhea, cramping abdominal pain, and nutritional disorders. Intestinal lesions associated with UC are usually restricted to the rectum before moving into the colon. Lesions that penetrate the intestine or cause strictures are characteristic of Crohn's disease.

A client had a colon resection and formation of a colostomy two days ago. Which color indicates to the nurse the stoma is viable?

Brick red

A patient is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient?

Cardiac dysrhythmias A serum potassium level less than 2.5 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac dysrhythmias (e.g., bradycardia, tachycardia, ventricular dysrhythmias). Other manifestations of potassium deficiency include muscle weakness and renal failure. Patients with anorexia nervosa commonly have iron-deficiency anemia and an elevated blood urea nitrogen level related to intravascular volume depletion and abnormal renal function.

A patient who has sustained severe burns in a motor vehicle accident is starting parenteral nutrition (PN). Which principle should guide the nurse's administration of PN?

Central PN requires rapid dilution in a large volume of blood. Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central line is preferred over the use of peripheral PN, and the nurse may not add any medications to PN.

The nurse is preparing to administer a scheduled dose of docusate sodium when the patient reports an episode of loose stool and does not want to take the medication. What is the appropriate action by the nurse?

Chart the dose as not given on the medical record and explain in the nursing progress notes. Whenever a patient refuses medication, the dose should be charted as not given with an explanation of the reason documented in the nursing progress notes. In this instance, the refusal indicates good judgment by the patient, and the patient should not be encouraged to take it today.

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea has a platelet count of 43,000/µL. It is most important for the nurse to take which action?

Check stools for presence of frank or occult blood.

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to avoid an error during this procedure?

Check the identifying information on the unit of blood against the patient's ID bracelet.

The nurse is teaching a patient with type 1 diabetes mellitus who had surgery to revise a lower leg stump with a skin graft about nutrition. What food should the nurse teach the patient to eat to best facilitate healing?

Chicken breast High-quality protein such as chicken breast is important for tissue repair. Nonfat milk, nuts, and fortified oatmeal have some protein but not as much as chicken breast.

A patient has scleroderma and hypertension. The nurse knows this could be related to which renal diagnoses?

Chronic glomerulonephritis Hypertension occurs with chronic glomerulonephritis, which may be found in patients with scleroderma. Obstructive uropathy, Goodpasture syndrome, and calcium oxalate urinary calculi are not related to scleroderma and do not cause hypertension.

A patient with type 2 diabetes is reporting a second urinary tract infections(UTI)within the past month. Which medication should the nurse expect to be ordered for the recurrent infection?

Ciprofloxacin This UTI is a complicated UTI because the patient has type 2 diabetes, and the UTI is recurrent. Ciprofloxacin would be used for a complicated UTI. Fosfomycin, nitrofurantoin , and trimethoprim-sulfamethoxazole should be used for uncomplicated UTIs.

A 22-yr-old man is admitted to the emergency department with a stab wound to the abdomen. The patient's vital signs are blood pressure 82/56 mm Hg, pulse 132 beats/min, respirations 28 breaths/min, and temperature 97.9° F (36.6° C). Which fluid, if ordered by the health care provider, should the nurse question?

D5W IV administration of 0.45% saline is hypotonic and is used for maintenance fluid replacement and dilutes the extracellular fluid. IV solutions used for volume expansion for hypovolemic shock include lactated Ringer's solution and 0.9% saline. If hypovolemia is due to blood loss, blood may be administered.

The nurse is providing care for a patient admitted to the hospital for treatment of nephrotic syndrome. What are the priority nursing assessments?

Daily weights and measurement of the patient's abdominal girth Peripheral edema is characteristic of nephrotic syndrome, and a key nursing responsibility in the care of patients with the disease is close monitoring of abdominal girth, weights, and extremity size. Pain, level of consciousness, and orthostatic blood pressure are less important in the care of patients with nephrotic syndrome. Abnormal calcium and phosphorus levels are not commonly associated with the diagnosis of nephrotic syndrome.

The nurse is caring for an older adult patient taking bumetanide. What age-related changes does the nurse inform the patient that may be experienced?

Decreased function of the loop of Henle Bumetanide (Bumex) is a loop diuretic that acts in the loop of Henle to decrease reabsorption of sodium and chloride. Because the loop of Henle loses function with aging, the excretion of drugs becomes less and less efficient. Thus, the circulating levels of drugs are increased and their effects prolonged. The benign enlargement of prostatic tissue, decreased sensation of bladder capacity, and loss of concentrating ability do not directly affect the action of loop diuretics.

The nurse requests a patient scheduled for colectomy to sign the operative permit as directed in the physician's preoperative orders. The patient states that the physician has not really explained very well what is involved in the surgical procedure. What is the most appropriate action by the nurse?

Delay the patient's signature on the consent and notify the physician about the conversation with the patient. The patient should not be asked to sign a consent form unless the procedure has been explained to the satisfaction of the patient. The nurse should notify the physician, who has the responsibility for obtaining consent.

The nurse is admitting a patient with severe dehydration and frequent watery diarrhea. A 10-day outpatient course of antibiotic therapy for bacterial pneumonia has just been completed. What is the most important for the nurse to take which action?

Don gloves and gown before entering the patient's room. Clostridium difficile is an antibiotic-associated diarrhea transmitted by contact, and the spores are extremely difficult to kill. Patients with suspected or confirmed infection with C. difficile should be placed in a private room, and gloves and gowns should be worn by visitors and health care providers. Alcohol-based hand cleaners and ammonia-based disinfectants are ineffective and do not kill all of the spores. Equipment cannot be shared with other patients, and a disposable stethoscope and individual patient thermometer are kept in the room. Objects should be disinfected with a 10% solution of household bleach.

A patient has sought care because of recent difficulties in establishing and maintaining a urine stream as well as pain that occasionally accompanies urination. How should the nurse document this abnormal assessment finding?

Dysuria Painful and difficult urination is characterized as dysuria. Whereas anuria is an absence of urine production, oliguria is diminished urine production. Enuresis is involuntary nocturnal urination.

A malnourished patient has been diagnosed with protein deficiency. Which complications should the nurse anticipate (select all that apply.)?

Edema Anemia Impaired wound healing Protein deficiency can cause complications such as edema, anemia, and impaired wound healing. Decreased albumin in the vascular space allows fluids to leak into the interstitial spaces causing edema. Without adequate protein, blood formation is impaired. Adequate protein is required for wound healing. Asthma does not develop due to protein deficiency. However, protein deficiency causes muscle weakness that could contribute to exacerbation of many conditions. A malabsorption syndrome may affect the amount of nutrients that are absorbed causing protein deficiency. Gastrointestinal bleeding is not a complication of protein deficiency.

Which focused assessments would have priority in the care of a patient recently started on parenteral nutrition (PN)?

Electrolyte levels and daily weights The use of PN necessitates frequent and thorough assessments. Key assessments include daily weights and close monitoring of electrolyte levels. Assessments of bowel sounds, integument, peripheral edema, level of consciousness, and lung sounds, may be variously performed, but close monitoring of fluid and electrolyte balance supersedes these in importance related to the PN.

A patient in the intensive care unit is receiving gentamicin for treatment of pneumonia from Pseudomonas aeruginosa. What assessment results should the nurse report to the health care provider?

Elevated creatinine level Gentamicin can be toxic to the kidneys and the auditory system. The elevated creatinine level must be reported to the physician because it probably indicates renal damage. Other factors that may occur with renal damage would include increased weight and decreased urinary output. Many medications have side effects of anorexia.

A patient with suspected renal insufficiency is scheduled for a creatinine clearance diagnostic test. Which instructions would be appropriate for the nurse to provide to the patient?

Empty your bladder and discard the urine; then save all urine for 24 hours." The patient should discard the first urination when this test is started. Urine should be saved from all subsequent urinations for 24 hours. Creatinine clearance testing does not involve the injection of contrast dye. A serum creatinine is determined during the 24-hour period and used in the calculation to determine creatinine clearance. Consumption of a high-protein meal is not indicated. Sterile containers would be indicated if cultures are performed to determine the presence of microorganisms.

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention?

Encourage deep breathing.

A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient?

Encourage foods high in protein, iron, vitamin C, and folate.

After an exploratory laparotomy, a patient on a clear liquid diet reports severe gas pains and abdominal distention. Which action by the nurse is most appropriate?

Encourage the patient to ambulate as ordered Swallowed air and reduced peristalsis after surgery can result in abdominal distention and gas pains. Early ambulation helps restore peristalsis and eliminate flatus and gas pain. Medications used to reduce gas pain include metoclopramide, which stimulates peristalsis. A heating pad can help to alleviate some of the pain and help make the patient more comfortable. There is no need for the patient to return to NPO status. Drinking ginger ale may be helpful.

A patient after a stroke who primarily uses a wheelchair for mobility has developed diarrhea with fecal incontinence. What is a priority assessment by the nurse?

Fecal impaction Patients with limited mobility are at risk for fecal impactions caused by constipation that may lead to liquid stool leaking around the hardened impacted feces, so assessing for fecal impaction is the priority. Perineal hygiene can be assessed at the same time. Assessing the dietary fiber and fluid intake and antidiarrheal agent use will be assessed and considered next.

A patient who has dysphagia after a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into the plan of care?

Flush the tube before and after feedings if the patient's feedings are intermittent. The nurse should flush feeding tubes with 30 mL of water, not normal saline, every 4 hours and before and after medication administration during continuous feeding or before and after intermittent feeding. Flushes of 100 mL are excessive and may cause fluid overload in the patient.

The patient has parenteral nutrition (PN) infusing with amino acids and dextrose. During shift change, the nurse reports the tubing, bag, and dressing were changed 20 hours ago. What care should the incoming nurse plan to deliver (select all that apply.)?

Giving the patient insulin if needed Ensuring that the next bag has been ordered Checking amount of solution left in the bag Verifying the accuracy of the new solution and ingredients The nurse should identify the amount of PN left in the bag when initiating care and request more if needed. Abrupt withdrawal of PN can cause hypoglycemia. The nurse should anticipate pharmacy preparation of a new bag may take significant time especially if additives are ordered. PN solutions are changed every 24 hours. The label on the bag should be verified with the order to ensure accuracy. The patient would receive insulin if hyperglycemic related to dextrose content parenteral nutrition or underlying diabetes mellitus. Sliding-scale coverage or addition of regular insulin to the parenteral nutrition would be provided if ordered. The insertion site should be monitored, but the tubing is only changed every 72 hours unless lipids are being used.

A nurse is admitting a patient with advanced renal carcinoma. Which clinical manifestations represent the "classic triad" observed in patients with renal cancer?

Hematuria, flank pain, and palpable mass There are no characteristic early symptoms of renal carcinoma. The classic manifestations of gross hematuria, flank pain, and a palpable mass are those of advanced disease.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?

High osmolarity of the feedings

The nurse is caring for a patient admitted with a suspected bowel obstruction. The nurse auscultating the abdomen listens for which type of bowel sounds that are consistent with the patient's clinical picture?

High-pitched and hyperactive above the area of obstruction Early in intestinal obstruction, the patient's bowel sounds are hyperactive and high pitched, sometimes referred to as "tinkling," above the level of the obstruction. This occurs because peristaltic action increases to "push past" the area of obstruction. As the obstruction becomes complete, bowel sounds decrease and finally become absent.

The nurse is developing a plan of care for a patient with an abdominal mass and suspected bowel obstruction. Which factor in the patient's history does the nurse recognize as increasing the patient's risk for colorectal cancer?

History of colorectal polyps A history of colorectal polyps places this patient at risk for colorectal cancer. This tissue can degenerate over time and become malignant. Osteoarthritis, lactose intolerance, and the use of herbs do not pose additional risk to the patient.

What information would have the highest priority for the nurse to include in preoperative teaching for a patient scheduled for a colectomy?

How to deep breathe and cough Because anesthesia, an abdominal incision, and pain can impair the patient's respiratory status in the postoperative period, it is of high priority to teach the patient to cough and deep breathe. Otherwise, the patient could develop atelectasis and pneumonia, which would delay early recovery from surgery and hospital discharge. Care for the wound and location and care of the drains will be briefly discussed preoperatively but will be done again with higher priority after surgery. Knowing which drugs will be used during surgery may not be meaningful to the patient and should be reviewed with the patient by the anesthesiologist.

A nurse is caring for a client with endocrine problems. Which lab finding will alert the nurse that aldosterone will be released?

Hyponatremia Hyponatremia stimulates the secretion of aldosterone. Hypoglycemia inhibits the secretion of insulin. Hyperkalemia, not hypokalemia, stimulates the secretion of aldosterone. Hypochloremia is associated with increased levels of antidiuretic hormone.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone?

Hyponatremia and decreased urine output

Which clinical manifestation occurs in a client with vasopressin deficiency?

Hypotension

Monitoring vital signs, particularly the blood pressure and the rate and quality of the pulse, is essential in detecting physiologic adaptations in a preschool child with nephrotic syndrome. Which clinical manifestation should the nurse be able to detect from these vital signs?

Hypovolemia

The blood bank notifies the nurse that the two units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure?

Infuse the blood slowly for the first 15 minutes of the transfusion.

The nurse receives a physician's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product?

Infuse the fresh frozen plasma as rapidly as the patient will tolerate.

A hospitalized patient has just been diagnosed with diarrhea due to Clostridium difficile. Which nursing interventions should be included in the patient's plan of care (select all that apply.)?

Initiate contact isolation precautions. Disinfect the room with 10% bleach solution. Teach any visitors to wear gloves and gowns. Initiation of contact isolation precautions must be done immediately with a patient with C. difficile, which includes washing hands with soap and water before and after patient or bodily fluid contact. Alcohol-based sanitizers are ineffective. Visitors need to be taught to wear gloves and gowns and wash hands. A clear liquid diet is not necessary. The room will be disinfected with 10% bleach solution when the patient is dismissed and may be done periodically during the patient's stay, depending on the agency policy.

The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, which strategy should be included in the client's plan of care?

Instructing the client to drink at least 3L of fluid daily

The nurse finds that a client with a urinary disorder has very pale-yellow-colored urine. What is the significance of this abnormal finding?

It indicates dilute urine. Dilute urine tends to appear very pale-yellow in color. Dark-red or brown color urine indicates the presence of blood in the urine. Dark-amber color urine indicates concentrated urine. Red color urine may indicate the presence of myoglobin.

What is the nurse's priority when changing the appliance for a patient with an ileal conduit?

Keep the skin free of urine. The nurse's priority is to keep the skin free of urine because the peristomal skin is at high risk for damage from the urine if it is alkaline. The peristomal area will be assessed; the area will be gently cleaned and dried, and the appliance will be affixed to the faceplate if one is being used, but these are not as much of a priority as keeping the skin free of urine to prevent skin damage.

Eight months after the delivery of her first child, a 31-yr-old woman sought care for occasional incontinence when sneezing or laughing. Which measure should the nurse recommend first?

Kegel exercises Patients who experience stress incontinence frequently benefit from Kegel exercises (pelvic floor muscle exercises). The use of incontinence pads does not resolve the problem, and intermittent self-catheterization would be a premature recommendation. Dietary changes are not likely to influence the patient's urinary continence.

You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention?

Listen to the patient's lung sounds and assess respiratory status. After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further orders.

You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the health care provider?

Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.

A healthcare provider prescribes furosemide for a client with hypervolemia. The nurse recalls that furosemide exerts its effects in what part of the renal system?

Loop of Henle

Which parts of the nephron are the sites of action for furosemide? Select all that apply.

Loop of Henle Distal tubule Proximal tubule

A client has severe diarrhea, and the health care provider prescribes intravenous fluids, sodium bicarbonate, and an antidiarrheal medication. Which drug does the nurse expect the health care provider to prescribe?

Loperamide Loperamide inhibits peristalsis and prolongs transit time by its effect on the nerves in the muscle wall of the intestines. Bisacodyl is a laxative, not an antidiarrheal; it increases gastrointestinal motility. Psyllium is not an antidiarrheal; it is a bulk laxative that promotes easier expulsion of feces. Docusate sodium corrects constipation, not diarrhea; water and fat are increased in the intestine, permitting easier expulsion of feces.

A dehydrated patient is receiving a hypertonic solution. Which assessments must be done to avoid adverse risks associated with these solutions (select all that apply.)?

Lung sounds Blood pressure Serum sodium level Blood pressure, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

The nurse knows that hemolytic anemia can be caused by which extrinsic factors?

Macroangiopathic or microangiopathic factors

A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure?

Macula densa

The nurse is administering a cathartic agent to a patient with renal insufficiency. Which order will the nurse question?

Magnesium hydroxide Milk of Magnesia may cause hypermagnesemia in patients with renal insufficiency. The nurse should question this order with the health care provider. Bisacodyl, lubiprostone, and cascara sagrada are safe to use in patients with renal insufficiency as long as the patient is not currently dehydrated.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation?

Maintain a high intake of fluid and fiber in the diet. Increased fluid intake and a high-fiber diet reduce the incidence of constipation caused by immobility, medications, and other factors. Fluid and fiber provide bulk that in turn increases peristalsis and bowel motility. Analgesics taken for lung cancer probably cannot be discontinued. Eating several small meals per day and position do not facilitate bowel motility.

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient?

Maintain oxygenation.

Which nursing intervention is most appropriate when caring for a patient with dehydration?

Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume.

The patient is admitted with hypercalcemia; polyuria; and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient?

Multiple myeloma

A patient admitted to the emergency department after a motor vehicle accident. Which urinalysis findings would the nurse expect if kidney trauma occurred (select all that apply.)?

Myoglobinuria Red blood cells After kidney trauma, the nurse will expect urinalysis results to be positive for myoglobin and red blood cells. Casts in urine indicate blood destruction intravascularly. Glucose in urine could indicate diabetes. Bilirubin in urine is suggestive liver dysfunction. White blood cells in urine indicate infection.

The nurse is caring for a 73-yr-old male patient with a history of benign prostatic hyperplasia and symptoms of a urinary tract infection. Which diagnostic finding would support this diagnosis?

Nitrites and leukocyte esterase are present in the urine. A diagnosis of urinary tract infection is suspected if there are nitrites (indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an enzyme present in WBCs indicating pyuria). The presence of glucose and ketones indicate uncontrolled diabetes mellitus. An elevated WBC count (>11,000 cells/µL) indicates a bacterial infection. AASO titer is a blood test to measure antibodies against streptolysin O, a substance produced by group A Streptococcus bacteria.

The nurse should administer an as-needed dose of magnesium hydroxide after noting what information when reviewing a patient's medical record?

No bowel movement for 3 days Magnesium hydroxide is an osmotic laxative that produces a soft, semisolid stool usually within 15 minutes to 3 hours. This medication would benefit the patient who has not had a bowel movement for 3 days. It would not be given for abdominal pain and bloating, decreased appetite, or signs of hypomagnesemia.

A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action should the nurse take next?

Notify the healthcare provider that the potassium level is below normal

The nurse provides nutritional counseling for a 45-yr-old man with nephrotic syndrome. The nurse determines teaching has been successful if the patient selects which breakfast menu?

Oatmeal, nondairy creamer, banana, and orange juice Patients with nephrotic syndrome should follow a low-sodium (2-3 g/day), low- to moderate-protein (0.5-0.6 g/kg/day) diet. Ham, milk products, peanut butter, and bacon are high in sodium. Eggs, milk products, and peanut butter are high in protein.

The serum ammonia level of a client with hepatic cirrhosis and ascites is elevated. What nursing intervention is the priority?

Observe the client for increasing confusion.

After several episodes of intermittent abdominal pain and vomiting, a 5-month-old infant is admitted to the pediatric unit. A diagnosis of intussusception is made. What is the priority nursing assessment that will help confirm the diagnosis?

Observing characteristics of stools

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?

Obtain the vital signs before the transfusion is initiated.

The urinalysis of a patient reveals a high microorganism count. What data should the nurse use to determine which part of the urinary tract is infected (select all that apply.)?

Pain location Urethral discharge Although all the manifestations are evident with urinary tract infections (UTIs), pain location is useful in differentiating among pyelonephritis, cystitis, and urethritis because flank pain is characteristic of pyelonephritis, but dysuria is characteristic of cystitis and urethritis. Urethral discharge is indicative of urethritis, not pyelonephritis or cystitis. Fever and chills and mental confusion are nonspecific indicators of UTIs. Urinary hesitancy and postvoid dribbling may occur with a UTI but may also occur with prostate enlargement in the male patient.

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results?

Partially compensated respiratory acidosis A low pH (normal, 7.35-7.45) indicates acidosis. In a patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal, 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.

A male client who is receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. What is the nurse's best initial action?

Perform a finger stick to test the client's blood glucose level. The client has signs of an increased serum glucose level, which may result from steroid therapy; testing the blood glucose level is a method of gathering more data. The symptoms are not those of benign prostatic hyperplasia. The blood glucose level, not the amount of ketones in the urine, should be assessed. The symptoms presented are not those of fluid retention, but of hyperglycemia.

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy?

Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Because hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal, 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

Plasma proteins moving out of the intravascular compartment The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report what clinical manifestations?

Polyuria, polydipsia, and polyphagia

A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

Position the patient with a 45-degree head of bed elevation. UAP may position the patient receiving enteral feedings with the head of bed elevated. A licensed practical nurse/licensed vocational nurse or an RN could perform the other activities.

A client who recently has had an abdominoperineal resection and colostomy accuses the nurse of being uncomfortable during a dressing change because the "wound looks terrible." The nurse identifies the client as using which defense mechanism?

Projection Projection is the attribution of unacceptable feelings and emotions to others. Sublimation is the substitution of socially acceptable feelings or instincts to replace those that are threatening to the ego. Compensation is overachievement in a more comfortable area, thereby covering up a weakness. Intellectualization is the use of mental reasoning processes to deny facing emotions and feelings involved in a situation.

What should nursing care for a child admitted with acute glomerulonephritis be directed toward?

Promoting diuresis With the reduction of edema the child's health improves, the appetite increases, and the blood pressure normalizes. Ambulation does not have an adverse effect on this disorder; most children voluntarily restrict their activities and remain in bed during the acute phase. Fluids are not encouraged because the kidneys are inflamed and cannot tolerate large amounts of fluid. Sodium intake is decreased, not eliminated; sodium restriction is not tolerated well by children and may further decrease their appetite.

A nurse is counseling a woman who has had recurrent urinary tract infections. Which factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection?

Proximity of the urethra to the anus Because a woman's urethra is closer to the anus than a man's, it is at greater risk for becoming contaminated. Urinary pH is within the same range in both men and women. Hormonal secretions have no effect on the development of bladder infections. The position of the bladder is the same in men and women.

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve?

Raising mucous secretions from the chest In addition to dilation of bronchi, treatment is aimed at expectoration of mucus. Mucus interferes with gas exchange in the lungs. Curing the condition permanently is an unrealistic goal; asthma is a chronic illness. Increased fluid intake helps liquefy secretions. Asthma has a psychogenic factor, but this is not the only cause; it may occur as an allergic response to an antigen, such as dust.

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. For which immediate response is it most important for the nurse to monitor?

Rapid, thready pulse

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and IV fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve?

Reduce colonic irritation A low-residue diet is designed to reduce colonic irritation, motility, and spasticity. Reduction of gastric acidity is the aim of bland diets used in the treatment of gastric ulcers. Reducing colonic irritation, motility, and spasticity hopefully will increase, not reduce, intestinal absorption. This diet is to allow the bowel to rest, not to reduce infection rates.

A healthcare provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure?

Reduces the circulating blood volume

A nurse is evaluating a client's understanding of peritoneal dialysis. Which information in the client's response indicates an understanding of the purpose of the procedure?

Removing toxins in addition to other metabolic wastes

A 22-yr-old patient's blood pressure during a pre-employment physical examination was 110/68 mm Hg. During a health fair 2 months later, the blood pressure is 154/96 mm Hg. What renal problem could contribute to this rise in blood pressure?

Renal artery stenosis Renal artery stenosis contributes to an abrupt rise in blood pressure, especially in people younger than 30 or older than 50 years of age. Renal trauma usually has hematuria. Renal vein thrombosis causes flank pain, hematuria, fever, or nephrotic syndrome. Benign nephrosclerosis usually occurs in adults 30 to 50 years of age and is a result of vascular changes resulting from hypertension.

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply.)?

Renal calculi may occur as a complication of hypercalcemia. Weight-bearing exercises can help keep calcium in the bones. The patient should increase daily fluid intake to 3000 to 4000 mL. A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

A patient is admitted with metabolic acidosis. Which system is not functioning normally?

Renal system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes HCl acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.

A patient with an intestinal obstruction has a nasogastric (NG) tube to suction but complains of nausea and abdominal distention. The nurse irrigates the tube as necessary as ordered, but the irrigating fluid does not return. What should be the priority action by the nurse?

Reposition the tube and check for placement. The tube may be resting against the stomach wall. The first action by the nurse is to reposition the tube and check it again for placement. The physician does not need to be notified unless the nurse cannot restore the tube function. The patient does not have bowel sounds, which is why the NG tube is in place. The NG tube would not be removed and replaced unless it was no longer in the stomach or the obstruction of the tube could not be relieved.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition?

Respiratory acidosis

The nurse is caring for a patient after a right kidney biopsy. Which position would be the most appropriate for this patient immediately after the procedure?

Right lateral side-lying position After a renal biopsy, a pressure dressing should be applied. The patient should be kept on the affected side for 30 to 60 minutes to apply additional pressure from the patient's own body weight and then on bed rest for 24 hours. High Fowler's position with arms supported is a position for a patient in respiratory distress. Reverse Trendelenburg position is used to maintain circulation to the legs in peripheral artery insufficiency. Supine with legs elevated puts excessive pressure on the diaphragm and should generally be avoided.

When caring for a patient with nephrotic syndrome, which food selection indicates the patient understands dietary teaching?

Salad made of fresh vegetables Of the options listed, only salad made with fresh vegetables would be acceptable for the diet that limits sodium and protein as well as saturated fat if hyperlipidemia is present. Peanut butter and crackers are processed, so they contain significant sodium, and peanut butter contains some protein. A pork chop is a high-protein food with saturated fat. Canned spaghetti sauce is also high in sodium.

A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) admitted for pneumonia. What laboratory finding would be consistent with decreased kidney function in this patient?

Serum creatinine 2.3 of mg/dL An expected assessment finding related to decreased kidney function in the aging process is an increased serum creatinine. Other expected assessments include an elevated BUN and inability to concentrate urine (with urine specific gravity fixed at 1.010). Uric acid is used as a screening test for disorders of purine metabolism or kidney disease; values depend on renal function, rate of purine metabolism, and dietary intake of food rich in purines. Normal reference intervals: serum creatinine, 0.6 to 1.3 mg/dL; BUN, 6 to 20 mg/dL; urine specific gravity, 1.003 to 1.030; and serum uric acid, 2.3 to 6.6 mg/dL (female) or 4.4 to 7.6 mg/dL (male).

A patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse?

Serum phosphate level of 1.9 mg/dL Refeeding syndrome can occur if a malnourished patient is started on aggressive nutritional support. Hypophosphatemia (serum phosphate level 11,000/µL) could indicate an infection. Normal serum potassium levels are between 3.5 and 5.0 mEq/L.

The nurse is evaluating the nutritional status of a patient undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would best indicate the patient has protein-calorie malnutrition (PCM)?

Serum prealbumin In the absence of an inflammatory condition, the best indicator of PCM is prealbumin; prealbumin is a protein synthesized by the liver and indicates recent or current nutritional status. Decreased transferrin levels and elevated liver enzyme levels (ALT) are other indicators that protein is deficient. CRP is elevated during inflammation and is used to determine if prealbumin, albumin, and transferrin are decreased related to protein deficiency or an inflammatory process.

When teaching a client how to prevent constipation, the nurse evaluates that the dietary teaching is understood when the client chooses which breakfast cereal?

Shredded wheat

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what?

Sodium

You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change?

Sodium, 135 mEq/L; potassium, 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore, for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

The nurse is providing care for a patient who is a strict vegetarian. Which dietary choices would the nurse recommend to prevent iron deficiency?

Soybeans and hot breakfast cereal Vegetarians are at a particular risk for iron deficiency, a problem that can be prevented by regularly consuming high-iron foods such as hot cereals and soybeans. The other foods listed are not classified as high sources of iron.

A 50-yr-old woman with hypertension has a serum potassium level that has acutely risen to 6.2 mEq/L. Which type of order, if written by the health care provider, should the nurse question?

Spironolactone (Aldactone) daily Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits the exchange of sodium for potassium in the distal renal tubule and helps to prevent potassium loss. Spironolactone is contraindicated in a patient with hyperkalemia (serum potassium >5.0 mEq/L). Management of patients with hyperkalemia may include limiting foods high in potassium, administering IV insulin and glucose, administering IV calcium gluconate, changing to potassium-wasting diuretics (e.g., furosemide [Lasix]), hemodialysis, administering sodium polystyrene sulfonate (Kayexalate), and IV fluid administration.

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about?

Strict hand washing Daily skin care and oral hygiene Private room with a high-efficiency particulate air (HEPA) filter

Which nursing intervention is most appropriate in providing care for an adult patient with newly diagnosed adult onset polycystic kidney disease (PKD)?

Suggest genetic counseling resources for the children of the patient. PKD is one of the most common genetic diseases. The adult form of PKD may range from a relatively mild disease to one that progresses to chronic kidney disease. Polyuria, deafness, and blindness are not associated with PKD.

The nurse is performing an assessment for a patient and preparing to palpate the kidneys. How should the nurse position the patient for this assessment?

Supine To palpate the right kidney, the patient is positioned supine, and the nurse's left hand is placed behind and supports the patient's right side between the rib cage and the iliac crest. The right flank is elevated with the left hand, and the right hand is used to palpate deeply for the right kidney. The normal-sized left kidney is rarely palpable because the spleen lies directly on top of it.

The nurse is preparing to administer a daily dose of docusate sodium to a patient that will continue taking it after discharge. What information should the nurse provide to the patient to optimize the outcome of the medication?

Take each dose with a full glass of water or other liquid. Docusate lowers the surface tension of stool, permitting water and fats to penetrate and soften the stool for easier passage. The patient should take the dose with a full glass of water and should increase overall fluid intake, if able, to enhance effectiveness of the medication. Dietary fiber intake should be a minimum of 20 g daily to prevent constipation. Mineral oil and extra salt are not recommended.

The wound, ostomy, and continence nurse (WOCN) selects the site where the ostomy will be placed. What should be included in site consideration?

The patient must be able to see the site. In selection of the ostomy site, the WOC nurse will want a site visible to the patient so the patient can take care of it, within the rectus muscle to avoid hernias, and on a flat surface to more easily create a good seal with the drainage bag. Care should be taken to avoid skin creases, scars, and belt lines, which can interfere with the adherence of the appliance.

You are caring for a patient admitted with diabetes mellitus, malnutrition, and a massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient?

The potassium level may be increased if the patient has nephropathy. There may be excess potassium being released into the blood as a result of massive blood transfusion. The potassium level may be increased because of dehydration that accompanies high blood glucose levels. Hyperkalemia may result from hyperglycemia, renal insufficiency, or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Because malnutrition does not cause sodium excretion accompanied by potassium retention, it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an nasogastric tube and not be eating.

The nurse is caring for a patient with a diagnosis of disseminated intravascular coagulation (DIC). What is the first priority of care?

Treat the causative problem.

A patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment?

Treatment type and expected side effects

A client with esophageal varices has severe hematemesis, and a Sengstaken-Blakemore tube is inserted. What design and purpose does the tube have?

Triple-lumen; for esophageal compression

A patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient?

Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine

A client with type 1 diabetes who has been adhering to a prescribed insulin regimen is admitted to the hospital in ketoacidosis. Which factor may have precipitated the ketoacidosis?

Upper respiratory infection

The nurse counsels a 64-yr-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the patient avoid?

Venison, crab, and liver Foods high in purines (e.g., venison, crab, liver) should be avoided to prevent uric acid calculi formation. Foods high in calcium (e.g., milk, yogurt, dried fruit, lentils, chocolate) should be avoided to prevent calcium calculi formation. Foods high in oxalate (e.g., spinach, cabbage, tea, asparagus, chocolate) should be avoided to prevent oxalate calculi formation (see Table 45-12).

A patient received a small-bore nasogastric (NG) tube after a laryngectomy. Which action has the highest priority before initiating enteral feedings?

Verifying NG tube placement on x-ray It is imperative to ensure that an NG tube is in the gastrointestinal tract rather than the patient's lungs. When an NG tube has been recently inserted, it is important to confirm this placement with an x-ray that will identify the tube's radiopaque tip. Aspiration and air auscultation may not differentiate between gastric and respiratory placement of the tube. Although elevating the head of bed at least 30 degrees is necessary to prevent aspiration, placement must first be confirmed before initiating feedings.

A patient who cannot afford enough food for her family states she only eats after her children have eaten. At a clinic visit, she reports bleeding gums; loose teeth; and dry, itchy skin. Which vitamin deficiency would the nurse suspect?

Vitamin C This patient is lacking vitamin C as evidenced by the bleeding gums, loose teeth, and dry, itchy skin. Clinical manifestations of folic acid deficiency include megaloblastic anemia, anorexia, fatigue, sore tongue, diarrhea, or forgetfulness. Clinical manifestations of vitamin D deficiency include muscular weakness, excess sweating, diarrhea, bone pain, rickets, or osteomalacia. Clinical manifestations of vitamin K deficiency include defective blood coagulation.

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient (select all that apply.)?

Weakness Depressed reflexes Signs of hypercalcemia are lethargy, fatigue, weakness, depressed reflexes, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?

Wear cotton underpants.

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss?

Weighing the child at the same time each day

A nurse in the pediatric clinic is examining a toddler with suspected enterobiasis (pinworm infestation). For which first sign of an infestation should the nurse assess the child?

anal itching

The nurse is caring for a 76-yr-old woman admitted to the medical unit with hypernatremia and dehydration after prolonged fever. The best beverage to offer the patient is

orange juice. Orange juice would be the safest option because it has the least amount of sodium (~2 mg in 8 oz). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 oz. Malted milk has approximately 625 mg sodium in 8 oz.

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis?

pH: 7.28; PCO2: 28; HCO3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO2 indicates compensatory hyperventilation. A low pH and elevated PCO2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO2 indicates compensatory hypoventilation. An elevated pH and low PCO2 reflect hyperventilation and respiratory alkalosis.

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as

within normal limits. The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Because the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.