Exam 5
To assess the quality of Natalie's pain, the nurse asks which question?
"What word best describes the pain you are experiencing?"; The quality of pain experienced is typically a descriptive term, such as burning, crushing, aching, or stabbing.
Normal range of urine per day is:
1-2 L per day
Urine output less than _____________ for more than _____________ or excessive output is cause for concern.
30 ml/hour; 2 hours
The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe?
A decrease in heart rate; vagal responses would be a sudden drop in heart rate and blood pressure.
Surgery triggers __________
ADH release
What is a laissez-faire, observing leader do?
Allows group members to take over the group. Under this style, the group members might learn how to make behavioral changes because the leader has no input
Who developed the code of ethics?
American Nurse Association
Which client care activity may the nurse safely delegate to an unlicensed health care worker?
Assisting a client who is recovering from an abdominal hysterectomy to the bathroom; A UAP is taught how to safely ambulate patients as this activity does not require extensive nursing knowledge or expert clinical judgement (assessment, teaching, and evaluation of client responses to care all require clinical judgement and a license to practice nursing).
The nursing manager issued orders to take the utmost care of a client with myocardial infarction and expects the staff to obey and follow the rules immediately. Which type of decision making is the manager using?
Autocratic; the autocratic method results in rapid decision-making and is more appropriate in a crisis situation
Since Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position?
Blood pressure
For ongoing evaluation of Donna's fluid volume status, it is most important to obtain which assessment data?
Body weight
If patient has difficultly swallowing, what should you check for first to determine if you can open the capsule and mix it with food?
Check to see if the medication is in extended-release form; opening or crushing the medication will adversely affect this action.
Which is the most important skill of the nurse leader?
Clinical care coordination; The most important leadership skill for the nurse leader is clinical care coordination
What is the action of an antidiuretic hormone (ADH)?
Decreases water loss in urine
The student obtains a 16 French Foley catheter from the supply room. The student nurse explains the procedure to Mr. Ellis, who gives permission to begin. After cleansing the urinary meatus, the student nurse maintains sterile technique while inserting the catheter into the urethra about 4 inches. While inflating the balloon, Mr. Ellis cries out in obvious pain. What action should the student nurse take?
Deflate the balloon and insert the catheter farther; the catheter has not been inserted far enough, and the pressure of the inflated balloon in the urethra is painful. Since the student nurse has maintained aseptic technique, the balloon can be deflated and the catheter inserted farther. Typically, the catheter should be inserted 6 to 9 inches to ensure proper placement in the adult male.
Which leadership style is best to achieve the group members' goal to participate more fully in life by gaining insight and changing behavior?
Democratic and guiding; this leader aims to facilitate and balance group's forces to maximize group potential for growth and change.
The objective of a therapy group is to assist the members to change behavior so they are able to participate in life in a more satisfying manner. Which leader ship style is best to achieve this objective?
Democratic, guiding; A democratic guiding leader assisted group to develop its maximum potential by facilitating and balancing group forces. Group members are encouraged to take responsibility for personal and group outcomes
Which action of the nurse leader is appropriate when preparing to share information with followers?
Determining which information is to be shared; The nurse leader would determine the information that has to be shared with followers but should not give all information out once.
After reviewing Mr. Ellis' diagnostic test results, the nurse consults with the HCP and receives a prescription for a new antibiotic. Since Mr. Ellis' creatinine level is elevated, the nurse is concerned about which problem in administering the medication?
Drug toxicity due to reduced drug excretion; an elevated creatinine level reflects a problem with the kidneys. If the kidneys are unable to excrete drug molecules efficiently, the drug will remain in the body for a prolonged period of time, which may result in drug toxicity.`
Mr. Ellis' hematuria continues. Two hours later, he becomes restless and appears to be in pain. The nurse observes that there has been no urinary output during the last 2 hours. Which assessment should the nurse complete first?
Evaluate the urinary drainage tubing; the client has had no urine output in 2 hours, he has been experiencing blood clots in his urine, and he is in obvious discomfort. The nurse should first consider that the catheter tubing is obstructed and assess for kinks or pressure on the tubing that might cause an obstruction. The nurse should also note the presence of any observable blood clots, which can also obstruct urine flow. This simple, noninvasive measure could easily identify and immediately resolve the client's discomfort.
What qualities with the professional nurse required to lead and manage a team?
Exercising self-awareness, motivating self and others, and managing emotions in self and others
An increase in venous pressure caused by liver disease can result in the development of:
Hemorrhoids; pressure leading to hemorrhoids can also occur from straining during defecation and from pregnancy.
The comatose patient in the ICU has not had a bowel movement in 4 days and is suddenly incontinent of liquid stool. What should the nurse suspect?
Impaction; prolonged constipation followed by diarrhea that seeps around the impacted stool are symptoms of a fecal impaction.
The nurse leader has developed an objective for a strategic planning. Which point indicates that the nurse possess the ability to write clear and concise objectives?
Inclusion of the timeline and deadline; For objectives to be clear and concise, they should have a timeframe within which the activity or improvement must be achieved
Which action by the nurse leader is indicative of transactional leadership?
Inspiring the self-interest of the employees by offering external rewards; transactional leadership relies on the power of organizational position and formal authority to reward or punish performance
Mr. Ellis states that prior to his stroke, he would get up five or six times during the night to empty his bladder but that he was able to control the urge long enough to make it to the bathroom. How should the nurse describe the urinary pattern that Mr. Ellis is describing?
Nocturia; this specifically refers to voiding frequently at night. The incidence of nocturia increases greatly in the older male client who has an enlarged prostate. It may also indicate an inability to concentrate urine because of poor blood flow to the kidneys.
What kind of saline is used for bladder irrigation?
Normal saline
And which role does the nurse oversee the budget of a specific nursing unit or agency?
Nurse manager
Implementation for urination:
Patient teaching, promote normal voiding, voiding routine/schedule, good hygiene, maintain privacy, and most important is to prevent infection
What is the role of the nurse administrator in a health care setting?
Preparing the budget, staffing, strategic planning of programs and services, employee evaluations, and employee development
In providing effective nursing care to clients from different cultural backgrounds, which strategy would the nurse follow?
Provide care that fits the clients' cultural beliefs; helps provide effective nursing care to the satisfaction of the client.
Which theory states that leaders act as change catalysts and innovators?
Quantum theory
Which activity would the nurse manager complete during an emergency event when acting as the triage officer according to the Hospital Incident Command System (HICS)? Select all that apply.
Rapidly evaluating each person who comes to the hospital
To help manage Mr. Ellis' incontinence, the nurse initiates a bladder training program. Which instruction should the nurse provide to the unlicensed assistive personnel (UAP) who will be helping care for Mr. Ellis?
Remind the client to void every 2 hours while awake and to call for assistance to the bathroom; a toileting schedule is an effective means to retrain the bladder. Bladder training should start with voiding every 2 hours in the daytime and every 4 hours at night and then be adapted to the individual needs. The call bell should be near the client so that he can ring the bell for assistance to prevent the risk of falling.
Which action by the RN represents her leadership ability?
Supervising the tasks assigned to unlicensed nursing personnel; this ensures the clients safety
As part of informed consent, a surgeon explains to the clients scheduled for surgery the details of the surgery and the related care. The nurse leader witnesses the complete procedure. Which information would the nurse leader ensure was provided to the client?
Surgical procedure, name of the surgeon, and explanation of the possible risks
If a patient had to have part of the colon (large intestine) removed, which of the following may result?
The patient could experience an acid-base imbalance; A primary function of the colon is secretion of bicarbonate for chloride and the release of potassium. Any alteration in secretory function could result in an acid-base imbalance.
Which diagnostic test result would make the nurse concerned that the client is at risk for sepsis?
Urine culture shows resistance to the prescribed antibiotic; if the microorganisms causing the urinary tract infection are resistant to the prescribed antibiotic, the antibiotic is ineffective, and the client is at risk for sepsis, or generalized infection.
What do you use on a patient as a skin barrier when they're incontinent and defecating a lot?
Zinc
What size cath do you initially insert and why?
a 14 Fr. Cath (smallest used to avoid trauma and unnecessary dilation of the urethra?
A.S.A. (aspirin) stands for ____________
acetylsalicylic acid
Blood supply to the kidneys is linked to ____________________
blood pressure
Triple-lumen catheter is used for:
continuous irrigation
Prescriptions for TPN is dependent on ____________
daily lab values
A decrease in skin turgor is __________
dehydration
Potassium is pulled with ____________
diuretics (10 mEQ is all that can be administered with 100 ml/hour
How often should patient's void (when catheter is removed)?
every 6-8 hours
Anesthesia slows ___________
filtration
Drugs with shorter half-lives have to be _______________________
given more frequently that those with longer half-lives
Substances excreted:
hydrogen ions, potassium ions, ammonia, and certain drugs
Water is absorbed in the __________________
large intestine
Substances reabsorbed:
large percent of water, partially sodium, glucose entirely, and other nutrients/ions
To accurately assess urine color:
look at the color of the urine in the drainage tube (the tube contains the most recent urine from the bladder)
Naloxone and _________ are the same thing
narco
What forms urine?
nephrons
NEVER push what?
potassium chloride
Veracity refers to:
practicing truthfulness
Priority for catheter implementation is to:
prevent infection
What techniques help a patient void?
running water and placing client's hands in warm water
Nutrients are absorbed in the ___________________
small intestine
Nephrons are ____________
the functional unit of the kidney
What is the function of the kidneys?
to remove waste from the blood to form urine
Narcotics cause ______________
urinary retention
Kidneys absorb _____________
water
