Exam 5 PrepU

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? A. assessing the client for claustrophobia B. assessing the wound for active bleeding C. assessing for the use of antihypertensives D. assessing the client's mental status

B

The nurse has collected blood from a client for laboratory analysis. Which dressing will the nurse select to cover the site from which the blood was drawn? A. hydrocolloid B. gauze C. transparent D. tape with eyelets

B

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of? A. Wearing an appliance pouch only at bedtime B. Taking only enteric-coated medications C. Increasing fluid intake to prevent dehydration D. Consuming a low-protein, high-fiber diet

C

A client undergoes surgery to remove a malignant tumor followed by a urinary diversion procedure. Which postoperative procedure is the most important for the nurse to perform? A. Suggest a visit to a local ostomy group. B. Show photographs and drawings of the placement of the stoma. C. Maintain skin and stomal integrity. D. Determine the client's ability to manage stoma care.

C

The nurse is assessing a client for constipation. Which factor should the nurse review first to identify the cause of constipation? A. Activity levels B. Alcohol consumption C. Usual pattern of elimination D. Current medications

C

An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"? A. stool consistency and client comfort B. two bowel movements daily C. one bowel movement every other day D. one bowel movement daily

A

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. A. "Your wound edges are right next to each other." B. "Very little scar tissue will form." C. "The margins of your wound are widely separated." D. "This is a simple reparative process." E. "Your wound will be purposely left open for a time."

A,B,D

The nurse is evaluating the effectiveness of discharge teaching for a client with an oxalate urinary stone. Which statement by the client indicates the need for further teaching by the nurse? Select all that apply. A. "I need to take allopurinol." B. "I'm so glad I don't have to make any changes in my diet." C. "I need to drink eight to ten glasses of water every day." D. "Tylenol is best to control my pain." E. "I will never have another urinary stone again."

A,B,D,E

The nurse is caring for a 7-month-old female infant diagnosed with a urinary tract infection (UTI). The parents are upset as this is the infant's second UTI with a fever. Which instruction is most helpful? Select all that apply. A. A fever is commonly noted with a UTI. B. Female urethras are shorter and straighter than males. C. UTI's are common in male infants at this age. D. Change diapers promptly, especially after bowel movements. E. After 3 days on antibiotics, the infection is clear.

A,B.D

Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply. A. Disturbed body image B. Chronic pain C. Risk for impaired skin integrity D. Urinary retention E. Deficient knowledge: management of urinary diversion

A,C,E

The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply. A. Provide careful perineal care. B. For those patients who are incontinent, insert indwelling catheters. C. Encourage patients to wear briefs. D. Perform hand hygiene prior to patient care. E. Assist the patients with frequent toileting.

A,D,E

A client who has a history of neurogenic bladder presents with fever, burning on urination, and suprapubic pain. What would the nurse suspect is the problem? A. urethral strictures B. urinary tract infection C. urinary retention D. urinary incontinence

B

A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care? A. Turn the patient every 2 hours around the clock. B. Monitor urine output hourly and report output less than 30 mL/hr. C. Clean the stoma with soap and water after the patient voids. D. Administer pain medication every 2 hours.

B

A resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. The client receives nutrition via a PEG tube, has adapted well to the tube feedings, and remains physically and socially active. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. What is the most likely cause of this client's constipation? A. lack of solid food B. lack of free water intake C. increased fiber D. lack of exercise

B

After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence? A. Obstruction due to fecal impaction or enlarged prostate B. Decreased pelvic muscle tone due to multiple pregnancies C. Increased urine production due to metabolic conditions D. Bladder irritation related to urinary tract infections

B

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? A. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. B. Rotate the swab several times over the wound surface to obtain an adequate specimen. C. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. D. Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station.

B

Patients with urolithiasis need to be encouraged to: A. Supplement their diet with calcium needed to replace losses to renal calculi. B. Increase their fluid intake so that they can excrete up to 4 liters every day. C. Limit their voiding to every 6 to 8 hours so that increased volume can increase hydrostatic pressure, which will help push stones along the urinary system. D. Participate in strenuous exercises so that the tone of smooth muscle in the urinary tract can be strengthened to help propel calculi.

B

The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following? A. Stoma retraction B. Peritonitis C. Stoma ischemia D. Postoperative pneumonia

B

The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence? A. Cholinergic B. Anticholinergic C. Diuretics D. Anticonvulsant

B

A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time? A. Paralytic ileus B. Constipation C. Peritonitis D. Accumulation of gas

C

An 82-year-old client experiences urinary incontinence. Which factor should the nurse assess before beginning a bladder training program for this client? A. Occupational history B. Smoking habits C. Physical and environmental conditions D. History of allergies

C

An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale? A. Reveals causative microorganisms B. If risk for chronic pyelonephritis is likely C. Detects calculi, cysts, or tumors D. Shows damage to the kidneys

C

Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet? A. High sodium B. High protein C. Low purine D. Low oxalate

C

Sympathomimetics have which of the following effects on the body? A. Decrease of heart rate B. Constriction of bronchioles C. Relaxation of bladder wall D. Constriction of pupils

C

The nurse anticipates that the initial treatment for small bowel obstruction will involve which of the following? A. Insertion of a rectal tube for drainage B. Colonoscopy and irrigation C. Surgical intervention D.Decompression of bowel via nasogastric tube

D

The nurse is preparing a client for a test that involves inserting a thick barium paste into the rectum with radiographs taken as the client expels the barium. What test will the nurse prepare the client for? A. Kidneys, ureters, bladder (KUB) B. Abdominal radiography C. Colonic transit studies D. Defecography

D

A 64-year-old man is seeing his urologist for an annual check-up, post prostatectomy. The health care provider is concerned with the symptom he finds because it is considered diagnostic for bladder cancer. Which of the following signs/symptoms is diagnostic for bladder cancer? A. Painless, gross hematuria B. Muscle spasm and abdominal rigidity over the flank C. Decreasing kidney function associated with fever and hematuria D. Deep flank and abdominal pain

A

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? A. Clean the wound from the top to the bottom and from the center to outside. B. Clean the wound in a circular pattern, beginning on the perimeter of the wound. C. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. D. Use clean technique to clean the wound.

A

Which of the following is the most common site of a nosocomial infection? A. Skin B. Urinary tract C. Gastrointestinal tract D. Respiratory tract

B

A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? A. Right upper quadrant B. Left lower quadrant C. Right lower quadrant D. Left upper quadrant

C

Vomiting results in which of the following acid-base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

C

Which term refers to inflammation of the renal pelvis? A. Cystitis B. Urethritis C. Interstitial nephritis D. Pyelonephritis

D

Which type of medication may be used to inhibit bladder contraction in a client with incontinence? A. Anticholinergic agent B. Tricyclic antidepressants C. Over-the-counter decongestant D. Estrogen hormone

A

A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following? A. Diabetes mellitus B. Hyperparathyroidism C. Pancreatitis D. Hyperuricemia

A

A patient with a UTI is having burning and pain when urinating. What urinary analgesic is prescribed for relief of these symptoms? A. Pyridium B. Levaquin C. Septra D. Bactrim

A

A client reports constipation. Which nursing measure would be most effective in helping the client reduce constipation? A. Assist client to increase dietary fiber. B. Provide adequate quantity of food. Obtain medical and allergy history. Obtain complete food history.

A

The nurse is aware that the most common cause of small bowel obstruction is which of the following? A. Adhesions B. Hernias C. Neoplasms .D. Volvulus

A

What is the most common presenting objective symptom of a urinary tract infection in older adults, especially in those with dementia? A. Incontinence B. Back pain C. Hematuria D. Change in cognitive functioning

D

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect? A. Renal cell carcinoma B. Urinary calculi C. Acute glomerulonephritis D. Ureteral stricture

B

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? A. Superficial abscess accompanied by pruritus B. Superficial contusion accompanied by pruritus C. Diffuse fungal infection accompanied by pruritus D,Diffuse dermatitis accompanied by pruritus

D

A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation? A. Importance of urinating every 4 to 6 hours while awake B. Suggestion to take tub baths instead of showers c. Need to wear underwear made from synthetic material D. Need to urinate after engaging in sexual intercourse

D

A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? A. Giving the client a glass of soda before bedtime B. Taking the client to the bathroom twice per day C. Consulting with a dietitian D. Encouraging intake of at least 2 L of fluid daily

D

Which finding is an early indicator of bladder cancer? A. Nocturia B. Occasional polyuria C. Dysuria D. Painless hematuria

D

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development? A. Braden scale B. Glasgow scale C. FLACC scale D. Morse scale

A

A nurse is caring for a client who has a 6 × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist, with a yellow-and-red wound bed. Which dressing does the nurse anticipate is most likely to be ordered by the primary care provider? A. hydrocolloid B. alginate C. transparent D. hydrogel

A

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? A. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. B. Clean the wound from the top to the bottom and from the center to outside. C. Clean the wound in a circular pattern, beginning on the perimeter of the wound. D. Use clean technique to clean the wound.

B

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: A. limit oral fluid intake for 1 to 2 weeks. B. notify the physician about cloudy or foul-smelling urine. C. report bright pink urine within 24 hours after the procedure. D. report the presence of fine, sandlike particles through the nephrostomy tube.

B

Potassium chloride may be administered in the patient with small bowel obstruction and dehydration to correct hypokalemia. The nurse knows that a patient experiencing decreased potassium levels would exhibit which of the following signs and symptoms? A. Increased thirst, polyuria B. Hypotension, muscle weakness C. Hypertension, bradycardia D. Increased reflexes, tachycardia

B

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? A. Utilize the culture swab to obtain cultures from multiple sites. B. Cleanse the wound after obtaining the wound culture. C. Keep the swab and the inside of the culture tube sterile prior to collecting the culture. D. Stroke the culture swab on surrounding skin first.

C

The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective? A. "A catheter will drain urine directly from my kidney." B. "My urine will be eliminated with my feces." C. "My urine will be eliminated through a stoma." D. "I will not need to worry about being incontinent of urine."

C

The nurse is giving discharge instructions to the client with uric acid renal calculi. Which statement by the client indicates the client understands the prescribed diet? A. "I will eliminate milk and other dairy products from my diet." B. "I should avoid raw fruits and vegetables." C. "I should limit my intake of meat and fish." D. "Chocolate, spinach, and strawberries are not allowed."

C

The nurse is performing a rectal assessment and notices a longitudinal tear or ulceration in the lining of the anal canal. The nurse documents the finding as which condition? A. Hemorrhoid B. Anorectal abscess C. Anal fissure D. Anal fistula

C

The nurse is preparing to assess a client's new stoma. Which finding would the nurse include in the documentation of a healthy stoma? A. Dry in appearance B. Black color C. Pink color D. Pain

C

The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention? A. Empty the pouch. B. Secure or patch it with barrier paste. C. Change the wafer and pouch. D. Secure or patch it with tape.

C

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? A. Maceration B. Necrosis C. Desiccation D. Evisceration

C

Which medication may be ordered to relieve discomfort associated with a UTI? A. Ciprofloxacin B. Levofloxacin C. Phenazopyridine D. Nitrofurantoin

C

A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a 1-week fishing trip. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting? A. The child did not want to go on the fishing trip and is now retaliating against being made to go. B. The child is out of the habit of waking himself up during the night to void. C. The child has a urinary tract infection due to not bathing while on the fishing trip. D. The child has been sexually abused, maybe on the fishing trip.

D

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence? A. Functional B. Overflow C. Stress D. Urge

D

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect? A. Renal cell carcinoma B. Acute glomerulonephritis C. Ureteral stricture D. Urinary calculi

D

Which of the following is considered a bulk-forming laxative? A. Mineral oil B. Milk of Magnesia C. Metamucil D. Dulcolax

C

Which of the following is classified as a upper urinary tract infection (UTI)? Select all that apply. A. Renal abscess B. Urethritis C. Prostatitis D. Cystitis E. Acute pyelonephritis

A,E

The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for: A. hypernatremia. B. hyponatremia. C. hypokalemia. D. hyperkalemia.

C

Which factor contributes to UTI in older adults? A. Active lifestyle B. Low incidence of chronic illness C. Immunocompromise D. Sporadic use of antimicrobial agents

C

Which nursing intervention should the nurse caring for the client with pyelonephritis implement? A. Straight catheterize the client every 4 to 6 hours. B. Administer acetaminophen (Tylenol). C. Teach client to increase fluid intake up to 3 liters per day. D. Restrict fluid intake to 1 liter per day.

C

A nurse is caring for an adult who had Mohs surgery on the nose. The client asks, "Is there anything I can do to prevent getting skin cancer again?" How should the nurse respond? A. "There are preventative measures you should take to limit exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." B. "I am so sorry, there are preventative measures such as limiting your exposure to UVA and UVB rays; however, since you have had skin cancer I am uncertain this would help you. You should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." C. "There are preventative measures you should take to limit exposure to UVA and UVB rays, such as only going outside when there is cloud cover; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." D. "Absolutely, skin cancer can be prevented by limiting exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing."

A

A client reports severe pain and bleeding while having a bowel movement. Upon inspection, the health care provider notes a linear tear in the anal canal tissue. The client is diagnosed with a: A. fistula. B. hemorrhoid. C. pilonidal cyst. D. fissure.

D

A client with Crohn's disease is to receive prednisone as part of the treatment plan. Which of the following instructions would be appropriate? A. "Once your symptoms improve, you can stop taking the drug." B. "Take the drug on an empty stomach to avoid upsetting your stomach." C. "Make sure to increase your salt intake to compensate for the loss of fluid." D."Avoid contact with other people who might have an infection."

D

An older adult client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale? A. Reveals causative microorganisms B. If risk for chronic pyelonephritis is likely C. Shows damage to the kidneys D. Detects calculi, cysts, or tumors

D

The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances? A. Calcium B. Struvite C. Cystine D. Uric acid

D

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of pressure injuries. What is the name given to the factor responsible for this risk? A. shearing force B. ischemia C. necrosis of tissue D. friction

A

Which medication may be ordered to relieve discomfort associated with a UTI? A. Phenazopyridine B. Nitrofurantoin C. Ciprofloxacin D. Levofloxacin

A

The nurse is irrigating a client's colostomy when the client begins to report cramping. What is the appropriate action by the nurse? A. Increase the rate of administration. B. Clamp the tubing and allow client to rest. C. Change irrigation fluid to normal saline. D/ Discontinue the irrigation immediately.

B

The nurse is monitoring a client's postoperative course after an appendectomy. The nurse's assessment reveals that the client has vomited, has abdominal tenderness and rigidity, and has tachycardia. The nurse reports to the physician that the client has signs/symptoms of which complication? A. Pelvic abscess B. Peritonitis C. Ileus D. Hemorrhage

B

The nurse who teaches a client about preventing recurrent urinary tract infections would include which statement? A. Increase intake of coffee, tea, and colas. B. Void immediately after sexual intercourse. C. Take tub baths instead of showers. D. Void every 5 hours during the day.

B

The initial symptom of abdominal pain described by the patient in which of the following ways would lead the nurse to suspect a small bowel obstruction? A. Rebound, squeezing B. Sharp, knife-like C. Colicky, crampy D.Dull, aching

C

The nurse observes a client's uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest? A. A diet high in fruits and vegetables B. A diet high in calcium C. A low-sodium diet D. A low-purine diet

D