Funds II LP 3 & 4 Exam

rhonchi

Coarse, low-pitched breath sounds heard in patients with chronic mucus in the upper airways. Sounds like snoring

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

-Lightly scrub the stoma with soap and water. -Cut the opening on the appliance ½ inch larger than stoma.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

"I need to decrease fiber in my diet."

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. Select all that apply.

-Check the bladder for distention. -Review intake and output record. -Check to ensure drainage tubing is not kinked. -Ask the client about bladder spasms and discomfort.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily.

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

-Empty pouch when ⅓ to ½ full. -The stoma should be moist and pink to red. -The skin barrier should be within 1⁄16 to ⅛ inch of the stoma. -Change the appliance about every 3 days, or sooner, if it is leaking effluent.

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply.

-Have the client void and then perform the bladder scan. -If residual urine is less than 100 mL, continue to monitor.

An older client complains of chronic constipation. Which instructions should the nurse reinforce with the client? Select all that apply.

-Increase fluids to at least eight glasses a day. -Respond in a timely manner to the urge to defecate.

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? Select all that apply.

-Increase your fluid intake. -Include more fiber in your diet. -Ferrous sulfate changes the color of stool to black. -Iron slows colonic acid and often leads to constipation.

pleural friction rub

continuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.

-Apply disposable gloves. -Lubricate the enema tube and insert it approximately 4 inches. -Clamp the tubing if the client expresses discomfort during the procedure. -Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? Select all that apply.

-Character of drainage -Presence of blood clots -Amount of drainage emptied -Client complaint of pain/spasms -Type and amount of irrigation fluid used

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply.

-Maintain adequate fluid intake of 2 quarts. -Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. -Take all discharge medication as prescribed including antibiotics, and notify your primary health care provider if symptoms or signs of a UTI reappear. -Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating.

Which factors contribute to the problem of stress incontinence? Select all that apply.

-Obesity -Sneezing

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? Select all that apply.

-Placing the scan head on the symphysis pubis and aiming toward the bladder -Applying a generous amount of transmission/conductivity gel across the client's abdomen

Why do nurses perform the head to toe assessment?

-helps determine care plan and assess patient needs

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.

250 mL Rationale: 200 mL × 8 hr = 1600 mL, which is the amount of normal saline infused. 850 − 1600 = 250 (total in receptacle minus irrigation)

lung crackles

high-pitched crackling and popping noises, not cleared by cough

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Advance the catheter to the bifurcation and inflate the balloon.

lung wheeze

high-pitched musical sound similar to a squeak; heard more commonly during expiration, occurs in small airways

Head findings

inspect and palpate: size, shape, masses or tenderness, symmetry of skull inspect facial features for shape, symmetry, involuntary movements, or swelling around eyes

Sims' position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back

The nurse should recognize that which type of enema has the highest risk of water intoxication?

Tap water

Objective integumentary findings

color, temperature, excessive dryness or moisture, skin turgor, texture, excessive bruising, itching, rash, hair loss, or nail abnormalities such as pitting; lesions, scars, birthmarks, edema, capillary filling time

Breast assessment

pain or tenderness, lumps or thickening, swollen axillary lymph nodes, nipple discharge, trauma or injury to breast, medications being taken, family history, mammograms as prescribed, self-examination compliance -check size and symmetry of breasts

Fowler's position

reduces swelling and edema in neck area

Subjective integumentary findings

self-care behaviors, history of skin disease, medications being taken, environmental or occupational hazards and exposure to toxic substances, change in skin color or pigmentation, change in a mole or a sore that does not heal, presence of tattoos

Female genital assessment

-check for urinary difficulties such as frequency, urgency, or burning, vaginal discharge, pain -for external: look at even distribution of the hair -no inflammation of labia, as well as edema, lesions, or lacerations -urethral orifice is observed for color and position -vaginal orifice is inspected for inflammation, discoloration, discharge, and lesions

Urinary catheter care

-use gloves and wash the perineal area with warm soapy water -with the non-dominant hand, pull back labia or foreskin to expose meatus -cleanse along the catheter with soap and water -anchor the catheter to the thigh according to agency policy -maintain catheter bag below level of bladder

Normal eye assessment findings

-pupils are round, symmetrical, and equal -eyebrows are symmetrical -check eyelids for drooping -conjunctiva should be clear -sclera should be white

Abdominal assessment

-subjective data: changes in appetite or weight, difficulty swallowing, dietary intake, intolerances to certain foods, nausea or vomiting, pain, bowel habits, medications being taken, history of abdominal problems or surgery -client is asked to empty bladder and then then inspect; note any bulges or masses, skin should be smooth and even, umbilicus should be midline and inverted -bowel sounds are heard in right lower quadrant but auscultate all four quadrants - identify as normal, hypoactive, or hyperactive

Musculoskeletal system assessment

-subjective data: joint pain or stiffness, redness, swelling, warm joints, limited motion, muscle pain, cramps, or weakness; bone pain, exercise patterns -inspect gait, and posture and for cervical, thoracic, and lumbar curves -palpate all bones, joints and surrounding muscles, and check range of motion

Reflex assessments

-tendon is tapped quickly with reflex hammer -or tested with a pointed but not sharp object

A client has been diagnosed with functional incontinence. Which interventions are most appropriate to care for this type of incontinence? Select all that apply.

-Schedule toileting every 2 hours. -Modify clothing for easy removal. -Assess environment for obstacles.

Normal nose and sinuses assessment

-check for discharge or nosebleed -check for facial or sinus pain -check for history of frequent colds, altered sense of smell, allergies, medications being taken -check for history of nose trauma or surgery -nose should be midline and in proportion to other features -ask patient to plug one nostril and sniff through one side

Different types of aphasia

-expressive: damage occurs in Broca's area of the frontal brain; client understands what is said but is unable to communicate verbally -receptive: injury involves Wernicke's area in brain; client is unable to understand spoken and/or written word -global/mixed: language dysfunction occurs during expression and reception