Funds Quiz 4 (29, 33, 34, 36, 37)

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor?

The client returned from a foreign country 2 days ago.

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?

"All four abdominal quadrants auscultated. Inaudible bowel sounds."

The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about deep breathing. When the client asks, "Why am I practicing breathing when I'm having hernia surgery," what is the appropriate nursing response?

"It decreases the postoperative risk for respiratory complications."

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this?

"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."

A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client?

"How frequently do you urinate each day?"

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?

"I can have a hamburger and French fries as soon as I wake up."

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?

"I make sure to limit how much I drink so that I don't have accidents."

The nurse is teaching a client how to manage postoperative pain through a patient controlled analgesia (PCA) pump. The nurse determines that additional teaching is needed when the client make which statement?

"I should only take medication when my pain is intense."

A nurse is caring for a client whose primary care provider has written an order for "enemas until clear." Which explanation to the client about this procedure is correct?

"I will administer enemas until the enema return is without stool."

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?

"Let's review the types of fluids that your child drinks in the morning."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"Let's review your medication history and whether you consume bladder irritants."

A client comes to the clinic and states to the nurse, "I am traveling overseas for a project frequently and am having a difficult time adjusting because of jet lag. What is the best response by the nurse?

"Light therapy can be beneficial and help ease the transition to a new time schedule or zone."

The nurse is promoting bedtime rituals with a family. Which statement indicates the nurse may need to provide further instructions to the mother?

"My boys love to rough-house in their room right before bedtime."

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

"Void a small amount, stop, and discard it."

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.

-"The client is willing to look at the stoma." -"The client makes neutral or positive statements about the ostomy." -"The client expresses interest in learning self-care."

What information must be provided to a client to obtain informed consent? Select all that apply.

-A description of the procedure or treatment, along with potential alternative therapies -The underlying disease process and its natural course -Explanation of the risks involved and how often they occur

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? (Select all that apply.)

-Assess for pain control 30 minutes after administering an analgesic. -Consider cultural implications of the perception of pain. -Provide pain medication before activity that may increase pain.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

-Clean each labial fold, then the area directly over the meatus. -Insert the lubricated catheter into the urethra. -Advance the catheter until there is a return of urine. -Inflate the balloon with the correct amount of sterile saline. -Discard used supplies.

The nurse is assessing several clients for postsurgical risk factors. Which risk factor does the nurse identify that could create postoperative complications? Select all that apply.

-Clients with respiratory disease may experience alterations in acid-base balance after surgery. -Kidney and liver diseases influence the client's response to anesthesia. -Endocrine diseases increase the risk for slow surgical wound healing.

The nurse is caring for a client who reports muscular and joint pain after an ankle sprain when playing soccer last week. How will the nurse document this type of pain? Select all that apply.

-Somatic -Acute

The nurse is administering an oil-retention enema to a client. Which nursing actions in this procedure are performed correctly? Select all that apply.

-The nurse administers the oil-retention enema at body temperature. -The nurse instructs the client to retain the oil for at least 30 minutes. -The nurse administers a cleansing enema after the oil-retention enema.

A nurse is caring for a client with fecal impaction. Which factors cause fecal impaction? Select all that apply.

-Weak abdominal muscles -Severe dehydration -Unrelieved constipation

The nurse is caring for a client who reports urinary incontinence over the past 2 months. In reviewing the electronic health record, which new prescriptions will the nurse look for that may be related to the concern? Select all that apply.

-diuretics -antihypertensives -antidepressants -sleeping pills

A client who works night shift is struggling with sleeping during the day after working all night. What actions can the nurse suggest to help promote sleep? (Select all that apply.)

-sleeping in a room with curtains that block the light -eating breakfast before going to sleep

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

0100.

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?

3

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation.

A nurse is preparing to receive a client in post-anesthesia care unit (PACU). The client is diabetic and has undergone knee surgery. Which information would be most important for the receiving nurse to obtain to develop an appropriate plan of care for this client?

Amount of blood loss

Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications?

76-year-old client with a history of renal failure and chronic bronchitis

A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? (Select all that apply.)

Diminished ability of kidneys to concentrate urine may result in nocturia. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. Decreased bladder contractility may lead to urine retention and stasis. Neuromuscular problems may interfere with voluntary control of urination. Altered thought processes may cause urinary frequency.

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?

Assess the factors that the client believes contribute to the problem.

Which nursing action should the PACU nurse take to prevent postoperative complications in clients?

Assist the client to do leg exercises to increase venous return.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C 3 days before testing?

Avoid more than 250 mg

The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid?

Brussels sprouts

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

Cleansing enema

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?

Dark pink and moist.

The nurse is administering magnesium citrate to a client with constipation. What mechanism of action would the nurse expect from this drug?

Drawing water into the intestines to stimulate peristalsis

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

Endorphins

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure?

Ensure that the client fasts 6 to 12 hours before the test as per policy.

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

Hypothalamus

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Monitor the client closely and promote fluid intake.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?

Notify the physician of the oversight.

A nurse is collecting a routine urinalysis on a client presenting to the emergency room with abdominal pain. What nursing action is important in the collection of this specimen?

Obtain a nonsterile specimen and send it to the lab.

Which nursing action will best promote pain management for a client in the postoperative phase?

Performing relaxation technique

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client?

Place the client in a flat position with legs elevated 45 degrees.

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation?

Prime the tubing with the solution.

A new client in the medical-surgical unit complains of difficulty sleeping and is scheduled for an exploratory laparotomy in the morning. The nursing diagnosis is Sleep Pattern Disturbance: Insomnia related to fear of impending surgery. Which step is most appropriate in planning care for this diagnosis?

Provide an opportunity for the client to talk about concerns.

A client has an order for a narcotic analgesic every 3 to 4 hours and he received his last dose 3 hours earlier. Which action is most appropriate for the nurse to take in response to the client's request for pain medication on his first postoperative day?

Provide the client with pain medication.

A client tells a nurse, "I have this pounding feeling on the side of my head, like someone is hitting my head with a hammer." The nurse should identify what characteristic of pain assessment?

Quality

A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

Sedation

The nurse is completing an admission assessment for a client scheduled for back surgery after a construction accident. The nurse notes the client is having slowed speech and focus, irritability, yawning, and that he reports severe lumbar and right leg pain. The nurse suspects a nursing diagnosis of:

Sleep Pattern Disturbance related to acute pain.

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration?

Sims

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?

The graduate places the client in Fowler's position.

Which statements accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain?

The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly?

Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers?

Yogurt and buttermilk

Which client would a nurse monitor most closely for postoperative respiratory complications?

a 55-year-old client with a history of asthma who had a colon resection

The nurse knows the term perioperative phase refers to care given to the client:

before, during, and after the operative phase.

A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample?

a sample of urine that is considered sterile

Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?

a woman who takes daily anticoagulants to treat atrial fibrillation

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback.

When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to:

blue

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency.

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?

loss of urine without any identifiable pattern or warning

A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed?

lubricates and softens stool

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?

oil

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of:

physiologic or lifestyle changes in the client.

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client?

prior to surgery

In Stage 4 sleep, the:

pulse rate is slow

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:

pus

A client who was a victim of domestic violence for many years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a debilitating headache and have to go lie down to make the pain go away." Which nursing intervention reflects practice according to the Endogenous Opioid Theory?

requesting healthcare provider to order opioid medication

The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is:

reviewing the client's sleep diary for the past 2 weeks.

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress

The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the healthcare provider?

temazepam (Restoril)

The nurse is caring for a male client with weakness who has been ordered to stay on bed rest for several days. Which method for urinary elimination does the nurse provide?

urinal

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention