Intro to Adult Health Unit 3

A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? A- constipation B- abdominal pain C- an episode of diarrhea D- hematest-positive nasogastric tube drainage

C- an episode of diarrhea anti-diarrheal medication; common name is Immodium and can find it over the counter

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action? A- withdraw the catheter slightly and reinflate the balloon B- remove the catheter, and reinsert a new one that is 1 size smaller C- finish inflating the balloon; the discomfort is normal and temporary D- aspirate the fluid, advance the catheter farther, and reinflate the balloon

D- aspirate the fluid, advance the catheter farther, and reinflate the balloon pain indicates that foley has not been inserted far enough in for the balloon to be sitting inside the bladder; it is probably still sitting in the urethra why when we see urine that we advance the catheter 1-2 inches more to ensure that we are in the bladder

A cystectomy is performed for a client with a diagnosis of bladder cancer, and a Kock pouch is created for urinary diversion. In creating a discharge teaching plan for the client, the nurse should include which instruction in the plan? A- dietary restrictions B- technique of catheterization C- external pouch and application care D- proper administration of prophylactic antibiotics

B- the technique of catheterization created a bladder out of the ileum part of the small intestines; the patient is going to straight cath themselves through the stoma every 3-4 hours to drain urine

The nurse has performed a nutritional assessment on a client with a urinary tract infection. The nurse should tell the client to consume which beverage to minimize the recurrence of a urinary tract infection? A- tea B- water C- coffee D- white wine

B- water water is best fluid for someone to drink to prevent UTI's; will clear the system out anything with caffeine or alcohol will irritate the bladder in the urinary tract system and could cause urinary tract infections

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further teaching? A- The enema will be given while I am sitting on the toilet B- I should try and hold the fluid for as long as possible after it is instilled C- I know that there will become cramping after the enema administration D- I should tell the nurse if cramping occurs during the installation of the fluid

A- The enema will be given while I am sitting on the toilet the patient gets the enema while laying in bed in the left sim's position

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? A- elevated creatinine level B- decreased hemoglobin level C- decreased red blood cell count D- increased number of white blood cells in the urine

A- elevated creatinine level denotes kidney issue; serum creatinine level is gold standard for telling us how kidneys are doing increased creatinine = kidneys are not functioning properly

A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? A- high-fiber diet B- full liquid diet C- low-fiber diet D- low-sodium diet

A- high-fiber diet worrying about it becoming an impaction; get her on diet to help bulk up stool

The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? A- I walk 1-2 miles every day B- I need to decrease fiber in my diet C- I have a bowel movement every other day D- I drink 6-8 glasses of water every day

B- I need to decrease fiber in my diet if we want to prevent constipation, we actually want to INCREASE fiber in diet C- is right because we want them to have a regular pattern of bowel movements

The nurse is providing care for a client with a recent transverse colostomy. Which observation required immediate notification of the health care provider? A- stoma is beefy red and shiny B- purple discoloration of the stoma C- skin excoriation around the stoma D- semi-formed stool noted in the ostomy pouch

B- purple discoloration of the stoma purple= losing blood supply where we have decreased perfusion to that stoma IF WE DON'T FIX IT, STOMA CAN DIE

A client tells the nurse about a pattern of a strong urge to void, followed by incontinence before the client can get to the bathroom. Based on the data provided, which condition should the nurse suspect? A- reflex incontinence B- total incontinence C- stress incontinence D- urge incontinence

D- urge incontinence patient feels like they really have to go now but they can't make it to the bathroom; usually have episode of incontinence before they can make it to the bathroom