PrepU EXAM2 ch 5, 36, 37, 38

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

A nurse is working in a clinic that serves a community with a high population of immigrants. Which nursing assessment is the priority?

language assessment

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 client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

nephron

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a:

neurogenic bladder

A client who is taking supplements reports severe flushing and itching an hour after ingestion. The nurse is aware that the supplement is most likely:

niacin

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 has had abdominal surgery and 72 hours later develops abdominal distention and absence of bowel sounds with pain. The nurse suspects the client has:

paralytic ileus.

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter

Which medical diagnosis is most likely to necessitate testing for fecal occult blood?

peptic ulcer

A client refuses to allow any healthcare worker of Asian descent to provide care. This client is demonstrating what practice?

racism

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube?

radiographic confirmation of position (X-ray)

The spouse of a client asks the nurse whether the spouse may bring in a cream from home to apply to the client's skin. The spouse says, "Whenever anyone gets sick, we always use this cream." The nurse interprets this as:

ritual

A preconceived and untested belief about an individual or group of individuals is:

stereotyping

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

straight catheter

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

A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?

stress

Which type of incontinence is caused by pelvic floor muscle weakness?

stress

The health care provider prescribes a long-term continuous drainage system to monitor a chronically ill client. What type of catheter would best suit this client's needs?

suprapubic catheter

The nurse prepares to administer large-volume cleansing enemas to a client scheduled for bowel surgery. For which client should the nurse stop administration of the enemas and notify the primary care provider?

the client who experiences severe abdominal pain

A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason?

to res the GI tract and promote healing

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice?

urinal

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

urinary retention

A client has a history of long-term alcohol use. Which nutrient would need to be required in increased amounts?

vitamin B

The nurse is caring for a client who has been experiencing prolonged wound healing from a surgical procedure. A deficiency in which nutrient would be associated with this condition?

vitamin C

A client who has bleeding tendencies has a deficiency in which vitamin?

vitamin K

When planning interventions in the immediate hours after birth the nurse recognizes the need to provide an injection of which vitamin (to manage a lack of it), due to lack of bacteria in the intestinal tract?

vitamin K

The nursing researcher is studying so-called "unnatural illnesses." What cause of such illnesses would be included in the study?

witchcraft

The nurse is caring for a client who has a history of renal failure. What is an accurate step when caring for the client's hemodialysis access?

Auscultate over the site with a stethoscope to listen for a bruit. Explanation:

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

"This test detects heme, an iron compound in blood within the stool."

The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the best response by the nurse?

"We can wait until your spiritual healer arrives and work together to answer these questions."

A nurse is admitting a client to the unit. What cultural question is most appropriate?

"What are your dietary needs and preferences?"

A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145 lb/ 65.7 kg

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24 hour specimen

The nurse is administering an oil-retention enema to a client. Which nursing actions in this procedure are performed correctly? Select all that apply. 1. The nurse administers a cleansing enema prior to the oil-retention enema. 2. The nurse chooses a large rectal tube. 3. The nurse administers the oil-retention enema at body temperature. 4. The nurse instructs the client to retain the oil for at least 30 minutes. 5. The nurse administers a cleansing enema after the oil-retention enema.

3. The nurse administers the oil-retention enema at body temperature. 4. The nurse instructs the client to retain the oil for at least 30 minutes. 5. The nurse administers a cleansing enema after the oil-retention enema.

A nurse is caring for a client who has a nursing diagnosis of Risk for Aspiration. When preparing to assist this client with eating, how can the nurse best reduce this risk?

Assess the client's level of consciousness.

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate?

Assess when client generally eats meals.

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

a flexible sheath that is rolled around the penis

What is the priority assessment for the nurse when developing a plan of care for a client living in poverty?

Access to care

When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response?

Ask the client about personal space preferences.

A community health nurse is providing care to a group of Hispanic people living in an area that is predominantly populated by white people. What are the Hispanic people in this community an example of?

a minority

The nurse correctly differentiates race from ethnicity by noting that race is based on which characteristics?

Biological

The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next?

Blood sugar

The nurse is caring for a client who is postoperative 3 days from coronary artery bypass graft. The client has a prescription to ambulate. What is the best action by the nurse?

Discuss with the client the need for assistance during ambulation.

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 staff nurse meets with the charge nurse and is reporting that all the new nurses are leaving messes on the unit. The staff nurse states, "These youngsters think they can waltz in here and get our jobs." What is this nurse demonstrating?

Cultural conflict

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings.

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 is caring for a postoperative client after knee arthroplasty. The nurse plans to help the client ambulate but is aware that the client may feel threatened by physical closeness because the client is from a culture that tends to prefer more personal space when interacting with others. Using the principles of culturally competent care, what would be the most appropriate nursing action?

Explain the purpose and need for assistance during ambulation.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last?

Palpation

A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?

Plans to eat a snack of fruit twice per day.

A nurse is preparing to obtain a client's capillary blood sample for glucose testing. The nurse should perform which action?

Hold the lancet perpendicular to the skin and prick the site.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

Which medication causes constipation?

Iron supplements

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 assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

Left lateral

The nurse is caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid?

iodine

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding?

Reddened perineal skin

A nurse is reviewing a client's laboratory values. Which laboratory value would be indicative of a client's level of malnutrition?

Serum albumin

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily.

(T/F) Use of an indwelling urinary catheter leads to the loss of bladder tone.

TRUE

A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise?

The client is dehydrated.

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 client with constipation has been instructed to increase the intake of foods high in fluid. Which food(s) will the nurse include in the client's education? Select all that apply. Watermelon Strawberries Cantaloupe Lettuce Cucumber

Watermelon Strawberries Cantaloupe Lettuce Cucumber

The community health nurse is developing a workshop for a group of Native American/First Nation clients. Which topic should the nurse teach?

alcohol use disorder

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?

anuria

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

A new resident in a long-term care facility who was having difficulty adapting to the routine has begun participating in activities on a daily basis. Which stage of culture shock is this resident displaying?

beginning resolution

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood

What symptom will have a great impact on the extracellular fluid for water conservation?

burns

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake.

A student nurse studying human anatomy knows that a structure of the large intestine is the:

cecum

A client could experience increased urination when using which classification of medication?

cholinergic agents

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?

cloudy, foul odor

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

contact health provider

A family recently immigrated to a new country. The parent reports that the teenager is showing signs of fear, has vague reports of stomach pain, and feels humiliated by peers because of their culture. What is the priority assessment for the nurse?

culture shock

Upon moving to another country, a college student is very confused by many local customs. The student is especially bothered by the custom of men and women eating in separate areas and it makes the student angry and resentful of the new culture. What are the feelings experienced by this student?

culture shock

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

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?

every 4 to 6 hours

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination

A client is receiving total parenteral nutrition (TPN). The nurse will assess for complications related to:

fluid and electrolyte levels

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence?

functional

A 75-year-old man was admitted to the hospital for altered mental status. He had been in his usual state of good health until this morning when a nurse at the long-term care facility where he lives noticed that he was confused. Shortly after being admitted to the hospital, he became combative and had to be restrained. His bed linens have to be changed frequently because of urinary incontinence. Which nursing diagnosis best describes this client's condition?

functional incontinence

A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours?

functional incontinence

A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs?

gastronomy tube

The nurse is teaching a client about the use of MyPlate. Which teaching will the nurse include regarding the food group that should constitute 30% of the client's daily meals? grains fruit protein vegetables dairy

grains vegetables

Persistent gaps between the health status of minorities and non-minorities are defined as:

health disparities

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?

intermittent urethral catheter