PRNU 114 exam 2 practice questions

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client?

"Are you taking any B-complex vitamins?" Certain drugs can cause the urine to change color. Vitamin B-complexes can turn the urine green. Diuretics may cause the urine to turn pale yellow. Phenazopyridine may cause the urine to turn orange or orange-red, whereas levodopa may cause the urine to turn brown or black.

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient?a. Teach the patient that incontinence is a normal occurrence with aging. b. Ask the patient's family to purchase incontinence pads for the patient. c. Teach the patient to perform PFMT exercises at regular intervals daily. d. Insert an indwelling catheter to prevent skin breakdown.

c. Kegel exercises may help a patient regain control of the micturition process. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. An indwelling catheter is the last choice of treatment.

A nurse is caring for a client with a gastrostomy tube in place. Which is an accurate guideline for care of the insertion site?

If the gastric tube insertion site has healed and the sutures are removed, use soap and water to clean the site. If the gastric tube insertion site has healed and the sutures are removed, wet a washcloth and apply a small amount of soap onto it. Gently cleanse around the insertion site, removing any crust or drainage. If the gastrostomy tube is new and still has sutures holding it in place, dip a cotton-tipped applicator into sterile saline solution and gently clean around the insertion site, removing any crust or drainage. Avoid adjusting or lifting the external disk for the first few days after placement, except to clean the area.

The nurse is performing digital removal of a fecal impaction. Which nursing actions follow guidelines for this procedure? Select all that apply.

Place the client in a side-lying position. Use nonsterile gloves for the procedure because the intestinal tract is not sterile. Provide a sitz bath or tub bath after the procedure to soothe the perianal area The nurse would have the client in a side-lying position. The nurse would use nonsterile gloves for the procedure because the intestinal tract is not sterile. The nurse would lubricate the index finger generously to reduce irritating the rectum, and insert the finger gently into the anal canal. The nurse would not have the client lie on the stomach. The nurse would use a gentle action, not a vigorous one, to break up the hardened mass of stool. The nurse would not use an enema unless it was ordered by the health care provider.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

The client will have to wear an external appliance to collect urine An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order

Place the client in high Fowler's position. Measure the intended length to insert the NG tube. Lubricate the tube tip with water-soluble lubricant. Direct the tube upward and backward along the floor of the nose. Instruct the client to place the chin onto the chest. Advance the tube while the client swallows. An upright position is more natural for swallowing and protects against bronchial intubation aspiration, if the client should vomit. Therefore, the high Fowler's position is recommended for the client. Measurement ensures that the tube will be long enough to enter the client's stomach. Lubrication reduces friction and facilitates passage of the tube into the stomach. Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likelihood of mucosal injury. Bringing the head forward helps close the trachea and open the esophagus. Swallowing helps advance the tube, causes the epiglottis to cover the opening of the trachea, and helps to eliminate gagging and coughing.

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 A clean-catch specimen is a sample of urine that is considered sterile. A clean-catch specimen is preferred to a randomly voided specimen. This method of collection is preferred when a urine specimen is needed during a client's menstrual cycle. A void specimen is a sample of fresh urine collected in a clean container. A catheter specimen is a sample of urine collected in a sterile environment using a catheter. A 24-hour specimen is a sample of urine collected over a 24-hour period

A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a. Remove the tray from the room. b. Administer an antiemetic and encourage the patient to take small amounts. c. Explore with the patient why she does not want to eat her food. d. Offer high-calorie snacks such as pudding and ice cream.

a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? a. Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. b. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. c. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. d. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals.

A nurse nutritionist is collecting assessment data for a patient who complains of "tiredness" and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm? a. Malabsorption b. Anemia c. Protein depletion d. Reduction in total muscle mass

b. Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased indicates anemia, if increased indicates dehydration. Serum albumin tests for malnutrition and malabsorption. Protein depletion and malnutrition are diagnosed with serum albumin, prealbumin, transferrin, and blood urea nitrogen tests. The creatinine test may indicate dehydration, reduction in total muscle mass, and severe malnutrition.

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 Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide?

"This test detects heme, a type of iron compound in blood in the stool." The nurse will teach the client that that the FOBT detects heme. It does not test for food issues, nor does it test for infection. The fecal immunochemical test (FIT) results have a high rate of specificity for colorectal cancer.

Total parenteral nutrition (TPN) has been ordered for a client. The nurse is aware that the assessment criteria for ordering TPN is what?

-Client is not able to absorb nutrients properly -A debilitating condition for more than 2 weeks -Renal or hepatic failure Assessment data to determine if a client is eligible for TPN include inability to absorb nutrients, a debilitating condition lasting more than 2 weeks, and renal or hepatic failure. If the client has an intact gastrointestinal tract then the client should be able to adhere to a regular diet. Tolerating a full-fluid diet also assesses that the gastrointestinal tract is functional and TPN is not warranted.

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority?

Asking the client when he or she had last urinated In assessing the bladder, the nurse would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.

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

Avoid more than 250 mg The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. To insert a nasointestinal tube, the nurse should measure the tube from the tip of nose to the earlobe and from the earlobe to the xiphoid process and add 8 to 10 in (20 to 25 cm) for intestinal placement. The client should be placed on his or her right side. Analgesia is not normally required in anticipation of placement.

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.

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. The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds. If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds. Allowing the low intermittent to continue during the assessment will interfere with the auscultation of the sounds. Disconnect of the tube can occur immediately and not for 1 hour prior to the assessment.

The nurse is assessing a client with a urinary sheath catheter. After removing the catheter, the nurse observes a break in skin integrity on the penis. What actions by the nurse would be appropriate at this time?

Do not reapply the urinary sheath Allow the skin to be open to air as much as possible Arrange for a consult with a wound nurse If the nurse finds a break in skin integrity when assessing the client's penis, the should not reapply the external urinary sheath. The nurse should allow the skin to be open to air as much as possible. If the facility has a wound, ostomy, and continence nurse, a consult should be arranged. An indwelling catheter should be used as a last resort due to the increased risk of urinary tract infection.

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter?

Fasten the condom securely enough to prevent leakage without constricting blood flow. Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1 to 2 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.

An older adult client tells the nurse, "I give myself a mineral oil enema every day." What is the appropriate nursing response?

Mineral oil enemas can interfere with absorption of fat-soluble vitamins." The nurse will caution the client that self-administration of mineral oil to relieve constipation can interfere with absorption of fat-soluble vitamins. The nurse can then further discuss the reason the client is performing this treatment and determine other appropriate interventions to relieve constipation.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment?

Monitoring the characteristics of the urinary output The effectiveness of therapy is determined by the urine characteristics. On completion of the therapy with continuous bladder irrigation, the client should exhibit urine that is clear, without evidence of clots or debris. The client will have no PVR during therapy. Palpation of the bladder region and calculation of a particular outflow rate do not determine the success or failure of therapy.

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 Radiographic (x-ray) examination is the only absolutely reliable method to determine accurate tube placement. In the absence of an x-ray, pH testing is predicative of correct placement. Although visualization of aspirated contents can help confirm correct placement of the tube, this method is not as reliable as an x-ray.

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. If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?

The client has an enlarged prostate Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician?

The stoma is prolapsed. If the stoma is found to be prolapsed, the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.

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 A condom catheter is a flexible sheath that is rolled around the penis. A urinary bag (U-bag) is a bag attached by adhesive backing to the skin surrounding the genitals. A straight catheter is a urine drainage tube inserted but not left in place. A retention (or indwelling) catheter is a urine drainage tube that is left in place over a period of time.

A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract c. A patient who is underweight and needs short-term nutritional support d. A patient who is comatose and needs long-term nutritional support e. A patient who has anorexia and refuses to take foods via the oral route f. A patient with burns who has not been able to eat adequately for 5 days

a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract; and when oral intake has been or is expected to be inadequate over a 7- to 14-day period (McClave et al., 2016; Worthington & Gilbert, 2012). PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. a. A patient diagnosed with peritonitis b. A patient who is on prolonged bedrest c. A patient who has diarrhea d. A patient who has gastroenteritis e. A patient who has an early bowel obstruction f. A patient who has paralytic ileus caused by surgery

a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes (Hogan-Quigley, Palm, & Bickley, 2017)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction.

A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply. a. Draw up 30 mL of saline solution into the syringe. b. Unclamp the suction tubing near the connection site to instill solution. c. Place the tip of the syringe in the tube to gently insert saline solution. d. Place the syringe in the blue air vent of a Salem sump or double-lumen tube. e. After instilling irrigant, hold the end of the NG tube over an irrigation tray. f. Observe for return flow of NG drainage into an available container.

a, c, e, f. The nurse irrigating an NG tube connected to suction should draw up 30 mL of saline solution (or the amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container.

A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply. a. Absence of nausea, vomiting b. Weight gain c. Bowel sounds within normal range d. Large amount of gastric residue e. Absence of diarrhea and constipation f. Slight abdominal pain and distention

a, c, e. Criteria to consider when evaluating patient feeding tolerance include: absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits.

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. a. A 78-year-old male patient diagnosed with an enlarged prostate b. An 83-year-old female patient who is on bedrest c. A 75-year-old female patient who is diagnosed with vaginal prolapse d. An 89-year-old male patient who has dementia e. A 73-year-old female patient who is taking antihistamines to treat allergies f. A 90-year-old male patient who has difficulty walking to the bathroom

a, c, e. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.

A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. a. Measure the patient's fluid intake and output. b. Keep the skin around the stoma moist. c. Empty the appliance frequently. d. Report any mucus in the urine to the primary care provider. e. Encourage the patient to look away when changing the appliance. f. Monitor the return of intestinal function and peristalsis.

a, c, f. When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.

The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? a. The male urethra is more vulnerable to injury during insertion. b. In the hospital, a clean technique is used for catheter insertion. c. The catheter is inserted 2 to 3 in into the meatus. d. Since it uses a closed system, the risk for UTI is absent.

a. Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6 to 8 in. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.

A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? a. A saline osmotic laxative b. A bulk-forming laxative c. Methylcellulose d. A stool softener

a. Certain saline osmotic laxatives can lead to fluid and electrolyte imbalances and should not be used in older adults or those with kidney or cardiac disease.

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? a. Decreased and highly concentrated b. Decreased and highly dilute c. Increased and concentrated d. Increased and dilute

a. Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? a. Have the patient follow a low-fiber diet several days before the test. b. Have the patient take bisacodyl and ingest a gallon of bowel cleaner on day 1. c. Prepare the patient for the use of general anesthesia during the test. d. Explain that barium contrast mixture will be given to drink before the test.

a. If possible, a low-residue diet (low fiber) should be followed several days before the procedure. Most will maintain the low-residue diet; others may have full liquid diet the day before the procedure. There are multiple types of bowel preps for this procedure. The provider performing the procedure will decide which is best for the individual patient. The prep is usually given as a split dose, with half being given the night before and rest the morning of the procedure. It is recommended the second dose be given at least 5 hours and completed at least 2 hours before the study. There are some who may receive the prep the same day as the procedure, especially if the procedure is scheduled for later in the day. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and small-bowel series of tests.

A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment?a. Use warm water or air and gentle pressure to remove the clog. b. Use a stylet to unclog the tubes. c. Administer cola to remove the clog. d. Replace the tube with a new one.

a. In order to remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.

A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish red today; is there something wrong with me?" What would be the nurse's best response? a. "This is a normal finding when taking phenazopyridine." b. "This may be a sign of blood in the urine." c. "This may be the result of an injury to your bladder." d. "This is a sign that you are allergic to the medication and must stop it."

a. Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine; the patient needs to be aware of this.

A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What action would be a priority when caring for this patient? a. Preventing the tubing from kinking to maintain free urinary drainage b. Not removing the sheath for any reason c. Fastening the sheath tightly to prevent the possibility of leakage d. Maintaining bedrest at all times to prevent the sheath from slipping off

a. The catheter should be allowed to drain freely through tubing that is not kinked. It also should be removed daily to prevent skin excoriation and should not be fastened too tightly or restriction of blood vessels in the area is likely. Confining a patient to bedrest increases the risk for other hazards related to immobility.

A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? a. Vitamin B malnutrition b. Obesity c. Dehydration d. Vitamin C deficiency

a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient? a.Incontinence b. Constipation c. Electrolyte imbalances d. Infection

a. The outcomes for this IPAA surgery are not always ideal, and many patients experience decreased quality of life due to frequent defecation and fecal seepage and incontinence.

A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process?a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime.

a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? a. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. b. The nurse wets a washcloth and washes the area around the tube with soap and water. c. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. d. The nurse tapes a gauze dressing over the site after cleansing it.

a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a. A patient who is taking narcotics for pain b. A patient who is taking metformin for type 2 diabetes mellitus c. A patient who is taking diuretics d. A patient who is dehydrated e. A patient who is taking amoxicillin for an infection f. A patient taking over-the-counter antacids

b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.

A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 lb. What would the nurse document as his BMI? a. 50.5 b. 52.4 c. 54.5 d. 55.2

b. 52.4 bmi= weight in pounds (325) divided by /(height in inches (66) X height in inches (66) ) all multiplied by 703

A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient? a. Administering pain medication after meals. b. Encouraging food from home when possible. c. Scheduling his respiratory therapy before each meal. d. Reinforcing the importance of his eating exactly what is delivered to him.

b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? a. Pouring warm water over the patient's fingers. b. Having the patient ignore the urge to void until her bladder is full. c. Using a warm bedpan when the patient feels the urge to void. d. Stroking the patient's leg or thigh.

b. Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding.

For which patient would a nurse expect the primary care provider to order colostomy irrigation? a. A patient with IBS b. A patient with a left-sided end colostomy in the sigmoid colon c. A patient with post-radiation damage to the bowel d. A patient with Crohn's disease

b. Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, post-radiation damage to the bowel, diverticulitis, and Crohn's disease (Kent et al., 2015).

A nurse caring for a patient's hemodialysis access documents the following: "5/10/20 0930 AV fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider? a. Positive bruit noted. b. Area is warm to touch and edematous. c. Patient denies pain and tenderness. d. Positive thrill noted.

b. The nurse would report a site that is warm and edematous as this could be a sign of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein. If these are not present, the access may be cutting off. No report of pain is a normal finding.

A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow? a. The nurse would use different equipment for catheterization of male versus female patients. b. The nurse should use the smallest appropriate indwelling urinary catheter. c. The nurse should always sterilize the equipment prior to insertion. d. The nurse should choose a 12F, 5-mL or 10-mL balloon, unless ordered otherwise.

b. The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient (ANA, 2014; SUNA, 2015a). The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16F gauge commonly used (Bardsley, 2015a). A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise (ANA).

A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply. a. Wear underwear with a synthetic crotch b. Take baths rather than showers c. Drink 8 to 10 8-oz glasses of water per day d. Drink a glass of water before and after intercourse and void afterward e. Dry the perineal area after urination or defecation from the front to the back f. Observe the urine for color, amount, odor, and frequency

c, e, f. It is recommended that a healthy adult drink 8 to 10 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse.

A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? a. A 19-year-old patient who is a vegan b. An older adult patient who takes daily nutritional drinks c. A 43-year-old patient who takes ginkgo biloba and an aspirin daily d. An infant who is breastfeeding

c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery.

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? a. Elevate the head of the bed 30 degrees and reposition the rectal tube. b. Place the patient in a supine position and modify the amount of solution. c. Lower the solution container and check the temperature and flow rate. d. Remove the rectal tube and notify the primary care provider.

c. If the patient reports severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. The head of the bed may be elevated 30 degrees for the patient's comfort if the patient needs to be placed on a bedpan in the supine position while receiving the enema.

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? a. Reassure the patient that this is a normal finding with a new ostomy. b. Notify the primary care provider that the stoma is prolapsed. c. Have the patient rest for 30 minutes to see if the prolapse resolves. d. Remove the appliance and redo the procedure using a larger appliance.

c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? a. Irrigation of long-term urinary catheters is a routine order.I b. Irrigation is recommended to prevent the introduction of pathogens into the bladder. c. A blood clot threatens to block the catheter. d. It is preferred to irrigate the catheter rather than increase fluid intake by the patient.

c. The flushing of a tube, canal, or area with solution is called irrigation. Natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction (Gould et al., 2009; SUNA, 2015a). However, intermittent irrigation is sometimes prescribed to restore or maintain the patency of the drainage system. Sediment or debris, as well as blood clots, might block the catheter, preventing the flow of urine out of the catheter.

A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient? a. The nurse administers a large volume of solution (500 to 1,000 mL) b. The nurse mixes milk and molasses in equal parts for an enema c. The nurse instructs the patient to retain the enema for at least 30 minutes d. The nurse administers the enema while the patient is sitting on the toilet

c. The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer's instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort.

A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should be the nurse's next action?a. Reassure the patient that this is a normal reaction to the procedure. b. Stop the procedure, prepare to administer CPR, and notify the primary care provider. c. Stop the procedure, assess vital signs, and notify the primary care provider. d. Stop the procedure, wait 5 minutes, and then resume the procedure.

c. When a patient reports dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the health care provider. The vagus nerve may have been stimulated.

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. a. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. b. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. c. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. d. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. e. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. f. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

d, e, f. A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.

A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a. "When you inspect the stoma, it should be dark purple-blue." b. "The size of the stoma will stabilize within 2 weeks." c. "Keep the skin around the stoma site clean and moist." d. "The stool from an ileostomy is normally liquid." e. "You should eat dark-green vegetables to control the odor of the stool." f. "You may have a tendency to develop food blockages."

d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark-green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? a. c, b, d, a b. d, c, a, b c. a, b, d, c d. b, a, d, c

d. A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them.

Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18? a. Risk for Imbalanced Nutrition: More Than Body Requirements b. Imbalanced Nutrition: More Than Body Requirements c. Readiness for Enhanced Nutrition d. Imbalanced Nutrition: Less Than Body Requirements

d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced.

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? a. The stoma is hard and dry. b. The stoma is a pale pink color. c. The stoma is swollen. d. The stoma is a purple-blue color.

d. A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should subside with time. A normal stoma should be moist and dark pink to red in color.

A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? a. Auscultate the bowel sounds. b. Measure the gastric aspirate pH. c. Measure the amount of residual in the tube. d. Obtain an order for a radiographic examination of the tube.

d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement.

A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention? a. Using a diet that is low in bulk b. Decreasing fluid intake to 1,000 mL c. Administering an enema once a day to stimulate peristalsis d. Monitoring bowel movements

d. For a bowel-training program to be effective, the nurse should monitor bowel movements including frequency, consistency, shape, volume and color, as appropriate, monitor bowel sounds, teach patient about specific foods that are assistive in promoting bowel regularity, ensure privacy, and encourage adequate fluid intake.

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least important for the evaluation process? a. The incontinence pattern b. State of physical mobility c. Medications being taken d. Age of the patient

d. Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the care plan.

A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a. The patient consumed 75% of the liquids on her breakfast tray. b. The patient tells you she is hungry. c. The patient's abdomen is soft, nondistended, with bowel sounds. d. The patient reports fullness and diarrhea after breakfast.

d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.

A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a. Feed the patient solids first and then liquids last. b. Place the head of the bed at a 30-degree angle during feeding. c. Puree all foods to a liquid consistency. d. Provide a 30-minute rest period prior to mealtime.

d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.

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 client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine.

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

fecal occult blood test, barium studies, endoscopic examination There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

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 The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

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. Niacin, part of the B vitamins, has a known side effect of flushing and itching after ingestion. The other vitamins that make up the B complex vitamin are B1 thiamin, B2 riboflavin, B3 niacin, B5 pantothenic acid, B6 pyridoxine, B7 biotin, B9 folic acid, and B12 cobalamin. Other adverse effects of the B complex vitamins include nausea, vomiting, constipation, abdominal pain, and black stools.

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

past the internal sphincter To be effective, a suppository must be inserted past the internal sphincter, which is about the distance of the finger of insertion.

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?

removes hardened fecal impactions from the rectum Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction; preventing involuntary escape of fecal material during surgical procedures; promoting visualization of the intestinal tract by radiographic or instrument examination; and helping to establish regular bowel function during a bowel training program. Oil-retention enemas lubricate the stool and intestinal mucosa, making defecation easier. Enemas are not used for diarrhea.