Exam 2

teratogenic

Drugs known to cause birth defects

A client is to be discharged home with an indwelling catheter. The client asks, "How will I be able to move around and carry this bag?" Which statement by the nurse will teach the client about the appropriate use of a leg bag? "I can show you how to use a leg bag when you are up and walking about." "You can disconnect the bag when you want to get up and walk." "When you are at home, you can clamp the catheter so it does not drain." "Just hook it onto your trousers or pants when you need to."

"I can show you how to use a leg bag when you are up and walking about." Telling the client about the leg bag is the most appropriate response because it addresses the client's concern and provides the client with information to alleviate anxiety about ambulating. The bag should never be disconnected from the catheter because this would open the system and increase the risk for infection. The catheter should not be clamped unless the health care provider has prescribed it to be clamped, such as with a bladder retraining program. Telling the client to hook the bag on the pants is nontherapeutic and does not address the client's concerns.

A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient? 1)BP will be lower than 135/85 on all occasions. 2)BP will be normal after 2 to 3 weeks on medication. 3)Patient will not experience dizziness on rising. 4)Urine output will increase to at least 50 ml/hr

1) BP will be lower than 135/85 on all occasions

A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient>? The patient will increase his consumption of: 1) Bananas, peaches, molasses, and potatoes 2) Eggs, baking soda, and baking powder 3) Wheat bran, chocolate, eggs, and sardines 4) Egg yolks, nuts and sardines

1) Bananas, peaches, molasses, and potatoes

When the nurse enters a patient's room to administer a medication, the patient calls out from the bathroom telling the nurse to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed? 1) Inform the patient that she will return when he is finished in the bathroom. 2) Wait outside the bathroom door until the patient is ready for the dose. 3) Withhold the dose until the next administration time later in the day. 4) Document that the dose was omitted in the medication administration record.9.

1) Inform the patient that she will return when he is finished in the bathroom

A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with a nasogastric (NG) tube for gastric drainage. How should the nurse proceed? 1)Seek clarification from the surgeon about the medication order. 2)Clamp the NG tube while administering the dose by mouth. 3)Instill the medication through the NG tube. 4)Withhold the oral potassium chloride elixir.

1)Seek clarification from the surgeon about the medication order.

Which laboratory test result most accurately reflects a patient's nutritional status? 1)Albumin 2)Prealbumin 3)Transferrin 4)Hemoglobin

2) Prealbumin

The Primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug? 1)Place the drug in the cheek and allow it to dissolve. 2)Place the drug under the tongue and allow it to dissolve. 3)Inject the drug superficially into the subcutaneous tissue. 4)Give the pill and water to the patient for him to swallow the tablet.

2)Place the drug under the tongue and allow it to dissolve

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will: 1)Limit his intake of protein. 2)Avoid foods containing gluten. 3)Restrict his use of sodium. 4)Limit his intake of potassium-rich foods.

3) restrict his use of sodium

A nurse identifies the nursing diagnosis Diarrhea related to stress for a patient. Which nursing intervention should be included in the nursing care plan to help the patient relieve the cause of the diarrhea? 1)Monitor and record the frequency of stools on the graphic record. 2)Administer prescribed antidiarrheal medications as needed. 3)Encourage the patient to verbalize about stressors and anxiety. 4)Provide oral fluids on a regular schedule.

3)Encourage the patient to verbalize about stressors and anxiety.

Which urine specific gravity would be expected in a patient admitted with dehydration? 1)1.002 2)1.010 3)1.025 4)1.030

4) 1.030 (higher the number, the more dehydrated)

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate? An problem-focused nursing diagnosis A risk nursing diagnosis A possible nursing diagnosis A health promotion nursing diagnosis

A health promotion nursing diagnosis Explanation: The client is seeking information related to healthy practices. Health promotion nursing diagnoses are formulated to assist the client to meet that need. The client has no health problem, risk of a health problem, or possible problem, so a problem-focused, risk, or possible nursing diagnosis would be inappropriate.

medication reconciliation

A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.

Cognitive vs affective vs physiologic vs psychomotor

Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude, such as planning to attend the support group at the hospital. Physiologic outcomes are physical changes in the client, such as being able to eat a soft diet within 3 days after surgery. Psychomotor outcomes describe the client's achievement of new skills, such as emptying the ileostomy bag.

Outcome identification

Identify expected outcomes, individualize to the person, culturally appropriate, realistic and measurable, include a timeline "Pt will have soft, formed stool in 3 days."

A nurse caring for a client with a nephrostomy tube finds that the urine output from the tube has decreased and notifies the physician. The physician writes an order for the tube to be irrigated. Which would be most appropriate for the nurse to do when irrigating a nephrostomy tube? Use clean technique. Irrigate with sterile saline. Clamp the nephrostomy tube. Instill 50 mL of solution.

Irrigate with sterile saline.

A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the client's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is 3 hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which type of skills?

Legal/ethical reporting problems and unacceptable practices is an aspect of ethical/legal skills. Technical skills enable the safe performance of kinesthetic tasks while interpersonal skills are the manifestations of caring. Cognitive skills encompass knowledge and critical thinking.

The nurse is caring for an older adult client who has an indwelling catheter. Which intervention(s) will the nurse include in the client's plan of care to prevent complications commonly associated with indwelling catheters? Select all that apply. Allow the drainage bag to fill completely before emptying. Perform perineal care prior to care of the catheter. Put on sterile gloves before cleaning the catheter. Clean 6 to 8 in (15 to 20 cm) of the catheter, moving from the meatus downward. Slightly pull on the catheter during the cleaning motion to dislodge crusts. Maintain the drainage bag below the level of the bladder.

Perform perineal care prior to care of the catheter. Clean 6 to 8 in (15 to 20 cm) of the catheter, moving from the meatus downward. Maintain the drainage bag below the level of the bladder If the client has an indwelling catheter, daily care for the catheter is usually done after perineal care to prevent contamination of the perineum from any harmful pathogens that may be on the outside of the catheter. To prevent infection, the direction of cleaning is "clean to dirty," that is, cleanest (what is most proximal to the client's body) and dirtiest (what is most distal to the client's body). For this reason, the nurse will clean 6 to 8 in (15 to 20 cm) of the catheter, moving from the meatus downward. The drainage bag needs to be emptied regularly, regardless of whether it is full. A full bag has a greater chance of colonizing harmful pathogens. The drainage bag needs to be kept below the height of the bladder to prevent urine from flowing back into the bladder, which can pose a serious risk for a urinary tract infection. The nurse will don clean, not sterile, gloves before cleaning the catheter. The nurse will use caution not to pull or tug on the catheter during the cleaning motion, because this can cause tissue damage and/or discomfort, especially for an older adult client

Which interpersonal skill is essential to the practice of nursing?

Promoting the dignity and respect of clients as people Explanation: Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship. Keeping emotional distance is not part of the caring component of nursing. Keeping clients' personal information confidential is an ethical and legal skill. Performing technical skills is essential, but technical skills are not interpersonal skills.

The nurse has taught a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning? The patient:

Takes measures to reduce her stress level.

Pharmacodynamics

The process by which a medication works on the body.

Pharmacokinetics

The process by which drugs are absorbed, distributed within the body, metabolized, and excreted: absorption, distribution, metabolism, excretion

2000 calorie daily values

Total fat should be less than 65 g; saturated fat should be less than 20 g; cholesterol should be less than 300 mg, and sodium should be less than 2400 mg.

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? dehydration hypovolemia balanced fluids renal failure

dehydration

functional health assessment

health perception and health management; activity and exercise; nutrition and metabolism (eating habits); elimination/excretory function (bowel, bladder, and skin); sleep and rest; cognition and perception; self-perception and self-concept; roles and relationships (interactions with others); coping and stress tolerance; sexuality and reproduction; and values and beliefs (sources of support - daughter as caregiver).

A nurse formulates a nursing diagnosis of "constipation related to adverse effect of opioid analgesic as evidenced by no bowel movement in 4 days." The nurse identifies the defining characteristic as: constipation. adverse effects of medication. no bowel movement in 4 days. opioid analgesic.

no bowel movement in 4 days. Explanation: The defining characteristics are the observable cues or inferences that cluster as manifestations, which in this case is the lack of a bowel movement in 4 days. Constipation is the diagnostic label. Adverse effect of the medication is the related factor. Opioid analgesic is part of the related factor.

The nurse is reporting for work and notes each of the nurse's assigned clients have a percutaneous endoscopic gastrostomy (PEG) tube inserted. Which client should the nurse prioritize care for as the shift starts? residual of 210 ml bowel sounds of 6 per minute respiratory rate of 18 breaths/min and unlabored oral temperature of 99.8°F (37.6°C)

residual of 210 ml As a rule of thumb, the gastric residual should be no more than 100 mL or no more than 20% of the previous hour's tube feeding volume. If the residual is more than 200 mL, the feeding should be delayed and residual rechecked in 30 minutes. The nurse should ensure the feeding has been stopped and note what time the residual should be rechecked. Bowel sounds should be at least 5 per minute and a respiratory rate of 18 breaths/min and unlabored are within normal limits. The client with the slightly elevated temperature would be the next client of the nurse to assess.

Components of Nursing Diagnosis

the problem, the etiology (r/t), the symptoms (defining characteristic) ex: ineffective breathing pattern r/t hypoventilation aeb SpO2 of 85%

A nurse catheterizing a male client asks if he had an indwelling catheter previously and if so, why and for how long? The nurse uses this information to asses for which conditions? urinary incontinence urethral strictures prostate enlargement urinary tract infection (UTI)

urethral strictures The nurse asks the client if he has ever been catheterized. If he had an indwelling catheter previously, ask why and for how long it was used. The client may have urethral strictures, which may make catheter insertion more difficult.

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client? dorsogluteal site ventrogluteal site vastus lateralis site deltoid site

vastus lateralis site The vastus lateralis site is most desirable for administering injections to infants and small children, as well as clients who are thin or debilitated with poorly developed gluteal muscles. The dorsogluteal site is avoided in clients younger than 3 years because their gluteus maximus muscle is not sufficiently developed. The ventrogluteal site, however, is safe for children. The deltoid site is the least-used intramuscular injection site because it is a smaller muscle than the others. It is used only for adults because the muscle is not sufficiently developed in infants and children.