Exam 4 315

The nurse is preparing to teach a class on constipation prevention. The nurse is aware that high-fiber foods should be suggested and that which food is high in fiber? A) Raw fruits B) Cooked vegetables C) White bread D) Cooked fruits

A) Raw fruits

The nurse is caring for a client with chronic constipation. The nurse is aware that which may be causes of constipation? Select all that apply. A) Bed rest B) High-fiber foods C) Low-fiber foods D) Chronic laxative use E) Depression

A) Bed rest C) Low-fiber foods D) Chronic laxative use E) Depression

A client shows the nurse an area of erythema, swelling, and lesions under a wedding ring. What should the nurse realize this client is experiencing? A) Psoriasis B) Allergic contact dermatitis C) Eczema D) Irritant contact dermatitis

B) Allergic contact dermatitis B) Manifestations of allergic contact dermatitis include erythema, swelling, and pruritic lesions in the area of allergen contact, in this case under the client's wedding ring. Irritant contact dermatitis is an inflammation of the skin that occurs from irritants such as chemicals, soaps, and detergents. Eczema and psoriasis are secondary skin lesions that cause the skin to shed.

The nurse is caring for a client who has been experiencing intermittent diarrhea. The client has been advised to increase the amount of soluble fiber in the diet. The nurse has instructed the client and spouse regarding appropriate dietary choices. Which food selection by the client indicates that teaching has been effective? Select all that apply. A) Sunflower seeds B) Carrot slices C) Spinach salad D) Corn muffins E) Peas

B) Carrot slices E) Peas

The nurse is triaging a client who presents to the urgent care clinic with symptoms of severe flank pain with spasms, nausea, vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the lower back to the lower quadrants of the abdomen. What should the nurse do next? A) Complete the physical assessment. B) Refer the client to a urologist immediately. C) Instruct the client to increase fluids. D) Obtain a urine specimen for culture.

B) Refer the client to a urologist immediately.

A female client is admitted to the Emergency Department and diagnosed with urinary calculi. The client reports that she has had symptoms for 1 week. The nurse is planning care for the client. Which nursing diagnosis is appropriate for this client? A) Risk for Constipation B) Risk for Disuse Syndrome C) Imbalanced Nutrition D) Activity Intolerance

C) Imbalanced Nutrition

A nurse working at a burn center is caring for a client with an electrical burn. According to the American Burn Association, how would this burn be classified? A) Minor B) Moderate C) Major D) Significant

C) Major C) According to the American Burn Association, all electrical burns are classified as major. Significant is not a classification according to the American Burn Association, and all other choices are incorrect.

A client with urinary calculi has been admitted to the hospital. The nurse is planning care for this client. Which goal is appropriate for this client? A) The client will lose 25 pounds in 3 months. B) The client will ambulate three times a day. C) The client will request pain medication at the onset of pain. D) The client will shower independently.

C) The client will request pain medication at the onset of pain.

The nurse is caring for a client with a history of kidney stones. The stones have been analyzed and are all composed of calcium phosphate. The nurse teaches this client to reduce intake of which foods? A) Chicken, beef, and ham products B) Organ meats, sardines, and seafood C) Tomatoes, fruits, and nuts D) Flour, milk, and ice cream

D) Flour, milk, and ice cream

A client is being evaluated after suffering severe burns to the torso and upper extremities. The nurse notes edema at the burned areas. What best describes the underlying cause for this manifestation? A) Decreased osmotic pressure in the burned tissue B) Reduced vascular permeability at the site of the burned area C) Increased fluids in the extracellular compartment D) Inability of the damaged capillaries to maintain fluids in the cell walls

D) Inability of the damaged capillaries to maintain fluids in the cell walls D) Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. There is a reduction of fluids in the extracellular body compartments.

A client has a wound of the left lateral aspect of the thigh. What should the nurse do to promote wound healing for this client? A) Position to keep weight off of the wound. B) Position with weight directly on the wound. C) Restrict fluids. D) Enforce strict bedrest.

A) Position to keep weight off of the wound. A) To promote wound healing, the client should be positioned to keep pressure off the wound, not directly on it. The client should be assisted in early ambulation and strict bedrest should not be enforced. Fluid restriction does not encourage wound healing.

A client tells the nurse that flakes of skin come loose with every shampoo. Which type of secondary skin lesion is this client most likely experiencing? A) Nodule B) Macule C) Scale D) Crust

C) Scale C) Scales are flakes of greasy, keratinized skin tissue that vary in color from white, gray, to silver. An example of this type of skin lesion is dandruff. Macules and nodules are primary skin lesions. A crust is an area of dry blood, serum, or pus left on the skin surface when vesicles or pustules break.

The nurse is preparing to discharge a client who was admitted with a kidney stone. The client underwent a lithotripsy. What should the nurse teach the client to prevent further complications of urinary calculi after discharge? A) "You will need to increase your oral fluid intake to 1L/day." B) "It will be important that you not drive while taking pain medications." C) "It will be important to maintain a diet high in purines." D) "You will need to monitor for the signs and symptoms of a urinary tract infection (UTI)."

D) "You will need to monitor for the signs and symptoms of a urinary tract infection (UTI)."

The nurse is planning care for a client with a surgical wound. What would be the goal for this client? A) Discharge to home as soon as possible. B) Resume independent activities of daily living. C) Increase ambulation. D) Regain intact skin.

D) Regain intact skin. D) The client has impaired skin integrity because of a surgical wound. A goal of care would be for the client to have wound healing to achieve intact skin. Discharging the client to home may or may not be appropriate. The client may or may not be able to ambulate or perform independent activities of daily living.

A client is complaining of dull flank pain. List the order of the steps the nurse should take in conducting a physical assessment. 1. Instruct the client. 2. Assess the general appearance. 3. Position the client. 4. Inspect the abdomen for color, contour, symmetry, and distention.

1,3,2,4

A graduate nurse has joined the staff in the care of renal clients. The graduate asks the preceptor what puts a client at risk urinary calculi. The nurse identifies which client as having the greatest risk for urinary stones? A) A 35-year-old female with quadriplegia from an auto accident B) A 65-year-old male with a recent history of myocardial infarction C) A 50-year-old male with type II diabetes mellitus D) A 25-year-old female with several episodes of urinary infection

A) A 35-year-old female with quadriplegia from an auto accident

A nurse is working in a skilled nursing facility and is performing an assessment on an 87-year-old client. The nurse notes that the client has hypopigmentation of the skin on both hands. What causes this condition? A) Hyperplasia of melanocytes B) Decreased perfusion of the dermis C) Increased permeability of the epidermal layer D) Hyperplasia of capillaries

A) Hyperplasia of melanocytes A) Hypopigmentation, also known as age spots, is a common finding on the back of the hands of an older adult. Hypopigmentation is caused by hyperplasia of melanocytes. The other findings are incorrect.

The nurse is planning care for a client in the acute stage of a burn injury. Which areas will be included in the plan of care? Select all that apply. A) Nutrition B) Psychosocial support C) Pain management D) Fluid resuscitation E) Wound care

A) Nutrition C) Pain management E) Wound care Nursing care for the client during the acute stage of burn injuries will include wound care, nutritional therapy, and pain management. Fluid resuscitation occurs during the emergency phase of burn care. Psychosocial support will be needed once the client has stabilized.

The nurse educator is speaking with a group of students about renal disorders. The educator knows that which statement is true about renal stones? A) The elderly are particularly at risk for urolithiasis. B) Young- or middle-adulthood men are at an increased risk for stones. C) Women are affected more than men. D) Frequency is greater in the northern United States.

B) Young- or middle-adulthood men are at an increased risk for stones.

The nurse is caring for a client who was recently diagnosed with benign prostatic hyperplasia (BPH). The client is being seen in the clinic because of an increase in symptoms. Which statement by the client would best explain the source of the increased symptoms? A) "I have decreased oral intake at night." B) "I recently had a vasectomy." C) "I am using an over-the-counter cold medication for a cold." D) "I am taking over-the-counter saw palmetto."

C) "I am using an over-the-counter cold medication for a cold." C) Use of cold medications can increase symptoms because of their anticholinergic properties. Use of saw palmetto and decreased oral intake at night may resolve symptoms. A vasectomy does not affect the symptoms of BPH.

While assessing the feet and ankles of an older client, the nurse presses a finger into the client's skin in order to create an indentation. For what is the nurse assessing? A) Periorbital edema B) Ascites C) Pitting edema D) Sacral edema

C) Pitting edema C) Excess fluid trapped in bodily tissue, such as the feet and ankles, creates edema. To assess for the amount of edema, the nurse presses a finger into the edematous area to create an indentation. The amount of indentation indicates the level of edema. Ascites is abdominal swelling. Sacral edema is swelling around the hips and buttock region. Periorbital edema is swelling around the eyes.

The nurse reviewing discharge instructions with a client and his wife would identify the need for further instruction when the client's wife makes which statement? A) "While he is taking the antibiotics, it is very important for him to drink a generous amount of water to prevent damage to his kidneys." B) "Drinking cranberry juice will decrease the risk for developing urinary tract infections." C) "We should contact his doctor prior to his taking any over-the-counter medication." D) "Drinking cranberry juice will increase the risk for developing calcium-based urinary stones."

D) "Drinking cranberry juice will increase the risk for developing calcium-based urinary stones." D) Consuming cranberry juice and foods that acidify the urine reduces, not increases, the risk of repeated urinary tract infections and reduces, not increases, the formation of calcium-based urinary stones. Antibiotics can damage the kidneys; therefore, it is important to maintain a generous fluid intake while taking antibiotics. The client should contact the physician prior to taking any over-the-counter medication due to the risk of urinary retention when taking over-the-counter medications.

The nurse is planning care for a newly admitted bed-bound elderly client. Which nursing diagnosis would be most appropriate for a client on bed rest? A) Risk of Bowel Incontinence B) Disturbed Body Image C) Risk of Diarrhea D) Risk of Constipation

D) Risk of Constipation D) Lack of activity, like bed rest, is a major contributor to constipation. Lack of movement slows bowel movements. Lack of sphincter control, not bed rest, contributes to bowel incontinence. Diarrhea would come from a GI upset triggered by diseases, medication, or diet. Disturbed Body Image would affect a client who has undergone a bowel diversion.

The nurse is evaluating care provided to a client with contact dermatitis. Which observation indicates that treatment has been effective? A) The client is fatigued from inadequate sleep due to pruritus. B) The client is observed walking in the hallway. C) The client has areas of excoriation on the arms and anterior legs from scratching during sleep. D) The client has reduced areas of contact dermatitis with evidence of skin healing.

D) The client has reduced areas of contact dermatitis with evidence of skin healing. D) Reduced areas of contact dermatitis with evidence of skin healing indicate that treatment for contact dermatitis has been effective. If the client has excoriation from scratching, the treatment has not yet been effective. The client walking in the hallway does not necessarily indicate that treatment was effective. If the client is unable to sleep because of pruritus, treatment has not been effective.

The nurse at a health fair is educating clients on risk factors associated with urinary incontinence. The nurse is aware that which is a non-modifiable risk factor? A) Age B) Obesity C) Smoking D) Diabetes

A) Age A) Age is a non-modifiable risk factor and is a primary risk factor for the development of urinary incontinence; older individuals experience more frequent incontinence than younger individuals. Obesity, smoking, diabetes, inactivity, pregnancy, and depression are all modifiable risk factors for urinary incontinence.

A client has an excoriated skin area with drainage. Which diagnostic test might be used to determine the cause of the skin lesion? A) Skin biopsy B) Culture C) Wood's lamp D) Patch test

B) Culture B) Cultures to identify infections may be conducted on tissue samples, on drainage and exudates from lesions, and on serum. Skin biopsies are used to differentiate a benign skin lesion from a skin cancer. A Wood's lamp is used to identify infections through immunofluorescent studies. Patch tests are used to determine allergies.

A client is admitted with a gunshot wound to the leg. Which nursing diagnosis would be important to include in this client's plan of care? A) Situational Low Self-Esteem B) Risk for Infection C) Anxiety D) Ineffective Coping

B) Risk for Infection B) A client with a gunshot wound is at risk for infection because the wound is severe and caused by trauma. The other nursing diagnoses may or may not be appropriate for the client at this time.

The nurse has established as an expected outcome that a client will "demonstrate healing of a stage II pressure ulcer over the coccyx." Which finding indicates that the client failed to achieve this outcome? A) The rubber doughnut pressure relief device was not delivered by central supply. B) The client's serum albumin increased over the last month. C) A right side-back-left side-back turning schedule was utilized. D) Nurses did not document disinfection of the wound with alcohol with each dressing change.

C) A right side-back-left side-back turning schedule was utilized. C) Because this expected outcome was not met, the nurse looks for problems in the provision of care or changes in the client's condition. Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back for 50% of the time. The schedule should be right side-back-left side-right side. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not indicate failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. The use of alcohol interrupts healing, so it is good that nurses did not document its use.

The nurse is concerned that a client is at risk for pressure ulcers. What did the nurse assess in this client? Select all that apply. A) Age 54 B) Body temperature within normal limits C) Low serum albumin level D) Continence of urine and stool E) Prescribed bedrest

C) Low serum albumin level E) Prescribed bedrest Risk factors for pressure ulcer development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure ulcer development. The age of 54 would not increase the client's risk for pressure ulcer development. A normal body temperature would reduce the client's risk for pressure ulcer development.

The nurse is admitting a child who has had diarrhea for 1 week. The nurse is writing the plan of care for the client. What is an appropriate goal for this client? A) The client will increase the amount of sugar in the diet. B) The client will defecate regularly by discharge. C) The client will limit fluid intake for 3 days. D) The client will regain normal stool consistency by discharge.

D) The client will regain normal stool consistency by discharge. D) As this client is experiencing diarrhea, the goal will be to regain normal stool consistency, which means less water will be in the stool, resulting in a more formed consistency. Defecating regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal; the problem needs to be corrected first. Since the client is experiencing diarrhea, which can dehydrate the body and promote electrolyte loss, limiting fluid is not appropriate. Increasing the amount of sugar in the diet will just add to the diarrhea.

A client is recovering from minimally invasive surgery due to a diagnosis of benign prostatic hyperplasia (BPH). The client is being transferred to a medical-surgical unit. After assessing the client, the nurse expects which outcome for this client? A) Bowel continence B) Absence of pain C) No postoperative treatment D) Urinary continence

D) Urinary continence D) After surgery and removal of the catheter, the client should return to urinary continence as expected. The client will need postoperative teaching and will experience some amount of discomfort. Most clients, due to pain and swelling in the area, will have problems with constipation at first.

You are providing training for the staff of a skilled care facility and want to include information on functional incontinence. What are some risk factors for institutional clients? Select all that apply. A) Limited mobility B) Impaired vision C) Lack of access to facilities D) Dementia E) Depression

A) Limited mobility B) Impaired vision C) Lack of access to facilities D) Dementia An immobilized client may wet the bed if a call light is not within reach; a client with Alzheimer disease may perceive the urge to void but be unable to interpret its meaning or respond by seeking a bathroom. A client with impaired vision may not be able to find the bathroom. Minimal facilities can create problems in urinary control. Depression is not usually related to incontinence.

The client admitted with benign prostatic hyperplasia (BPH) is prescribed an alpha-adrenergic blocker. The nurse is aware that which alpha-adrenergic blocker may have caused an adverse reaction known as first-dose phenomenon? A) Prazosin (Minipress) B) Doxazosin (Cardura) C) Dutasteride (Avodart) D) Finasteride (Proscar)

A) Prazosin (Minipress) A) The medication prazosin (Minipress) is an alpha-adrenergic blocker that may cause first-dose phenomenon (severe hypotension and syncope) and tachycardia. The medication doxazosin (Cardura) is an alpha-adrenergic blocker that may cause orthostatic hypotension, headaches, or dizziness. The medication dutasteride (Avodart) is a 5-alpha reductase inhibitor that may cause sexual dysfunction, decreased libido, or decreased ejaculate volumes. The medication finasteride (Proscar) is a 5-alpha reductase inhibitor that has no serious adverse reactions.

A nurse educator is teaching a urology unit to a group of nursing students. The educator is reviewing risk factors for the diagnosis of benign prostatic hyperplasia (BPH). The educator includes which risk factor to the group? Select all that apply. A) Excessive exercise B) Diet high in meat and fats C) Diet high in milk D) Age E) Race

B) Diet high in meat and fats D) Age E) Race Although the exact cause is unknown, risk factors associated with BPH are increasing age, men of African-American descent, and a diet high in meat and fat. No link has been made to milk or exercise.

A client with urinary incontinence asks the nurse what may have caused this condition. Which client statement leads the nurse to believe education has not been effective? A) "Relaxation of pelvic muscles may be a factor in incontinence." B) "Reduced urethral resistance can be a cause of incontinence." C) "Incontinence is normal with aging." D) "A disturbance of my bladder is a factor in the development of incontinence."

C) "Incontinence is normal with aging." C) Incontinence is not a normal result of aging. A disturbance of the bladder, relaxation of the pelvic muscles, and reduced urethral resistance are all potential factors in the development of incontinence.

A client was admitted with benign prostatic hyperplasia (BPH). The client's primary concern is burning and difficulty when urinating. Based on the findings, the nurse formulating the plan of care would be aware that which of the following is the priority nursing diagnosis? A) Fluid Volume Overload B) Fluid Volume Deficit C) Acute Pain D) Deficient Knowledge

C) Acute Pain C) The patient presents with burning on urination and difficulty urinating. The burning indicates the patient is experiencing pain and would indicate a priority nursing diagnosis of acute pain. There is no evidence of fluid volume overload, fluid volume deficit, or knowledge deficit.

The nurse is caring for a client with a history of chronic urinary tract infections. The nurse has chosen a diagnosis of Urinary Retention related to scarring from repeat urinary tract infections as evidenced by a bladder scan. Based on the client's presentation, what would the nurse anticipate the physician to order? A) Antibiotic therapy B) An anticholinergic medication C) Intermittent straight catheterization D) Removal of bladder stones

C) Intermittent straight catheterization C) The doctor may order straight catheterization so the client can be taught to self-catheterize and manage the problem at home. Anticholinergic medications can cause urinary retention. Bladder stones are not the problem; scarring is. Antibiotic therapy is not indicated, as the client does not have an infection now.

A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. What should the nurse respond to this request? A) "I will need to obtain an order from the physician to perform a massage." B) "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care." C) "I will record these findings in the medical record." D) "Massaging the area may actually cause more harm to a potentially compromised area of skin."

D) "Massaging the area may actually cause more harm to a potentially compromised area of skin." D) The presence of redness may indicate the presence of a stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted. Massages, when therapeutic, do not require a physician's order.

A client diagnosed with benign prostatic hyperplasia is being discharged. The nurse is reviewing discharge instructions with the client. Which statements made by the client indicate an understanding of the instructions? Select all that apply. A) "I should urinate at first urge." B) "I should avoid alcohol and caffeine." C) "I should avoid over-the-counter cold and sinus medications that contain decongestants or antihistamines." D) "I should still be able to enjoy a few beers every evening." E) "When I need to, I can still take the over-the-counter decongestant I have at home."

A) "I should urinate at first urge." B) "I should avoid alcohol and caffeine." C) "I should avoid over-the-counter cold and sinus medications that contain decongestants or antihistamines." Clients with mild benign prostatic hyperplasia (BPH) may control symptoms of mild BPH with lifestyle changes, such as urinating at first urge, avoiding fluids within 2 hours of bedtime, regular exercise, stress reduction, and avoiding alcohol and caffeine. Urinary retention in men with BPH can be precipitated by several classes of medications, including those with anticholinergic properties and over-the-counter medications for the common cold, such as decongestants.

The nurse is assessing a 63-year-old female client in a urology clinic. The client reports that she has been having "accidents." She expresses her frustration about this normal part of aging. Which statement by the nurse will be most correct at this time? A) "Incontinence is not a normal part of aging. Tell me more about the incontinence you are experiencing." B) "You may need to have surgery to manage this problem." C) "I understand you are frustrated about this occurrence." D) "Unfortunately, aging and incontinence go hand in hand."

A) "Incontinence is not a normal part of aging. Tell me more about the incontinence you are experiencing." A) As the body ages, there are anatomical changes that make the body increasingly likely to experience urinary incontinence. Still, urinary incontinence is not a normal part of aging and it would be appropriate to expand upon the situation. Telling the client you understand does not provide empathy. It is beyond the nurse's scope of practice to recommend surgery to the client.

You have been providing educational and supportive assistance for Brian, a 4-year-old client with encopresis. Which statement would indicate parental understanding of appropriate care? Select all that apply. A) "We established a limited schedule of activities that has many breaks so that he has the opportunity to use the toilet regularly." B) "We brought Brian to a play therapist to deal with adjusting to our new baby." C) "We didn't change his diet because we were afraid it would stress him out." D) "We've worked on regular elimination after morning and evening meals."

A) "We established a limited schedule of activities that has many breaks so that he has the opportunity to use the toilet regularly." B) "We brought Brian to a play therapist to deal with adjusting to our new baby." D) "We've worked on regular elimination after morning and evening meals." The underlying constipation that leads to encopresis may be caused by the stress of a full schedule of activities or other environmental changes (e.g., birth of a sibling). Dietary changes including incorporating high-fiber foods and limiting refined and highly processed foods and dairy products may be helpful. It takes several months for the bowel to be retrained to respond to sphincter stimulation.

The nurse is admitting a client to the medical unit for a urinary disorder. Which physical assessment technique will the nurse use in assessing this client's urinary system? Select all that apply. A) Auscultation B) Palpation C) Inspection D) Percussion E) Ultrasound

A) Auscultation B) Palpation C) Inspection :The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient. Auscultation is the technique of listening. The three systems that should be assessed using this technique are cardiovascular, respiratory, and gastrointestinal. Percussion technique is the least frequently used by nurses, and it would cause discomfort if this client were already uncomfortable with a kidney condition. The nurse should not make matters worse. An ultrasound is typically an assessment technique performed by the bedside nurse.

An older client with poor intake is demonstrating signs of poor wound healing. What should the nurse do to assist this client? Select all that apply. A) Ensure an adequate fluid intake. B) Assist with deep-breathing exercises. C) Medicate for pain prior to dressing changes. D) Request a dietary consult for nutritional support. E) Encourage ambulation.

A) Ensure an adequate fluid intake. D) Request a dietary consult for nutritional support. The nurse should ensure that the client receives sufficient protein and vitamins to support wound healing. The nurse should consult with a dietitian to determine ways to improve the client's intake to support wound healing. The client also needs an adequate fluid intake for wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.

A client is scheduled for BPH surgery and appears confused about the surgery and possible outcome. What topics should the nurse include in a discussion with the client? Select all that apply. A) Function of the prostate gland and its exact location B) BPH diet C) Expected surgical approach D) Scope of preoperative activities and postoperative conditions E) Presence of a urinary catheter

A) Function of the prostate gland and its exact location C) Expected surgical approach D) Scope of preoperative activities and postoperative conditions E) Presence of a urinary catheter Lack of knowledge about the prostate is confusing to many men. There is no specific BPH diet. Clients may also be confused about the surgical approach because of the several different methods. Understanding the scope of preoperative activities and postoperative conditions increases client cooperation with postoperative care. Explain to the client that he will have a urinary catheter when he returns from surgery. .

A nurse is caring for a client who is scheduled to undergo diagnostic testing to determine the cause of the client's dermatitis. What is true regarding this testing? A) In patch testing, an adhesive patch with common allergens is placed on the client's back. B) The patch from the patch test is usually removed after 2 weeks. C) Skin prick and skin injection tests are used to test for delayed reactions. D) The client may shower or exercise while the patch from the patch test is in place.

A) In patch testing, an adhesive patch with common allergens is placed on the client's back. A) In patch testing, an adhesive patch with common allergens is placed on the client's back. The patch from the patch test is usually removed after 48 to 72 hours. Skin prick and skin injection tests are used to test for immediate reactions. The client should not shower or exercise to the point of perspiring while the patch from the patch test is in place.

When planning care for a client at risk for developing pressure ulcers, which intervention(s) should be included? Select all that apply. A) Initiate a frequent toileting schedule. B) Raise the heels off of the bed. C) Turn the client every 4 hours. D) Use inflatable doughnut-style devices to reduce pressure on the sacrum. E) Massage pressure areas with lotion every 4 hours.

A) Initiate a frequent toileting schedule. B) Raise the heels off of the bed. Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. Raising the heels off of the bed should be done to remove pressure from this area of the client's body. The client should be turned at least every 2 hours. Massage of pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, as they increase pressure and reduce perfusion to affected areas.

The nurse is caring for a client with a history of urinary tract infections (UTI). Which intervention should the nurse implement for the client in helping to prevent future UTIs? A) Instruct the client to completely empty the bladder. B) Tell the client to increase sugar in the diet. C) Encourage the client to take bubble baths. D) Remind the client to wipe from back to front.

A) Instruct the client to completely empty the bladder. A) Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection. Irritating soaps and bubble baths can contribute to infections and should be avoided. The client should wipe from front to back because wiping from back to front would contaminate the urinary meatus. The client should decrease the use of sugar in the diet because sugar promotes bacterial growth.

The nurse is preparing the client for treatment of renal calculi that have failed to respond to medication therapy. What is the preferred treatment? A) Lithotripsy B) Surgery on the kidney to remove the stones C) Diet control D) Increasing fluids

A) Lithotripsy A) When medication fails to dissolve stones, the preferred method of treatment is lithotripsy, which is using sound waves to crush the stones so they can be passed out of the urinary system. Depending on the location of the stones, surgery may be the next step in the treatment process. Diet and fluids are used to prevent further stone formation.

A client admitted to the hospital with a diagnosis of gout has also been diagnosed with uric acid renal calculi. Which diet should the nurse anticipate may be ordered by the physician? A) Low-purine diet B) Low-sodium diet C) A diet high in calcium D) A diet low in calcium

A) Low-purine diet A) A low-purine diet is appropriate in the management of a client with uric acid renal calculi. A low-sodium diet is useful in the management of a client with cystine renal calculi, and a diet limiting foods high in calcium is useful when managing a client with calcium phosphate renal calculi.

An older client is admitted for a hip fracture. During postoperative recovery, the nurse notices a stage I pressure ulcer forming on the client's sacrum. What should the nurse do to reduce the progression of this stage of ulcer? A) Maintain the head of the bed at 30° angle, with client positioned on the right or left side. B) Apply a heat lamp to the area to increase circulation. C) Apply a dry dressing to the pressure ulcer. D) Maintain the head of the bed at 45° angle.

A) Maintain the head of the bed at 30° angle, with client positioned on the right or left side. A) Keeping the head of the bed at an angle of 30° or less decreases pressure on the sacrum. An angle of 45° would be too severe and could exacerbate pressure ulcer formation on the sacrum. Dry dressings are not indicated with this stage of pressure wound. Heat lamp is a method no longer used because it does not provide therapeutic benefit.

A client recovering from abdominal surgery tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What action(s) should the nurse take to help this client? Select all that apply. A) Notify the client's surgeon. B) Pack the wound with nonadherent gauze. C) Turn the client onto the abdomen. D) Position the client in bed with knees bent. E) Cover the area with a large, saline-soaked dressing.

A) Notify the client's surgeon. D) Position the client in bed with knees bent. E) Cover the area with a large, saline-soaked dressing. Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.

The charge nurse is observing a newly licensed nurse conduct an abdominal assessment on a client admitted with an abdominal mass. Which actions observed would indicate to the charge nurse the need to intervene? Select all that apply. A) The newly licensed nurse is performing palpation before auscultation. B) The newly licensed nurse is performing auscultation before palpation. C) The newly licensed nurse utilizes inspection, auscultation, percussion, and palpation during the abdominal assessment of the client. D) The newly licensed nurse only utilizes inspection, percussion, and palpation during the abdominal assessment of the client. E) The newly licensed nurse uses deep palpation when palpating the abdomen.

A) Physical examination of the abdomen in relation to fecal elimination problems includes inspection, auscultation, percussion, and palpation. Auscultation should precede palpation, because palpation can alter peristalsis. Never use deep palpation on a client who has had a pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for hemorrhage. D) Physical examination of the abdomen in relation to fecal elimination problems includes inspection, auscultation, percussion, and palpation. Auscultation should precede palpation, because palpation can alter peristalsis. Never use deep palpation on a client who has had a pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for hemorrhage. E) Physical examination of the abdomen in relation to fecal elimination problems includes inspection, auscultation, percussion, and palpation. Auscultation should precede palpation, because palpation can alter peristalsis. Never use deep palpation on a client who has had a pulsatile abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for hemorrhage.

The nurse is attempting to place a urinary catheter in a 96-year-old female client. The nurse is unable to visualize the client's urinary meatus. An alternate position to facilitate the insertion of the catheter would be: A) Side-lying, lifting up the buttock. B) Supine, with the HOB elevated at 30°. C) Supine, with the head of bed (HOB) elevated at 45°. D) Supine, with the bed flat, legs bent and apart in stirrups.

A) Side-lying, lifting up the buttock. A) Because of estrogen-mediated changes in the perineal area of postmenopausal women, the urinary meatus may be very difficult to visualize. The side-lying position, lifting up the buttock, is an alternative that provides better visualization of the urinary meatus. The supine position, regardless of the leg position or height of the bed, would not increase the visualization of the urinary meatus because it is more distal from the changes in the perineal area.

The client is experiencing constipation. The physician orders Metamucil, a bulk-forming laxative. The nurse is aware that which is a nursing consideration when administering this medication? A) The client must always take with sufficient water. B) Can be administered orally or rectally. C) Used to treat acute constipation D) May cause tardive dyskinesia.

A) The client must always take with sufficient water. A) It is imperative that the client take Metamucil with a sufficient amount of water for the medication to be effective. Metamucil is an oral medication, and it is not typically for use in the treatment of acute constipation, as results from the medication are not immediate. Prokinetic drugs such as Reglan may cause tardive dyskinesia. Metamucil is not associated with the cause of tardive dyskinesia.

The nurse is updating the plan of care for a client with renal calculi. The nurse is aware that which are expected outcomes of a client with renal calculi? Select all that apply. A) The client rates pain at a 2 on a scale of 1-10 and states that a 2 is acceptable. B) The client is able to comfortably perform ADLs. C) The client demonstrates a fluid intake of 800-1,000mL/day. D) The client remains free of signs and symptoms of infection. E) The client chooses the appropriate diet to prevent the reoccurrence of renal calculi.

A) The client rates pain at a 2 on a scale of 1-10 and states that a 2 is acceptable. B) The client is able to comfortably perform ADLs. D) The client remains free of signs and symptoms of infection. E) The client chooses the appropriate diet to prevent the reoccurrence of renal calculi.

The nurse working on a medical unit is aware that a high pH, or more alkaline urine, could indicate which condition? A) Urinary tract infection B) Diarrhea C) Respiratory acidosis D) Metabolic acidosis

A) Urinary tract infection A) Alkaline urine may indicate a state of alkalosis, a UTI, bacteriuria, antibiotics, sulfonamides, sodium bicarbonate, acetazolamide, potassium citrate, or a diet high in fruits and vegetables. More acidic urine (low pH) is found in starvation, with diarrhea, with a diet high in protein foods or cranberries, in metabolic or respiratory acidosis, and with increased ammonium chloride and mandelic acid concentrations.

The nurse is creating a teaching plan for a client with allergic contact dermatitis. What should these instructions include? Select all that apply. A) Use the topical steroid for 2 to 3 weeks even when the skin is healing. B) Apply a thin film of steroid cream to damp skin area for 2 to 3 weeks. C) Apply topical steroid once a day before sleep. D) Soak hand in Burow's solution. E) Apply a thick layer of steroid cream to dry skin area twice a day for 1 month.

A) Use the topical steroid for 2 to 3 weeks even when the skin is healing. B) Apply a thin film of steroid cream to damp skin area for 2 to 3 weeks. The client should be instructed to apply a thin layer of steroid cream to damp affected skin for 2-3 weeks even when the skin is healing. Applying the steroid once a day before sleep may not be enough. Burow's solution is indicated for irritant contact dermatitis. The steroid cream should not be applied in a thick layer.

A client with contact dermatitis tells the nurse about scratching the skin raw at night from the itching. What should the nurse advise the client to do? A) Wear cotton gloves during sleep. B) Restrict fluids. C) Bathe every day. D) Apply a lotion containing alcohol to the affected area.

A) Wear cotton gloves during sleep. A) Cotton gloves may be worn at night if scratching during sleep causes skin excoriation. The nurse should suggest that the client wear cotton gloves during sleep. The client should maintain good hydration; there is no need to restrict fluids. It is not necessary to take a bath every day. The client should avoid lotions containing alcohol.

A 53-year-old woman has high blood pressure that is not responding to medications. Where should you auscultate if you suspect renal stenosis? A) renal arteries B) kidneys C) ureters D) internal urethral sphincter E) bladder

A) renal arteries A) The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic bruits ("whooshing" sounds) may indicate renal artery stenosis.

A 58-year-old male presents to the urologist with complaints of getting up to urinate several times a night and difficulty starting a stream of urine. After medical testing is completed, a diagnosis of benign prostatic hyperplasia (BPH) is made. Which of the following statements by the client indicates the need for additional teaching? A) "Alpha blockers can be used to control my symptoms." B) "I know I will get cancer of the prostate because of this." C) "As my condition progresses, I may need to consider surgical management." D) "There are nonsurgical treatment options available."

B) "I know I will get cancer of the prostate because of this." B) This is a benign condition that does not necessarily progress to cancer. It is caused by an increase in size of the prostate gland and is seen in older males. There are nonsurgical treatments available, such as medication to shrink the gland or a surgical resection. Alpha blockers will help control the symptoms.

A client is being seen in the clinic for a follow-up visit and progress check. The client was recently diagnosed with benign prostatic hyperplasia (BPH). The nurse is planning care and selects Urinary Retention as a nursing diagnosis based on which client statement? A) "I am aware that I need to report no urine output." B) "I need to drink 20 ounces of water at each meal." C) "I have stopped taking over-the-counter decongestants for my allergies." D) "I use the double-voiding technique."

B) "I need to drink 20 ounces of water at each meal." B) A single intake of a large volume of fluid results in rapid bladder filling and a risk for retention. Over-the-counter decongestants increase the risk for urinary retention. Clients are taught the double-voiding technique to help avoid urinary retention. No urine output is a sign that requires immediate medical attention, not just the diagnosis Impaired Urinary Retention.

A nurse manager is teaching a group of student nurses about newborn skin and factors that relate to this concept. Which statement will the nurse manager include in the teaching? A) "The newborn's skin is about 40% to 60% thicker than an adult's skin at birth." B) "The newborn's skin contains more water than an adult's and has loosely attached cells." C) "The newborn's thicker skin decreases absorption of harmful chemical substances and topical medications." D) "The newborn's skin has a greater percentage of underlying subcutaneous fat compared to adults."

B) "The newborn's skin contains more water than an adult's and has loosely attached cells." B) The newborn's skin contains more water than an adult's and has loosely attached cells. The newborn's skin is about 40% to 60% thinner than an adult's, which makes the newborn's skin more susceptible to absorption of harmful chemical substances and topical medications. The newborn's skin has less subcutaneous fat compared to adults.

A client is surprised to learn of having a vitamin D deficiency when three glasses of milk are consumed each day. What should the nurse respond to this client? A) "A loss of melanin causes a decrease in vitamin D." B) "The skin synthesizes vitamin D from sunlight." C) "Insufficient protein intake causes a vitamin D deficiency." D) "Not all milk contains vitamin D."

B) "The skin synthesizes vitamin D from sunlight." B) The skin performs several essential functions. One of these is the synthesis of vitamin D from ultraviolet light. If the client is not exposed to ultraviolet light, there is a risk for developing a vitamin D deficiency. In the United States cow's milk is fortified with vitamin D, and there is nothing to suggest the client is drinking another kind of milk. A loss of melanin does not lead to a decrease in vitamin D. Insufficient protein intake does not cause a vitamin D deficiency.

A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate? A) "I will need to get an order from the physician." B) "Using the doughnut can cause skin breakdown." C) "You will need to wait until discharge and use this at home." D) "I will obtain the device for you."

B) "Using the doughnut can cause skin breakdown." B) The use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened, but this is due to the loss of sensation. The use of the device should be avoided whether at the hospital or at home.

A nurse working in the pediatric intensive care unit (PICU) is planning care for a pediatric client who is being admitted with a partial-thickness thermal burn. What is true regarding this type of burn? A) Partial-thickness burns are deeper than superficial burns but still involve the epidermis only. B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. C) A deep partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. D) A superficial partial-thickness burn is less painful than a deep partial-thickness burn.

B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis B) A superficial partial-thickness burn extends from the skin's surface into the papillary layer of the dermis. Partial-thickness burns are deeper than superficial burns, extending from the epidermis into the dermis layer as well. A superficial partial-thickness burn is often bright red and has a moist, glistening appearance with blister formation. A deep partial-thickness burn is less painful than a superficial partial-thickness burn because sensation is decreased at the site.

The nurse is caring for a group of clients on a medical-surgical nursing unit. The nurse knows that which client is most at risk for difficulty in urinary elimination? A) The client with hypertension who takes a diuretic every day for her blood pressure The nurse is caring for a group of clients on a medical-surgical nursing unit. The nurse knows that which client is most at risk for difficulty in urinary elimination? A) The client with hypertension who takes a diuretic every day for her blood pressure B) An 80-year-old male reporting frequent urination at night C) A 25-year-old female client with low self-esteem D) A client who had bladder cancer and now has a newly created ileal conduit

B) An 80-year-old male reporting frequent urination at night B) The client who is 80 years old with frequent urination at night is having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination. The 25-year-old experiencing low self-esteem has a psychological problem and will need therapy to find the root of the problem. The client who had bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder removed. Continued urine production through the ileal conduit will need to be observed and assessed frequently by the staff. The client with high blood pressure takes her medication to remove excess fluid from her body, and as long as urine elimination increases, there should be no problems.

An older client diagnosed with chronic obstructive pulmonary disease is scheduled for a total knee replacement. What should the nurse include in this client's plan of care? A) Monitor urine output. B) Assess postoperative wound healing. C) Restrict protein intake. D) Expect purulent drainage.

B) Assess postoperative wound healing. B) Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. The nurse should assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need an adequate intake of protein for wound healing; protein should not be restricted.

The nurse on the medical unit is admitting a 96-year-old client whose primary symptoms include fatigue, pruritus, and pain in the right flank area. Which assessment technique should not be used while assessing this client? A) Palpation over the costovertebral angles and flanks B) Blunt percussion over the costovertebral angles and flanks C) Palpation of the lower pole of both kidneys D) Capturing of both kidneys

B) Blunt percussion over the costovertebral angles and flanks B) Blunt percussion in a frail older individual is contraindicated. Instead, palpation of the costovertebral angles and flanks can be used to reveal any pain or tenderness. All other assessments are appropriate.

An older client complains of having dry skin. What would explain this client's complaint? Select all that apply. A) Reduction in elastin B) Depleted moisture in epidermal cells C) Reduced fluid intake D) Thinner subcutaneous skin layer E) Poor nutrition

B) Depleted moisture in epidermal cells C) Reduced fluid intake E) Poor nutrition The epidermal cells of the older person contain less moisture. This contributes to a dry, rough skin appearance. Reduced fluid intake and poor nutrition could cause dry skin. Another reason is the decline in moisture due to advanced age. Reduction in elastin leads to wrinkling and sagging of the skin. The older adult's thinner subcutaneous skin layer increases the risk for hypothermia and pressure ulcer formation.

The nurse is caring for a client with functional incontinence. The nurse is aware that which of the following are factors of functional incontinence? Select all that apply. A) Fecal impaction B) Depression C) Confusion D) Prostate surgery E) Impaired mobility

B) Depression C) Confusion E) Impaired mobility Functional incontinence occurs when the ability to respond to the need to urinate is impaired. Contributing factors may include confusion, depression, or impaired mobility. Fecal incontinence is a contributing factor to overflow incontinence and prostate surgery is a contributing factor to stress incontinence.

The nurse identifies a client at risk for contact dermatitis. What did the nurse assess in this client? Select all that apply. A) Blood pressure of 120/72 mmHg B) Frequent hand washing C) Heart rate of 76 and regular D) Cares for plants in a garden E) Employment as a computer operator

B) Frequent hand washing D) Cares for plants in a garden Risk factors for contact dermatitis include allergies, family history of eczema, regular exposure to a moist environment; burns; exposure to plants, chemicals, and metals; and occupations that require frequent hand washing. Employment as a computer operator does not increase the risk of developing contact dermatitis. Vital signs are not linked to the development of contact dermatitis.

The nurse is planning care for a client with contact dermatitis. What should be included in this plan of care? Select all that apply. A) Provide instruction in washing clothes in bleach and hot water. B) Instruct to avoid perfumes and lotions containing alcohol. C) Provide instruction in the use of hot water and soap to bathe the body. D) Teach the client the need to keep the skin dry. E) Stress the importance of utilizing prescribed medication for the entire course.

B) Instruct to avoid perfumes and lotions containing alcohol. E) Stress the importance of utilizing prescribed medication for the entire course. Clients should be instructed to use prescribed medications for the entire course. Stopping the treatment too soon could cause rebound dermatitis. The client should also be instructed to avoid perfumes and lotions containing alcohol because these will contribute to skin dryness. The client should be instructed to use tepid water and mild soap to bathe. The skin should be kept lubricated to prevent dryness and itching. Clothing should be washed in mild soap and rinsed an extra time to remove all soap.

The nurse at a health fair is educating clients on risk factors associated with urinary problems. The nurse is aware that which of the following are modifiable risk factors? Select all that apply. A) Age B) Obesity C) Urinary tract infections D) Spina bifida E) Constipation

B) Obesity C) Urinary tract infections E) Constipation Obesity and pregnancy are modifiable risk factors for urinary incontinence, obesity most likely because of the excess force placed on the bladder and pregnancy because of the weight of the expanding uterus on the bladder. Other modifiable risk factors for loss of bladder control include urinary tract infections, increased consumption of bladder irritants, and poor lifestyle habits. Individuals with bowel problems such as constipation are also at higher risk for developing urinary problems. Older age is a non-modifiable risk factor. The excretory function of the kidneys diminishes as individuals age, but function usually does not diminish significantly below normal levels unless a disease process intervenes. Disability and a family history of incontinence also increase an individual's risk of developing urinary incontinence. Genetic conditions such as myelomeningocele or spina bifida and conditions associated with aging such as Parkinson disease can also contribute to urinary problems.

A client who sustained burns to both lower extremities complains to the nurse about feeling frustrated by not being able to provide self-care. Which nursing diagnosis would be appropriate for the client at this time? A) Ineffective Coping B) Powerlessness C) Anxiety D) Situational Low Self-Esteem

B) Powerlessness B) The client is expressing frustration over not being able to provide self-care. The nursing diagnosis most appropriate for the client at this time would be Powerlessness. There is not enough information to determine whether the client is or is not experiencing situational low-self-esteem, ineffective coping, or anxiety.

A nurse working in the intensive care unit (ICU) is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a well-approximated midline surgical incision that has numerous staples and a "healing ridge" noted. Which healing phase best describes the incision? A) Inflammatory phase B) Proliferative phase C) Maturation phase D) Synthesis phase

B) Proliferative phase B) The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 post injury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. The synthesis phase does not exist. The other choices are incorrect.

An older client with severe burns over more than half of the body has an indwelling catheter. When evaluating the client's intake and output, what should be taken into consideration? A) The amount of urine will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase. C) The amount of urine will be reduced during the first 8 hours of the burn injury and will then increase as diuresis begins. D) The amount of urine output will be greatest in the first 24 hours after the burn injury.

B) The amount of urine will be reduced in the first 24 to 48 hours and will then increase. B) The client will have an initial reduction in urinary output. Fluid is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. After the shock period passes, the client will enter a period of diuresis. Diuresis begins between 24 and 36 hours after the burn injury.

The nurse determines that which goal is most appropriate for a client with mild benign prostatic hyperplasia (BPH) who is experiencing urinary retention? A) The client will increase fluid intake to at least 2-3 liters daily B) The client lists over-the-counter medications to be avoided. C) The client will voice an understanding of the importance of the use of antiembolic stockings and compression devices. D) The client will use a T-binder or scrotal support properly.

B) The client lists over-the-counter medications to be avoided. B) Avoiding over-the-counter medications can lessen or prevent the symptoms associated with mild benign prostatic hyperplasia (BPH). An increased fluid intake can assist in preventing burning on urination after catheter removal and reduces the risk of a urinary tract infection. There is no indication that this client had surgery or had a catheter placed. The use of antiembolic stockings and compression devices reduces the risk of developing a thromboembolism. There is no indication that this client had surgery or is at risk for developing a thromboembolism. The use of a T-binder or scrotal support is for those clients that have undergone surgery and are in need of scrotal support and support of the surgical dressing. There is no indication that this client had surgery or had a catheter placed.

The nurse is assessing a client with a surgical wound. Which observation indicates that care has been effective for this client? A) The client's temperature is 100°F. B) The client performs wound care independently. C) There is only a scant amount of purulent drainage on the dressing. D) A small area of erythema and edema is present.

B) The client performs wound care independently. B) Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.

The nurse is caring for a client who will be discharged with an indwelling catheter. The nurse has provided education to the client and family in regards to catheter care once the client is discharged. Which actions by the client and family demonstrate that they understand correct technique for caring for an indwelling catheter? A) The client hangs the drainage bag on the towel rod. B) The client takes a shower each day instead of taking a tub bath. C) The client will restrict the amounts of fluids per day. D) The client empties the drainage bag twice a day.

B) The client takes a shower each day instead of taking a tub bath. B) The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract. The drainage bag should be emptied regularly, not just once a day but at least three times a day. Hanging the drainage bag on the towel rod is too high. The drainage bag should be hung below the bladder. Adequate amounts of fluids should be consumed to help prevent sediments and infections.

The nurse is caring for a client with a history of stress incontinence. Which findings would the nurse expect to assess in this client? Select all that apply. A) The leakage of urine occurs when the client is talking. B) The leakage of urine occurs when the client coughs. C) The leakage of urine occurs when the client laughs. D) The skin of the client is clear, without discoloration. E) The client is wearing cotton undergarments.

B) The leakage of urine occurs when the client coughs. C) The leakage of urine occurs when the client laughs. Stress incontinence involves a small leakage of urine when a client laughs, coughs, or lifts something heavy, not if a client just carries on a conversation. A client with incontinence would wear some kind of undergarment pad. Cotton undergarments alone would not provide protection for catching the urine. If the client has been experiencing incontinence, the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the skin.

The nursing instructor conducting a lecture on alterations in urination would identify the need for further instruction when a student nurse makes which statement? A) "A client suffering from difficulty or painful urination is experiencing dysuria." B) "A client who has no urinary output is experiencing anuria." C) "A client who has a urinary output of 1,300 mL/day is experiencing oliguria." D) "A client who is up several times at night is experiencing nocturia."

C) "A client who has a urinary output of 1,300 mL/day is experiencing oliguria." C) Oliguria is scant urine; normal urinary output for an adult is less than 1,500 mL per day, so 1,300 mL output is not oliguria. The other statements are correct.

The nurse is caring for a female client on a medical-surgical unit. The client tells the nurse, "I don't get any sleep at night because I have to get up and use the bathroom every couple of hours!" Which of the following explanations by the nurse would be most accurate to explain the client's nocturia? A) "As you get older, there is a decrease in number of nephrons." B) "As you get older, there is a decrease in the blood supply to your bladder." C) "As you get older, you may have a decrease in bladder capacity." D) "As you get older, there is a decrease in cardiac output, which can cause your symptoms."

C) "As you get older, you may have a decrease in bladder capacity." C) Approximately 70% of older women and 50% of older men have to get up two or more times during the night to empty their bladders due to decreased bladder capacity. A decrease in blood supply causes an increase in urine concentration. A decrease in the number of nephrons decreases the filtration rate. A decrease in cardiac output decreases peripheral circulation, which would decrease urinary output day or night.

A client is being seen in an ambulatory care clinic. The client tells the nurse about experiencing frequent diarrhea. The nurse inquires about the client's diet. Which statement from the client would be of greatest concern for the nurse? A) "I like to eat a bran muffin and applesauce every morning for breakfast." B) "I like to eat popcorn for an afternoon snack." C) "I like to eat cottage cheese, peaches, and a turkey sandwich for lunch." D) "I like to eat baked chicken, yeast rolls, and a small salad for dinner."

C) "I like to eat cottage cheese, peaches, and a turkey sandwich for lunch." C) Dairy products can contain lactose, which might be difficult for certain clients to digest, resulting in diarrhea. The remaining selections are not associated with diarrhea.

The nurse is reviewing discharge instructions with the mother of a toddler who was hospitalized for constipation due to withholding. The nurse would identify the need for further instruction when the client's mother makes which statement? A) "I should recognize that when my child walks stiffly on his tiptoes, this could indicate withholding." B) "Rocking and crossing the legs could be a sign of withholding." C) "I need to make sure my child eats a low-fiber diet." D) "Soiling could be a sign of withholding because of involuntary overflow."

C) "I need to make sure my child eats a low-fiber diet." C) The most common clinical manifestations of withholding in children are tightening of the external sphincter and gluteal muscles, squatting, rocking, stiff walking on tiptoes, crossing legs, sitting with heels against the perineum, stretching of the rectum and lower colon, stool retention, and soiling by involuntary overflow. Clinical dietary therapies for withholding include a high-fiber diet and adequate fluid intake. Therefore, the mother's comment regarding ensuring that a low-fiber diet be provided to the child would indicate the need for further instruction. The child would be encouraged to eat a diet high in fiber.

The nurse is preparing to discharge a client with diarrhea. The physician has ordered kaolin to manage the client's diarrhea. The nurse instructs the client concerning use of the medication. What client statement indicates the need for further teaching? A) "If my diarrhea does not get better within 2 days, I will need to call my physician for further advice." B) "I will need to take the medication after each loose stool." C) "I should continue to take this medication daily until my stools are firm and dry." D) "If I start to have a fever, I need to contact my physician about continuing to take this medication."

C) "I should continue to take this medication daily until my stools are firm and dry." C) Continuing to take the medication daily until the stools are firm and dry could result in constipation. If constipation occurs, the client will have another issue for resolution. The other statements are correct.

The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. The client states, "I don't like to have a bowel movement anywhere but at home." Which response by the nurse would explain why this practice should be changed? A) "This is a common practice, and it will strengthen the reflex later." B) "You will get the urge later, so you should not worry about it." C) "If you continue to ignore the urge to defecate, it can lead to problems." D) "It is better to suppress the urge than to suffer embarrassment at work."

C) "If you continue to ignore the urge to defecate, it can lead to problems." C) When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause the urge to be lost. Embarrassment, while unwarranted, is preferable to losing the urge to defecate. Ignoring the urge will not strengthen the reflex later; it will weaken it.

The nurse is caring for a male client of Japanese descent. The client is experiencing urinary frequency and he asks the nurse if he has benign prostatic hyperplasia (BPH). Which statement by the nurse is the most appropriate? A) "No, you are not old enough yet to have the disease." B) "No, you do not have BPH, as you are of Asian descent." C) "The tests will determine your diagnosis, but men of Japanese descent are not at high risk for this disease." D) "Where did you get an idea like that?"

C) "The tests will determine your diagnosis, but men of Japanese descent are not at high risk for this disease." C) The nurse is always honest in replying to a client. The nurse tells the client that the tests will provide the actual results but that he is in a low-risk category. Telling the client that he does not have the disease is not wise as, Japanese or not, he could have BPH. Asking a client where he got that idea is demeaning.

The nurse is concerned that a client is at a high risk for a burn injury. What did the nurse assess in this client? Select all that apply. A) Part-time employment at a convenience store B) Diagnosis of hypertension C) Age 71 years D) Utilizes public transportation for grocery shopping E) Currently smokes 1 pack per day of cigarettes

C) Age 71 years E) Currently smokes 1 pack per day of cigarettes Older clients are more vulnerable to fire and burn injury because of decreased visual acuity, depth perception, sense of smell, and hearing, and impaired mobility. Alterations in cognition, such as dementia, are also risk factors. Careless smoking is another risk factor. All of these factors increase the risk of accidentally starting a fire and diminish the ability to survive it. Hypertension does not increase the client's risk for experiencing a burn injury. Part-time employment and use of public transportation do not increase the client's risk of experiencing a burn injury.

The nurse is caring for a client from another culture. The client tells the nurse that he is constipated. What is the nurse's initial action? A) Encourage the client to increase fluid intake and activity. B) Assess the client's intake of fiber and fluids. C) Determine what the client means by constipation. D) Obtain an order for a laxative and an enema from the physician.

C) Determine what the client means by constipation. C) The nurse should first carefully evaluate the client's concern and question the person as to what he considers to be constipation. Determining the client's normal frequency of bowel movement, consistency of stool, and effort in passing stool is important before deciding to act. The other suggestions-achieving adequate fluid intake, exercising, including fiber in the diet, and using a laxative (and possibly an enema)-may be appropriate once the nurse has adequately assessed the client's concern of constipation.

The nurse is planning care for a client with a large area of erythema, swelling, and pruritic lesions on the hands and arms. Which nursing diagnosis should the nurse use to guide this client's care? A) Impaired Social Interaction B) Anxiety C) Impaired Skin Integrity D) Situational Low Self-Esteem

C) Impaired Skin Integrity C) The client is experiencing manifestations of contact dermatitis. The nursing diagnosis that is the most appropriate for this client is Impaired Skin Integrity. If left untreated, the client could develop impaired social interaction, situational low self-esteem, or anxiety.

A client has a documented stage III pressure ulcer on the right hip. Which nursing diagnosis is most appropriate for this client? A) Impaired Skin Integrity B) Risk for Injury C) Impaired Tissue Integrity D) Ineffective Peripheral Tissue Perfusion

C) Impaired Tissue Integrity C) Because a stage III pressure ulcer involves tissues, not just skin, this client has criteria that qualify for impaired tissue integrity. Although it is true that pressure ulcers result from ineffective peripheral tissue perfusion, the diagnosis of Impaired Tissue Integrity is the more specific diagnosis. A diagnosis of Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury and so Risk for Injury does not apply.

A client with a burn injury is prescribed mechanical debridement of the wounds. What will the nurse plan to do when performing mechanical debridement? Select all that apply. A) Schedule the client for a homograft. B) Apply a topical agent to dissolve necrotic tissue. C) Irrigate the burn wounds. D) Apply wet-to-dry gauze dressings. E) Schedule the client for hydrotherapy.

C) Irrigate the burn wounds. D) Apply wet-to-dry gauze dressings. E) Schedule the client for hydrotherapy. Mechanical debridement is done by applying and removing wet-to-dry gauze dressings, using hydrotherapy, or using irrigation. Applying a topical agent to dissolve necrotic tissue is an example of enzymatic debridement. The application of a homograft is a type of dressing and not a type of debridement.

The client is experiencing urinary urgency and frequency. Which medication should the nurse anticipate may be ordered by the physician? A) Furosemide B) Bumetanide C) Oxybutynin D) Bethanechol chloride

C) Oxybutynin C) Oxybutynin is an anticholinergic that reduces urgency and frequency by blocking muscarinic receptors in the detrusor muscle of the bladder, thereby inhibiting contractions and increasing storage capacity. The nurse would anticipate an order for oxybutynin. Furosemide is a diuretic and works in a specific place within the nephron to increase fluid excretion and prevent fluid reabsorption. Bumetanide is a diuretic and works in a specific place within the nephron to increase fluid excretion and prevent fluid reabsorption. Bethanechol chloride is a cholinergic agent that stimulates bladder contraction and facilitates voiding.

The nurse is caring for an elderly male client who has returned to the unit following a resection of the prostate (TURP). The client has a three-way indwelling catheter. The client tells the nurse that he has to urinate. Which of the following nursing interventions is most appropriate? A) Deflate and then reinflate the catheter balloon. B) Irrigate the catheter. C) Retape the catheter to the abdomen. D) Reposition the catheter.

C) Retape the catheter to the abdomen. C) Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem. Deflating and reinflating the balloon is not an option. The surgeon knows how much pressure is needed to control bleeding after surgery. The catheter is usually taped to the client's leg after a TURP and is not to be manipulated. This also controls bleeding after surgery. Repositioning the catheter would not be an option right after surgery.

The nurse is caring for a client with a retention catheter. The nurse finds that the drainage bag is lying on the floor when she enters the room to assess the client. Which nursing diagnosis would be appropriate for this client? A) Urinary Incontinence related to an obstruction B) Risk for Impaired Skin Integrity related to catheter placement C) Risk for Infection related to improper handling D) Self-Care Deficit related to presence of a retention catheter

C) Risk for Infection related to improper handling C) The floor is the dirtiest place in any establishment, so the drainage device should never be placed on the floor. There is a possibility of skin impairment with a catheter, but the emphasis here is on where the drainage bag was found. Even with a catheter in place, a client can still administer self-care; the catheter does not restrict one from practicing basic hygiene. The client may need some assistance. The placement of a catheter prevents incontinence; it does not add to it. Placement of the catheter ensures flow, not obstruction.

A client has a pressure ulcer on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. How would the client's nurse describe the ulcer? A) Partial-thickness loss of dermis B) Non-blanchable erythema C) Suspected deep tissue injury D) Full-thickness tissue loss

C) Suspected deep tissue injury C) A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.

A nurse working in home care is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. The client's surgical wound has staples that are aiding in the wound healing. The nurse understands that this is an example of which of the following? A) Primary intention healing B) Secondary intention healing C) Tertiary intention healing D) Quaternary intention healing

C) Tertiary intention healing C) A wound that permits exudate to drain and then is closed with sutures, staples, or adhesive skin closures undergoes tertiary intention healing. Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.

A client is recovering from prostate surgery on a medical-surgical nursing unit. The client will be ready for discharge within the next few days. Which point would the nurse want to teach the client and family prior to discharge? A) The client should not drive for 6 weeks after surgery. B) The client should call the doctor immediately for any pain. C) The client should increase the fiber in his diet. D) The client should avoid heavy lifting for 2 weeks after surgery.

C) The client should increase the fiber in his diet. C) The client should be encouraged to increase the fiber in his diet, as straining for bowel movements after surgery can cause increased pressure in the prostate area. The client and family are taught good dietary habits to keep bowel movements regular and soft. The client may not drive for 2 weeks after surgery. The client is taught to avoid heavy lifting for 4-8 weeks after discharge and to call the doctor for severe abdominal or chest pain.

The client with a urinary disorder is admitted to the urology unit of the hospital. Which of the following urinalysis results would indicate a urinary tract infection? A) pH 5.2 B) Negative glucose C) WBC 10-15 D) Specific gravity 1.012

C) WBC 10-15 C) A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count. The pH, glucose and specific gravity are all within normal limits. A normal WBC is 0-4. The WBC count for this client is high and indicates infection.

The home health nurse is visiting a client with a history of constipation. The physician has order psyllium mucilloid (Metamucil) for the client. The nurse has just completed medication teaching. Which statement by the client indicates the need for further teaching? A) "This medication is a lot more natural than other laxatives." B) "I may be able to stop my Lipitor with this medication." C) "This medication takes several days to work." D) "I don't need to drink extra fluids while I take this medication."

D) "I don't need to drink extra fluids while I take this medication." D) Fluids must be increased when clients use psyllium mucilloid (Metamucil). Psyllium mucilloid (Metamucil) does take several days to work. Psyllium mucilloid (Metamucil) does help to reduce cholesterol levels; therefore, the client may be able to stop the Lipitor. Psyllium mucilloid (Metamucil) is more natural than other laxatives.

A nurse is caring for a client with congestive heart failure. The physician has ordered propranolol (Inderal) for the client. Which instruction should the nurse include when administering a beta-adrenergic like propranolol (Inderal) to the client? A) "This medication must be taken on an empty stomach." B) "You will need to discontinue the medication when your symptoms subside." C) "This medication causes constipation. You should take a laxative every day." D) "It is important to notify your physician if you experience urinary retention."

D) "It is important to notify your physician if you experience urinary retention." D) A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be of the utmost importance to notify one's physician. Clients should always check with their physician before stopping any medication, because there could be some major complications. Constipation has been reported from clients taking propranolol, but a laxative should not be taken every day, as one can become dependent. This medicine should be taken with food, not on an empty stomach, in order to enhance absorption.

A nurse is planning care for a client with a contact dermatitis. Which statement made by the nurse supports the client's need of home care instructions? A) "Bathe or shower twice daily to reduce allergen contact." B) "Avoid the use of all lotions." C) "When using steroid ointments, use a thick layer on dry skin for maximum absorption." D) "Use steroid ointments for 2 to 3 weeks for best results."

D) "Use steroid ointments for 2 to 3 weeks for best results." D) When educating a client regarding contact dermatitis, the teaching should focus on home care instructions. The client should be told to use steroid ointments for 2 to 3 weeks for best results. The steroid ointments should be applied in a thin layer on damp skin. The client does not need to bathe or shower twice daily or avoid all lotions. Some lotions with perfumes or dyes may irritate the client's skin; however, dry skin causes itching and places the client at risk for infection from scratching.

The nurse is evaluating the adequacy of the burn-injured client's nutritional intake. Which laboratory value is the best indicator of nutritional status? A) Creatine phosphokinase (CPK) B) BUN levels C) Hemoglobin D) Albumin level

D) Albumin level Albumin level is used to indicate protein synthesis and nutritional status. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels will fluctuate with the stages of the burn injury, dependent upon the fluid status.

A client has superficial burns on the hand from boiling water. What can the nurse suggest that the client use to help with the healing of these burns? A) Chamomile B) Vitamin C C) Evening primrose oil D) Aloe vera gel

D) Aloe vera gel D) The nurse should provide information on home remedies that could help in the healing of the client's burns. Aloe vera gel is useful to treat superficial burns. Evening primrose oil is helpful with atopic eczema. Chamomile is helpful with skin inflammation. Vitamin C is not recommended to help with the healing of burns.

A nurse is caring for a client with a Stage II pressure ulcer on the coccyx who is at risk for additional pressure ulcers. Which nursing intervention is appropriate while caring for this client? A) Clean the pressure ulcer as needed. B) Use hydrogen peroxide as chemical debridement of wound bed as needed. C) Maintain the head of the client's bed at 30°. D) Avoid placing the client in the side-lying position.

D) Avoid placing the client in the side-lying position. D) The nurse should avoid placing the client in the side-lying position because this position places increased pressure on the bony prominence of the greater trochanter. Also, the nurse should maintain the head of the bed at the lowest degree of elevation consistent with the client's medical condition and other restrictions. The nurse should clean the client's pressure ulcer at every dressing change, not as needed. Hydrogen peroxide should never be used on the wound bed due to the tissue damage it promotes.

A middle-age client tells the nurse that she does not want to develop "liver spots" like her parents did as they aged. What should the nurse instruct the client to do? A) Spend at least 15 minutes each day in the sun. B) Increase the intake of calcium. C) Increase the intake of dietary fat. D) Avoid the sun or use a sunscreen to reduce skin damage.

D) Avoid the sun or use a sunscreen to reduce skin damage. D) Small areas of hyperpigmentation, or liver spots, occur as an age-related skin change because of hyperplasia of melanocytes in sun-exposed areas. The nurse should instruct the client to avoid the sun or use a sunscreen to reduce skin damage. The nurse should not instruct the client to spend at least 15 minutes each day in the sun to avoid skin damage. The intake of dietary fat or calcium will not affect the development of liver spots.

A client is being prescribed a medication to treat a skin inflammation and pruritus. Which medication was this client most likely prescribed? Select all that apply. A) Erythromycin B) Bacitracin C) Gentamycin D) Desoximetasone E) Desonide

D) Desoximetasone E) Desonide Erythromycin is an antibacterial that interferes with bacterial DNA and protein synthesis, causing cell death. Bacitracin and Gentamycin are antibiotics that interfere with bacterial replication and synthesis and are used to treat infections. Desoximetasone and Desonide are topical corticosteroids that relieve inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.

After a skin graft procedure to the leg, a client is returned to the burn care unit. How will the nurse position the client? A) Place the client flat with the affected extremity abducted. B) Elevate the head of bed 30°. C) Maintain the head of the bed flat. D) Elevate the affected extremity.

D) Elevate the affected extremity. D) Elevating the affected extremity will reduce edema and promote perfusion. Elevating the head of bed, leaving the head of bed flat, and abducting the extremity will not increase healing or improve the client's long-range prognosis.

An older client with friable skin and poor skin turgor has slipped down in the bed. What should the nurse do to reposition the client safely in the bed? A) Use the bed sheet to slide the client up in the bed. B) Place the bed in reverse Trendelenburg. C) Use the client's arms to pull the client up in the bed. D) Lift the client, using the client's legs and arms for assistance.

D) Lift the client, using the client's legs and arms for assistance. D) The client is malnourished and has friable skin, which increases the potential for shearing forces. Shearing forces lead to skin breakdown and pressure ulcers. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client will cause skin shearing. Sliding on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg will not facilitate the appropriate adjustment of the client in the bed.

A client is diagnosed with acute allergic contact dermatitis over 25% of his body. What should the nurse realize that the client will be prescribed? A) Calamine lotion to affected skin area as needed B) Topical steroids applied twice a day for 2 to 3 weeks C) Cool compresses with Burow's solution twice a day D) Oral steroids for 7 to 10 days

D) Oral steroids for 7 to 10 days D) Acute allergic contact dermatitis that covers more than 10% of the body surface area will require treatment with oral steroids for 7 to 10 days. Topical steroids are applicable when the affected area is less than 10% of the total body surface area. Calamine lotion and Burow's solution are indicated in the treatment of irritant contact dermatitis.

A client has a laceration that was closed with tissue adhesive. What is the process by which this wound will heal? A) Open approximation B) Secondary healing C) Delayed closure D) Primary intention

D) Primary intention D) In primary intention wound healing, the edges of the wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds. Secondary healing involves wounds that cannot be approximated and that must "heal in." These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring. Open approximation or delayed closure wounds are left open for 3 to 5 days to allow edema or infection to resolve.

The nurse is working in a urology clinic. The nurse has just seen a client with stress urinary incontinence. The nurse has chosen the diagnosis of Stress Urinary Incontinence related to sphincter incompetence. Which is the desired outcome for a client with this diagnosis? A) The client will stop the flow of urine when voiding. B) The client will improve her incontinence within 1 month. C) The client will empty her bladder every time she voids. D) The client will perform 4-5 squeezes (Kegel exercises) for 10-15 seconds.

D) The client will perform 4-5 squeezes (Kegel exercises) for 10-15 seconds. D) Performing 4-5 squeezes for 10-15 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence. Emptying the bladder completely every time she voids would not be realistic in the beginning. This will take time. Improved continence takes 3-6 months, so 1 month is not a realistic goal. Clients are not instructed to stop the flow of urine when voiding, because this could lead to retention.

The nurse is preparing to discharge a client with urinary diversion. The nurse anticipates that the client will require some teaching prior to going home. Which point will the nurse incorporate into the plan? A) Instructing the client to notify the physician if the stoma is deep pink and shiny B) Instructing the client that strands of blood may appear in the urine C) The need to change the appliance every day D) The importance of increasing fluid intake

D) The importance of increasing fluid intake D) Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma. The appliance should be changed every 5-7 days. Everyday changing is unnecessary. A deep pink, shiny stoma is normal and does not require the notification of the physician. Strands of mucus, not blood, may appear in urine because of the mucus-producing cells of the ileum.

The charge nurse is observing a newly licensed nurse catheterize a 76-year-old male client admitted with an enlarged prostate. Which action observed would indicate to the charge nurse the need to intervene? A) The newly licensed nurse injects 10 mL of 2% lidocaine gel into the client's urethra. B) The newly licensed nurse inserts a 16 French coudé-tipped catheter. C) The newly licensed nurse clamps the catheter after draining 500 mL. D) The newly licensed nurse clamps the catheter after draining 800 mL.

D) The newly licensed nurse clamps the catheter after draining 800 mL. D) Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive, if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter for 5-10 minutes between increments may prevent this response. Draining 800 mL before clamping might cause a vasovagal response, so the charge nurse would need to intervene.

The nurse and doctor are discussing treatment options for a client diagnosed with benign prostatic hypertrophy (BPH) with the client and his wife. The client says, "I would like to try an alternative therapy before turning to traditional treatment." The nurse is aware that which of the following is an alternative therapy? A) Balloon uretoplasty B) Treatment with dutasteride (Avodart) C) Laser surgery D) Use of phytotherapy

D) Use of phytotherapy D) Phytotherapy includes use of barks and roots of the saw palmetto berry or Echinacea, among others. The mechanism of action is unknown, but clients do experience relief. Laser surgery, dutasteride (Avodart), and balloon uretoplasty are conventional methods of treating BPH.