FUND2PREPU

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

"Discard your first urine and begin the collection after that."

A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause?

"Have you ever had an elevated blood sugar?"

The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter?

"Let me talk to your health care provider about a condom catheter."

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem?

"Let's explore structuring activities and toileting breaks."

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

"Mineral oil enemas can interfere with absorption of fat-soluble vitamins."

A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?

"One signal of preparedness is when your child is dry for at least 2 hours."

A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate?

"Performing Kegel exercises can help with muscle strengthening."

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+

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

24-hour specimen

The nurse is providing care for several clients on a busy floor. The nurse receives a prescription to administer a transfusion of packed red blood cells for a client with decreased hemoglobin. Which action should the nurse take before entering the client's room to begin the transfusion?

Arrange for another nurse to monitor the nurse's other assigned clients. (Before administering a blood transfusion, the nurse should arrange for another nurse to monitor her assigned clients for at least 15 minutes, the nurse will need to remain with the client receiving the transfusion during this time to monitor for reaction.)

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

Asking the client when he or she had last urinated

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

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

A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate?

Avoid use of a tourniquet. -bulging rolling veins, tourniquet or too large gage needle will burst it AKA "BLOW THE VEIN" **use butterfly or small guage

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls. Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age. (huh??)

The nurse is teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen?

Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?

Check electronic health record for medical order.

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

Contact the health care provider

A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women?

Contract the pubic muscles for 3 seconds, then relax.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels (hypokalemia)

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?

Discontinue the infusion and record the volume left in the blood bag. ---->Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature. *dont kill anyone

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem?

Discuss the use of protective undergarments to avoid embarrassment from incontinence.

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Encourage fluid intake.

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?

Flush the IV with 3 mL of normal saline. If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this?

Having the client sign a consent form for the procedure

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

A nurse assesses the urine of a client who is using a bedpan and finds that it is a dark brown color. What medication might be causing this effect?

Levodopa

A nurse is caring for a female client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action?

Many clients find it embarrassing or degrading to use a bedpan.

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

Monitoring the characteristics of the urinary output

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis -tenderness, redness, warmth, and slight edema of the vein above the insertion site

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

Plans to eat a snack of fruit twice per day. (fruits and veg increase fiber)

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium -Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. -Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias.

Which urinary care teaching will the nurse provide to a young adult female client?

Refrain from douching unless ordered by a health care provider.

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?

Remove the peripheral intravenous catheter. (infiltration)

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed. (0.9% sodium chloride)

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

The client has an enlarged prostate

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?

To assure the IV solution is appropriate for this administration

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

Urinal

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?

Wearing gloves when handling the urine

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers?

Yogurt and buttermilk

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools -Young children, older adults, and people who are ill are especially at risk for hypovolemia. -Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. -A 5% weight loss is considered a pronounced fluid deficit -8% loss or more is considered severe -15% weight loss caused by fluid deficiency is life threatening.

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

a winged infusion needle.

Which hormone regulates the extracellular concentration of potassium within the human body?

aldosterone (Aldosterone regulates the extracellular concentration of potassium. It also enhances renal secretion of potassium.)

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. The client's skin is also excoriated from urinary incontinence. Which nursing concern is most appropriate for the nurse to include in this client's car plan?

altered skin integrity related to urinary bladder infection and dehydration

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

banana

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

bedside commode

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. a. Hypervolemia management b. Fluid restriction c. Intravenous therapy d. Electrolyte management e. Monitoring edema f. Nutrition management

c. Intravenous therapy d. Electrolyte management f. Nutrition management (**for HYPOvolemia) **these for HYPERvolemia** a. Hypervolemia management b. Fluid restriction e. Monitoring edema

The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect?

hypocalcemia

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?

hypokalemia (3.5-5.5)

The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing:

oliguria

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes -no longer 1 min (nurse taught me 30 secs irl tho)

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:

pus (pyuria)

A client has just been told that he has lung cancer. The health care provider then describes several potential courses of treatment to the client. When the health care provider leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

sensory overload.

The primary extracellular electrolytes are:

sodium, chloride, bicarbonate

Stages of Pitting Edema (2,4,6,8; who do we appreciate?)

stage 1+ =2mm- bounces right back stage 2+=4mm-few seconds stage3+=6mm-longer, like slow rise squishy stage4+=8mm-sits indented for a while with a divot

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?

strongly aromatic, dark amber

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?

"I've been taking antacids almost every 2 hours over the past several days."

The nurse is caring for a client who informs the nurse that it is difficult to void when experiencing stress, and asks why this happens. Which response by the nurse is appropriate?

"Stress causes the muscles to become tense."

A client admitted to the hospital with chronic kidney injury suddenly develops the following signs and symptoms: left arm arteriovenous (AV) fistula has weak thrill and bruit; blood pressure 88/40 mm Hg; states feeling dizzy. Which action will the nurse implement first?

Change to supine position. -The client is hypotensive and experiencing dizziness with it, so the first action the nurse must take is to lower the bed to a supine position to help increase the blood pressure by returning the venous blood to the heart. -The low blood pressure decreases the strength of blood flow to the AV fistula, which could lead to clotting off the client's access for dialysis. -The nurse would instruct the client to not get out of bed, examine the clothing that it is not constrictive on the arm with the AV fistula, and notify the primary care provider of the event, so further orders may be sought.

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

Check health record for provider's order.

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

Cholinergic agents (Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination.)

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation.

When providing chemotherapeutic agents, which catheter is accessed with a non-coring needle?

Implanted venous access catheters --->accessed with a non-coring needle such as a Huber point needle.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV. (phlebitis)

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies. Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction.

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. a. Contact the health care provider to ask for an order for catheter discontinuation. b. Delegate catheter discontinuation to the Unlicensed Assistive Personnel(UAP) c. Perform, or allow client to perform, perineal hygiene at least once daily. d. Ensure that the drainage bag is above the level of the bladder at all times. e. Discontinue to catheter and report this to the healthcare provider.

a. Contact the health care provider to ask for an order for catheter discontinuation. b. Delegate catheter discontinuation to the Unlicensed Assistive Personnel(UAP) c. Perform, or allow client to perform, perineal hygiene at least once daily.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. a. Rate of the IV solution b. Manufacturer of the IV catheter c. Location of the IV catheter access d. Client's reaction to the procedure e. Type of IV solution f. Gauge and length of the IV catheter

a. Rate of the IV solution c. Location of the IV catheter access d. Client's reaction to the procedure e. Type of IV solution f. Gauge and length of the IV catheter

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply. a. Urinary incontinence b. Difficulty voiding c Urinary retention d. Increased volume of urine output e. Burning or irritation while voiding f. Urinary frequency

a. Urinary incontinence b. Difficulty voiding c Urinary retention e. Burning or irritation while voiding

A nurse is providing education to an older adult client concerning ways to prevent constipation. Which diet choices would support that the education was successful? Select all that apply. a. hot tea with meals b. a turkey sandwich with whole-grain bread c. prune juice with breakfast d. ice cream with lunch and dinner e. diet soda with lemon

a. hot tea with meals b. a turkey sandwich with whole-grain bread c. prune juice with breakfast

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply. dark brown light brown black clay colored yellow

black clay colored yellow

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. a. Dry the perineal area after urination or defecation from the back to the front. b. Take baths instead of showers. c. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. d. Wear underwear with a cotton crotch. e. Avoid clothing that is tight and restrictive on the lower half of the body.

c. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. d. Wear underwear with a cotton crotch. e. Avoid clothing that is tight and restrictive on the lower half of the body. (take showers not baths) (clean front to back)

A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate?

functional

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

functional incontinence

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

isotonic Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

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

Reddened perineal skin

Which is a common anion?

chloride Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply. facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes provides free hydrogen ions for cells supplies glucose for energy

facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?

"Watery plasma, or serum, portion of blood."

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

The process of filtration begins at the:

glomerulus

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?

increased hydrostatic pressure

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Explanation: The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.

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

Avoid more than 250 mg

A client is scheduled for insertion of a peripherally inserted central catheter. When assisting with the procedure, the nurse would expect that which site would most likely be used?

Basilic vein

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching?

Be sure to shake the canister before using it.

A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first?

Clean each side of the urinary meatus with a separate wipe.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid."

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse?

"I will use clean gloves to handle the catheter and other equipment." (sterile gloves needed)

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

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

FLUIDS +TREATMENTS

-0.45% NaCl (½-strength normal saline) f5% dextrose in Lactated Ringer's solution d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. -5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. -0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. -5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options. 1. Provide instruction to the client. 2. Clean the area surrounding the urinary meatus with the provided cloth. 3. Void a small amount into toilet or bedpan. 4. Void into the provided collection device. 5. Secure the lid on the specimen container. 6. Submit collected specimen to the health care professional.

1. Provide instruction to the client. 2. Clean the area surrounding the urinary meatus with the provided cloth. 3. Void a small amount into toilet or bedpan. 4. Void into the provided collection device. 5. Secure the lid on the specimen container. 6. Submit collected specimen to the health care professional.

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?

Apply a tourniquet to the client's upper arm. Explanation: In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes.

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

Burns (Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.)

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?

Elevate the legs

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

Ensure proper positioning of the scanner head and rescan. . -Additional ultrasound gel may need to be added for the scanner to work properly. -The best position for bladder scanning is supine.

Grade 1 presents as erythema at access site with or without pain. Grade 2 phlebitis presents with pain at access site with erythema and/or edema Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

Grading *Phlebitis*

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings

Which client would be a candidate for total parenteral nutrition?

a client with colitis and bloody diarrhea

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

cleansing enema

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

liquid consistency. -contains large quantities of electrolytes

A client at a health care facility is being treated for cancer of the bladder. The health care provider uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60 (7.35-7.45) PaCO2: 64 mm Hg (8.51 kPa) (35-45 HCO3: 42 mEq/l (42 mmol/l)(22-26) metabolic alkalosis -alkaline pH -high CO2 & HCO3

A client who is blind is said to be experiencing:

sensory deficit. -Impaired or absent functioning in one or more senses, such as blindness, is termed sensory deficit.

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

stress (Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing.)

The nurse is providing care for an older adult admitted to the hospital with urinary retention. The client asks the nurse, "What is wrong with me?" Which is the best response by the nurse?

"As men age, the prostate enlarges over time."

The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2. Carbon dioxide retention Carbonic acid formed H2CO3 level in the blood decreases pH becomes more alkaline Blood level of CO2 decreases Decreased respirations

1. H2CO3 level in the blood decreases 2. pH becomes more alkaline 3. Blood level of CO2 decreases 4. Decreased respirations 5. Carbon dioxide retention 6. Carbonic acid formed When respirations are increased, the H2CO3 level begins to decrease, causing the pH to become more alkaline. When the blood level of CO2 decreases, respirations slow, resulting in CO2 retention and the formation of carbonic acid, signaling stabilization of the pH balance.

A health care provider has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

A hypotonic solution

The nurse is preparing to flush a client's peripheral venous access device. Which observable intervention best assures continued effective venous access at this location?

Anchoring extension tubing near entry site with tape

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline.

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)?

Ensure that the catheter is removed as soon as possible.

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?

Gauze dressing A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. (However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. )

The nurse is preparing to administer an enema to a client who is constipated. Upon assessment, the nurse notes painful distended veins on the exterior rectum. Which action will the nurse take next?

Generously lubricate the enema tube tip before proceeding.

A nurse is performing a client's intermittent closed catheter irrigation and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's best response to this situation?

Repeat the irrigation. (would drain into bag, not harmful to pt)

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

The birth can cause perineal swelling. (Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period)

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions?

The client drinks two glasses of water before and after sexual intercourse.

The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted?

The novice nurse asks the client to urinate before palpating the bladder. (bladder cannot be palpated when empty)

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted?

The novice nurse selects an 18 French Foley catheter to insert. (too big, should be 14f-16f)

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. Which information is essential for the nurse to review with the client as a strategy to decrease future risk of UTI?

Voiding before and after sexual intercourse

During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care?

condom catheter

A client has been NPO. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color?

dark amber (-Urine may be dark amber or orange-brown if it is very concentrated secondary to a decreased fluid intake. -Urine is lighter than normal if it is diluted DIURETICS/Lasix) -Foods or drugs can alter the color of urine. Tea-colored or very dark = dehydration.)

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

hypertonic

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?

hypertonic solution

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia. (frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body)

In which fluid compartment is most of the body's fluid is located?

intracellular 70%, ECF is 30%

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

"Are you taking any B-complex vitamins?"

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

What commonly used intravenous solution is hypotonic?

0.45% NaCl -Half-strength saline (0.45% NaCl) is hypotonic. -Normal saline (0.9% NaCl) and lactated Ringer's are isotonic. - 10% dextrose in water (D10W) is hypertonic.

The health care provider writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse? Record your answer using a whole number.

25 gtt/min 150 mL x 60 minutes / 10 drop factor = 25 drops per minute or: 150ml x 10 drop factor / 60 min = 25 drops per min

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client?

Regular toileting routine

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the side rail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which is the appropriate action for the nurse?

Remove the IV catheter and reinsert another in a different location.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

Restart infusion in another vein and apply a warm compress.

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?

Sacral area

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action by the UAP is noted?

UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?

Unless contraindicated, nurses should encourage clients to stand to use a urinal.

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply. a. "The client is willing to look at the stoma." b. "The client makes neutral or positive statements about the ostomy." c. "The client expresses interest in learning self-care." d. "The client agrees to take prescribed antidepressants." e. "The client uses spray deodorant several times an hour to mask odor."

a. "The client is willing to look at the stoma." b. "The client makes neutral or positive statements about the ostomy." c. "The client expresses interest in learning self-care."

The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. a. "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." b. "The kidneys react to hypovolemia by stimulating fluid retention." c. "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." d. "The adrenal glands regulate blood volume by secreting aldosterone." e. "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst."

a. "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." c. "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." d. "The adrenal glands regulate blood volume by secreting aldosterone." e. "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." (The heart and blood vessels (not the kidneys) react to hypovolemia by stimulating fluid retention)

The nurse is providing instructions to a client with kidney stones on measures to help prevent urinary tract infections (UTIs). Which statement made by the client would indicate to the nurse that further teaching is necessary? Select all that apply. a. "I will drink 10 ounces of cranberry juice every day." b. "I will bathe in the bathtub rather than take a shower." c. "I will drink about ten 8-oz glasses of water a day." d. "I will notify my health care provider if my urine starts smelling again." e. "I will start wearing underwear with a cotton crotch."

c. "I will drink about ten 8-oz glasses of water a day." d. "I will notify my health care provider if my urine starts smelling again." e. "I will start wearing underwear with a cotton crotch."

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should:

deflate the balloon, insert the catheter further, and slowly attempt reinflation.

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

dehydration

The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor?

delayed wound healing and wound infection

The health care provider has ordered a 24-hour urine specimen collection for a client. Which nursing action is appropriate? Select all that apply. a. Have client label own urine collection. b. Teach client to void only one time per hour. c. Discard first urine just before starting the test, then collect urine thereafter. d. Place urine in staff refrigerator. e. Ask client to void for the last time at exactly the 24-hour mark.

c. Discard first urine just before starting the test, then collect urine thereafter. e. Ask client to void for the last time at exactly the 24-hour mark.

A nurse is preparing to re-site a client's IV during the client's hospital stay following a mastectomy. What accurately describes an assessment that should be made before starting the infusion?

The nurse should assess the preferred site, ideally the dorsal and ventral surfaces of the upper extremities. The nondominant arm should be used for convenience, and extremities compromised from a previous condition should be avoided. AC becoms occluded, avoid if possible)

The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed?

Urine culture sensitivity - 100,000/mL (100,000 organisms per milliliter in a urine culture and sensitivity specimen is positive of UTI)

Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply. a. Maintain aseptic technique when opening sterile packages and IV solution. b. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. c. Squeeze drip chamber and allow it to fill one-quarter full. d. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. e. Allow fluid to flow and cap at end of tubing before all air bubbles have disappeared. f. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.

a. Maintain aseptic technique when opening sterile packages and IV solution. b. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. d. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. f. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines. c. (1/2 full) e. (remove cap to prime)

The client is a new client in the outpatient wellness clinic. The client reports frequent urinary incontinence of recent onset. The nurse reviews the client's list of medications. Which medication classification will the nurse review with the client to determine when the prescription was started?

antihypertensive (Antihypertensives may increase urinary incontinence, because they cause more fluid to enter into the vascular system)

A 57-year-old man is suffering from polyuria. What can cause polyuria?

diabetes insipidus

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product