med surge exam 3 review
which device drains urine from the kidney through a tube that exits through the skin
nephrostomy tube
which conditions are indications for a temporary rather than permenant ostomy. select all that apply
Trauma Infection Severe inflammation
CH 8 definition of pain
"an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."
There are four steps in nociception:
(1) transduction, (2) transmission, (3) perception, and (4) modulation
A nurse is reinforcing teaching to a female patient with incontinence. Which area illustrates the bladder?
2
A student nurse is assisting with data collection on a nursing home resident who has a medical diagnosis of arthritis. The student notes that both the residents hands are in a clenched position and lack full active or passive range of motion. Which term would the nurse use to document this limitation of joint movement?
Contracture
A nurse is using an open hand to gently press on a patients abdomen over the bladder to promote urine passage. What is the nurse demonstrating ?
Crede method
The nurse is preparing to complete a digital removal of impacted stool for a patient experiencing immobility. Which situation would the nurse assure is in place before completing the procedure?
A healthcare providers order
A nurse is administering dutasteride (Avodart) to a patient. Which patient is being prescribed this drug?
A male patient with an enlarged prostate
On a postsurgical unit, the nurse cares for many patients who are experiencing pain. In which instance is a patients pain threshold likely to be lower?
A patient who is anxious may have a lower pain threshold
Which patient requires repositioning every 2 hours Select all that apply
A patient with right hemiplegia who is unable to move independently A patient who is immobile and requires assistance with activities of daily living (ADLs) A patient who had knee replacement surgery yesterday and is unable to turn independently
Which information about a cutaneous ureterostomy is true? select all that apply
A pouch is needed to collect urine There is a risk for urinary tract infection If stenosis occurs it wil interfere with urine flow Hydronephrosis is a risk if there is an obstruction
Which signs and symptoms indicate small bowel obstruction after surgery to create an ileoanal reservoir? select all that apply
Abdominal distention nausea and vomiting changes in bowel patterns
Student nurses assigned to the obstetric unit clinical rotation are discussing the types of pain at a postconference gathering. Which response should the students provide when asked what classification of pain a laboring mother experiences?
Acute
A patient has fecal neurogenic incontince. The staff has tried scheduled toileting but it has not been successful. Which treatment would the nurse expect next?
Administer a constipating drug in the morning and a laxative at night
A patient has fecal neurogenic incontinence. The staff has tried scheduled toileting , but it has not been successful. Which treatment would the nurse expect next?
Administer a constipating drug in the morning and a laxative at night
Which nursing action is appropriate for a patient with fecal overflow incontince?
Administer daily enemas
which nursing action is appropriate for a patient with fecal overflow incontinence?
Administer daily enemas
A nurse is caring for a patient who is receiving an adjuvant medication to assist with pain control. Which medications may be used as an adjuvant? Select all that apply
Alaprazolam Amitriptyline Gabapentin Methocarbamol
A patient has fecal incontinence because of nerve damage therefore causing the muscles of the pelvic floor to be weak. The nurse recognizes this as which type of incontinence ?
Anorectal
The nurse has identified a patient with a Stage 2 pressure ulcer. Which is the expected treatment for a pressure ulcer at this stage?
Cleanse with mild soap and water.
Which foods would the patient with fecal incontinence be instructed to avoid? Select all that apply
Coffee and chocolate
A nurse is using an open hand to gently press on a patients abdomen over the bladder to promote urine passage. What is the nurse demonstrating?
Crede method
Factors affecting communication
Cultural differences , past experiences , emotions and mood , attitude of the individual
Which ostomies are forms of urinary diversions? Select all that apply
Cystostomy ileal conduit ureterostomy
Which medication classification are most commonly used for urinary incontinence management
Anticholinerigic and muscarinic receptor antagonist
Which action is appropriate for a shiny red area around a urinary stoma?
Apply nystatin powder
A patient has a colostomy with liquid stool that was performed for a right sided tumor in the intestine.WHich type of colostomy did the patient recieve ?
Ascending
a patient has a colostomy with liquid stool that was performed for a right sided tumor in the intestine? Which type of colostomy did the patient recieve?
Ascending
which location of an ostomy is expected to have the most liquid effluent?
Ascending colon
The LPN is assisting with the irrigation of the patients colostomy. Which action would the nurse perform first?
Ask the patient to choose the time of day that is most convenient
Which of these is a priority for the nurse related to a patients pain management?
Assess the patients pain.
The nurse is caring for an immobilized patient. The nurse is aware of which consequences of immobility apply to the respiratory system?
Atelectasis Growth of pathogens Hypostatic pneumonia Impaired oxygen and carbon dioxide exchange
After a motor vehicle accident a patient is complaining of continued pain despite a dose of morphine sulfate (morphine) given intravenously 1 hour ago. Which action by the nurse is best?
Attempt to reposition the patient.
The nurse is planning care for an older adult patient who is immobile. The nurse will be using interventions from the pressure ulcer prevention protocol. Which interventions would the nurse include? Select all that apply.
Avoid friction when moving the patient Protect the patients skin from moisture Keep bed linens dry, smooth, and free of wrinkles Avoid pressure points when positioning the patient
Which assessment finding is considered normal for a new stoma?
Beefy red darker than oral mucosa
A nurse is caring for a patient who is experiencing chronic pain related to a musculoskeletal disorder. Which statement regarding chronic pain is most accurate?
Chronic pain may not manifest in a change of vital signs.
CH12 The nurse is educating an older adult patient on adequate fluid intake to prevent complications of dehydration. Which information should the nurse include? Select all that apply
Confusion Constipation Urinary tract infection (UTI)
A patient is receiving fentanyl transdermal patches to relieve chronic pain associated with cancer. This patient is experiencing multiple side effects of the medication. Which of the side effects listed will continue, even with the development of tolerance?
Constipation
Which procedure involves creating an internal pouch from a loop of ileum for storing fecal matter?
Continent ileostomy
The licensed practical nurse ( LPN) is caring for a patient who has been diagnosed with stage 2 pressure ulcer. Which action should be the nurses priority ?
Continue to implement preventive measures
Which factor is considered an advantage of a kock pouch over a plain ileostomy
Drainage of liquid stool at intervals
Depending on the type of urinary incontinence a number of therapeutic measures may be prescribed. Which is the measure considered most effective in the management of urge incontinence ?
Drug therapy
A patient comes to the walk in clinic with complaints of urinary incontinence stating, "Every time I cough, sneeze or lift anything heavy I wet myself". The health care provider has prescribed duloxetine. The patient says. "isnt this an antidepressant? why is the physician prescribing an antidepressant when i need something for bladder control"? What is the nurse's response?
Duloxetine is an antidepressant but it is also prescribed to help with stress incontinence by sphinctercontraction
A patient is having a condom catheter placed. The nurse will intervene if the nursing assistant completes which action?
Encircles the penis with tape
The nurse is caring for a patient who has decreased mobility. Which patient intervention would the nurse include in the plan of care for this patient?
Encourage daily fluid intake of atleast 1200 mL
The nurse is caring for a patient with decreased mobility who is experiencing constipation. Which interventions would the nurse expect to see in the plan of care for this patient ?
Encourage defecation when the urge is present.
Which nursing interventions are appropriate for a patient who is diagnosed with stress urinary incontinence?Select all that apply
Encourage intake of normal amount of fluid Empty the bladder every 2 hours when awake Discuss weight loss if patient is overweight Instruct the patient on how to perform kegel exercises
Which are the natural opioid like substances produced in the human body? select all that apply
Endorphins Enkephalins
The nurse is attending a care planning conference for a patient who is immobile since a motor vehicle accident. The nurse expects the plan of care to include turning the patient how frequently?
Every 2 hours
Which factors increase the production of endorphins? Select all that apply
Exercise Acupuncture Massive trauma
The nurse is planning to use distraction as part of a cancer patients pain management. Which of these are examples of distraction to provide pain relief? select all that apply
Exercising Reading a book Listening to music Watching a movie
A manager is discussing nursing care as a major factor in pressure ulcer prevention. What information should the manager provide to the staff nurses about pressure ulcers? Select all that apply
Expensive to treat Increase mortaility Result in longer hospital stays Increase the likelihood of lonog term placement
A manager is discussing nursing care as major factor in pressure ulcer prevention. What information should the manager provide to the staff nurses about pressure ulcers? Select all that apply
Expensive to treat Increase mortality Result in longer hospital stays Increase the likelihood of long term placement
A patient is 12 hours post colostomy surgery and has not had any drainage from the colostomy. Which nursing action is appropriate ?
Explain to the patient that this a normal finding
The nurse is assessing a patient who reports painful defecation, fullness, in the rectum, abdominal distention, and small amounts of liquid stool. Which additional assessment should the nurse implement?
Fecal impaction
A patient reports that he is taking a medication used to treat overflow incontinence associated with prostate enlargement. The nurse is aware that which medication is used for this purpose?
Finasteride
A patient is being transferred from an acute care hospital to a long term care center. When receiving the report the nurse at the long term care center is informed that the patient has a stage 3 pressure ulcer. Which characteristics of the pressure ulcer will be expected by the nurse?
Full thickness skin loss involving damage or necrosis of the dermis and subcutaneous tissue
Which term describes a person who voids inappropriately because of an inability to get to the toilet or to manage the mechanics of the toilet?
Functional incontinence
After reviewing the chart which finding alerts the nurse to the cause of the patients sudden development of urinary incontinence?
Furosemide on the medication record
The nurse is teaching a class about low risk interventions for urinary incontinence. which interventions would the nurse include? Select all that apply
Habit training Kegel exercises Prompted voiding
Which factors increase the stimulation of large diameter nerve fibers according to gate control theory? Select all that apply
Heat application Application of ice
CH 14 The licensed practical nurse (LPN) is caring for a patient who is experiencing overflow fecal incontinence. What is the priority nursing intervention?
Help the patient increase fluid and fiber intake
The licensed practical nurse (LPN) is caring for a patient who is experiencing overflow fecal incontinence. What is the priority nursing intervention?
Help the patient increase fluid and fiber intake
The nurse is reviewing the medications for a patient who has recently developed urinary incontinence. Which of the patients medications may contribute to this condition? select all that apply
Hypnotics Loop diuretics Antihistamines
A patient had abdominal surgery 5days ago and the nurse is evaluating the plan of care to prevent the effects of immobility. Which statement would indicate that the care plan is successful ? Select all that apply
I am ready to walk a little further. I am able to walk to the sink to get water. I am able to walk in the halls using my walker.
Which statement by a patient treated for poor self concept indicates he defense mechanism of identification?
I just bought a whole new wardrobe that resembles my older sisters
Which statement indicates that patient teaching has been effective regarding pelvic muscle (kegal) exercises
I should practice tightening my perineal muscles
A nurse has reinforced teaching with a patient about medication tolterodine. Which response by the patient would indicate a correct understanding of the teaching ?
I should take this 1 hour before meals
Which medication is a nonopioid analgesic ?
Ibuprofen
The nurse is reviewing the prescriptions for a patient who is experiencing mild pain. Which of these are appropriate nonopioid analgesics for mild pain? Select all that apply.
Ibuprofen Acetaminophen
A partient experiencing postoperative abdominal pain tells the nurse that picturing herself floating on a raft in the middle of the ocean help control her pain. Which approach to pain control is t he patient implementing?
Imagery
The nurse is participating in an upcoming wellness fair and has been assigned to plan education about prevention of constipation. Which information should the nurse include? Select all that apply
Include high fiber foods in the diet Establish a regular exercise program Drink 6 to 8 glasses of water per day
Which specific consequence results from pressure ulcer development in patients?
Increased mortality
Bloody diarrhea loss of appetite and pain are indicative of which complication of an ileoanal reservoir?
Inflammation
The licensed practical nurse is caring for a patient who is experiencing the anorectal form of fecal incontinence. Which instruction would need to be included in patient teaching?
Instructing the patient on Kegal exercises
The healthcare provider recommended ice packs for a patient who experienced an ankle injury, and the nurse is providing instructions. Which purpose is most likely when using heat or cold therapy in pain control?
Interference of pain impulse transmission
A patient asks the nurse how a pessary is used. What would be the nurses response ?
It is a device that will be inserted into the vagina to hold pelvic organs in place
A patient asks the nurse how a pessary is used. What would be the nurses response ?
It is a device that will be inserted into the vagina to hold pelvic organs in place.
A patient is prescribed a patient controlled analgesia (PCA) delivery system for pain secondary to renal cancer. Which instruction would be correct for the nurse to include when educating the patient about the PCA system?
It uses an infusion system controlled by the patient.
Which actions must the nurse follow in preventing pressure ulcers? Select all that apply
Keep skin area clean ' Perform frequent position changes Ensure adequate nutritional intake for wound healing
The nurse is planning care for a patient. Which activities of daily living ( ADLs) and active range of motion (ROM) exercises can be accomplished simultaneously? Select all that apply
Knee flexion with walking Elbow flexion with bathing Elbow extension with shaving
A patient tells the nurse I am afraid i will not get along with the hospital staff, Which term describes this patients concern ?
Loss of autonomy
Which supplies should the nurse have in a room to care for the postoperative patient who had an ileostomy created?
Low intermittent suction
which supplies should the nurse have in the room to care for the postoperative patient who had ileostomy created?
Low intermittent suction
The nurse is reviewing the plan of care for an immobile patient with a stage 1 pressure ulcer. Which interventions would the nurse expect to see in the plan of care? Select all that apply
Maintain a moist environment Keep wound temperature close to body temperature
A patient has reflex incontinence. Which nursing action is important for this patient?
Maintain bladder drainage
The provider suggests employing the gate control theory to relieve the pain of an uncomfortable patient. Which interventions does the nurse know to provide ? Select all that apply
Massage Position change Hot or Cold applications
The nurse is teaching the patient how to perform intermittent self catherization at home. Which steps should the nurse include? Select all that apply.
Measure urine output Clean technique may be used Adjust the drain time interval as needed
Which is a description of an occupational therapist's patient responsibilities?
Modifies the physical environment ,restoring self care
Which findings are expected in a patient with an ileal conduit? select all that apply
Mucus in the drainage A ureteral stent in place to drain urine A pouch is attached to a collection device at night
When caring for a patient after cutaneous ureterostomy placement, the nurse would report which finding
Mucus in the urine
The nurse is reviewing a patient plan of care and notes a Norton score of 7. Which interventions would the nurse expect to see in the plan of care for this patient?
Position to avoid resting on pressure points.
The nurse should prepare to administer which medication to the patient experiencing respiratory depression after intravenous administration of morphine?
Naloxone
A patient is receiving a opioid analgesic for postoperative pain. The nurse is caring for this patient knows that if severe respiratory depression occurs she needs to stay with the patient and call for help. Which medication may the nurse administer in this scenario if prescribed?
Naloxone (if severe respiratory depression occurs the registered nurse may administer naloxone)
The nurse is receiving a morning report on a patient who recently underwent surgery to have a tube placed that diverts urine directly from the kidney through a tube that exits through the skin. The nurse knows that this patient has which type of urinary diversion?
Nephrostomy tube
which device drains urine from the kidney through a tube that exits through the skin?
Nephrostomy tube
Nociceptive pain originates when the tissue is injured. 1, Transduction occurs when there is release of chemical mediators. 2, Transmission involves the conduction of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3, Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going back down the spinal cord to modify incoming impulses.
Nociceptive pain originates when the tissue is injured. 1, Transduction occurs when there is release of chemical mediators. 2, Transmission involves the conduction of the action potential from the periphery (injury site) to the spinal cord and then to the brainstem, thalamus, and cerebral cortex. 3, Perception is the conscious awareness of pain. 4, Modulation involves signals from the brain going back down the spinal cord to modify incoming impulses.
Which activates the afferent pathways causing the patient to feel pain?
Nociceptors
which finding would alert the nurse that a patient has inadequate bladder emptying?
Postvoid residual of 60 mL
The licensed practical nurse would document which nursing action for a patient who has a pessary?
Presence of the pessary
The nurse is teaching a patient how to use the patient controlled analgesia (PCA) pump. Which instruction should t he nurse provide the patient?
Press the PCA button when the pain begins to return
The licensed practical nurse (LPN) is assisting with data collection on a newly admitted patient and notes that the patient scored 10 on the Norton scale for measuring risk for developing A pressure ulcer. Which is the most appropriate action based on this score?
Notify the RN to ensure that a pressure ulcer prevention program is started
The nurse is providing an opioid to a dying patient in a hospice setting who is experiencing severe cancer pain. Which statement is true?
Opioid administration in this situation is an appropriate nursing action .
The nurse is conducting a community class on the causes of decreased mobility. Which causes should include that relate to decreased mobility? Select all that apply
Pain Depression Joint disease
The nurse is reviewing the definition of pain. Which of these are correct when defining pain? Select all that apply
Pain is a subjective experience. Pain is an unpleasant sensory and emotional experience. Pain is an experience associated with actual or potential tissue damage.
When collecting data on an immobile patient which findings are consistent with a Stage 1 pressure injury? Select all that apply
Pain over the coccyx Non blanchable redness
A nurse teaching bladder training to a cognitively impaired patient would use which technique
Prompted voiding
Which foods will produce thicker stools through an ileoanal reservoir? Select all that apply
Pasta Boiled Rice Low fat cheese
Which treatment is appropriate for a patient with anorectal incontinence ?
Pelvic exercises and biofeedback
A patient complains of pain in the right foot, even though the right foot was amputated 1 week ago. Which type of pain is this patient experiencing?
Phantom
A patient is in the the hospital and has a history of urinary incontinence. Which nursing action will be included in the care?
Place a bedside commode at the patients bedside
The nurse is caring for a patient who is unable to move independently. Which interventions will the nurse consider when positioning the patient? Select all that apply
Position the patient every 2 hours Use the footboards , splints , and bed boards Use proper body mechanics to prevent injury
Which term describes the limit to which a joint may be safely moved?
ROM (range of motion)
Which explanation describes the defense mechanism known as reaction formation?
Reaction formation is being used when you constantly praise your husband even though he is abusive
Which step is in compliance with The Joint Commission (TJC) when documenting pain?
Reassessment of pain after intervention
The nurse is caring for a patient with recent onset of fecal incontinence. The licensed practical nurse is assisting with data collection. Which finding would be significant?
Recent travel to foreign country
A student nurse on clinical rotation is reviewing the medical record of the patient she has been assigned. The student notes that the patient has an area of erythema on the right hip area. Which term describes the condition of at the right hip?
Redness
A nurse is caring for a patient who is reporting an aching cramping type pain located around the umbilicus that began 1 hour ago. Subsquently , this patient was diagnosed by the primary care physician as having appendicitis. which type of pain is the patient experiencing?
Referred pain (referred pain is experienced in a location different from its source. The appendix is located in the lower right abdominal quadrant)
The nurse is reviewing the purpose of the patients rehabilitation. Which purpose relates to rehabilitation? Select all that apply.
Relearn lost skills Compensate for losses Increase self care activities
A patient has cerebrovascular accident (CVA) and right sided hemiplegia. Which actions by the nurse are appropriate? Select all that apply
Reposition the patient every2 hours Perform range of motion exercises when bathing the patient.
Which foods would the nurse encourage for a patient who is having fecal incontinence? Select all that apply
Rice Yogurt Oat bran
How should the stoma appear for a patient who had a colostomy 3 months ago
Rose red
A nurse is identifying the most frequent sites of skin breakdown in a patient. Using this information , in which area would the nurse assess the patients skin first?
Sacrum
The nurse is teaching a group of certified nursing assistants (CNA) about pressure ulcers. Which area of the body will the nurse state is the most frequent site of skin breakdown?
Sacrum
The licensed Practical Nurse is contributing to the plan of care for a patient who needs bladder training. Which intervention would the nurse recommend including in the care plan?
Schedule voiding every 2 to 3 hours while awake
Which type of treatment may be used for neurogenic incontinence ?
Scheduled toileting
The patient is receiving morphine sulfate for pain. Which signs or symptoms should the nurse observe for as adverse effects of this medication? Select all that apply
Sedation Constipation Decreased respiratory rate
A female patient is undergoing a physical examination because of reports of fecal incontinence. The health care provider plans to perform a pelvic and then a rectal examination to assess for prolapse of abdominal organs and to evaluate perineal muscle tone. The nurse prepares the patient and explains that the rectal examination is as assessment of which factor?
Sensation and sphincter tone
Verbal Communication
Spoken or written words
A patient who is immobile has reddened are on his coccyx. The skin is not broken. Which stage will the nurse document for this pressure ulcer?
Stage 1
The nurse is conducting a skin assessment on a newly admitted patient and notes a nonblanchable area of redness. Which stage of pressure ulcer would the nurse document?
Stage 1
The nurse is assessing an immobilized patients pressure ulcer and notes an intact serum fluid filled blistered area. Which stage will the nurse document for this pressure ulcer?
Stage 2
A patient is immobile and has a craterlike sore with involvement of the underlying structures. There is evidence of infection. Which stage is this pressure ulcer?
Stage 3
An older adult patient who is immobile has an area of exposed buttocks muscle with sloughing present and evidence of undermining. What is the stage of the pressure ulcer?
Stage 4
The nurse notes the documentation on a patients pressure ulcer to read "3 cm x 3 cm area on coccyx with full thickness tissue loss. Bone visible in mid wound bed with eschar on both sides of bone. " Which stage would the nurse document for this pressure ulcer"?
Stage 4
Which complication manifests as narrowing at the opening of the base of the stoma of a colostomy?
Stenosis
during her yearly gynecologic physical examination a patient confides in the nurse that she urinates every time she jogs. the nurse documents the presence of which type of incontinence?
Stress
during data collect a nurse discovers that a patient voluntarily expelled feces that were black and sticky. How would the nurse chart the finding
Tarry stool
Which actions would the nurse implement when caring for a patient with stress incontinence ? select all that apply
Teach kegal excercises avoid tea , coffee, and cola empty the bladder every2 hours while awake Maintain fluid intake to at least 2000 mL per day.
A patient has a Stage 2 pressure ulcer and asks the nurse why a dressing has been placed over the site and has not been changed for several days. Which information should the nurse provide to the patient about the dressing? Select all that apply
The dressing enhances would healing The dressing provides a moist enviroment It maintains a temperature close to body temperature
Which nurse understands appropriate teaching for patients with urinary problems?
The nurse who teaches a female to use clean technique when inserting a catheter at home
Pain experience
The pain experience is highly subjective and influenced by behavioral, physiologic, sensory, emotional (e.g., attention, anxiety, fatigue, suggestion, prior conditioning), and cultural factors for a particular person under a certain set of circumstances.
A patient has 80 mL of postvoid residual (PVR). How would the nurse interpret this information?
The patient has inadequate bladder emptying
The licensed practical nurse (LPN) is collecting data for several patients to determine who is at risk for pressure ulcer development. Which patients are most at risk for developing a pressure ulcer? Select all that apply
The patient in skeletal traction The patient who must be boosted in bed often The patient receiving total parental nutrition The patient who is incontinent of urine and stool.
A patient who recently verbalized fear about the inability to care for his mother in law at home develops paralysis with no medical cause. Which explanation describes the patients reaction?
The patient is using conversion as a defense mechanism
Which conditions are indications for a temporary rather than permanent ostomy? select all that apply
Trauma Infection Severe inflammation
The nurse is mentoring a nurse who recently graduated. Which intervention would indicate that the new graduate understands the effects of immobility?
The sheets are changed if the patient becomes diaphoretic.
Which information would the nurse include when teaching about irrigating a colostomy?
The solution should flow slowly Irrigation takes 45 min to 1 hour Use 500 to 1000 mL lukewarm solution.
For a patient placing a condom catheter which observation warrants immediate action by the nurse?
The tape is wrapped in a vertical pattern
The nurse assessing a patients wound notes a pink ulcer bed. How would the nurse interpret this finding?
The tissue is healthy and granulating
The nurse is educating a recently graduated nurse regarding wound management. Which statement by the new graduate indicates a need for further education?
The use of powder and lotions is healing
A nurse caring for a patient who is receiving analgesics as needed (PRN) for pain control rather than around the clock (ATC). Which is a disadvantage of receiving PRN rather than ATC medications?
There may be frequent periods of unrelieved pain and side effects
A patient with urge incontinence is prescribed amitriptyline. The patient states , " Why are they giving me an antidepressant? Im not depressed!" Which response by the nurse is correct?
This medication can be prescribed for a multitude of reasons including reducing your bladder contractions
Which patient finding indicates that the outcome was succesful for a patient with urinary urge incontinence ?
Time between voiding increases without leakage
A patient in a long term care facility suffers from chronic pain requiring opioid analgesics. Shift change reports for the past few shifts show that the patient is requiring the maximum dosage at the minimum interval for the prescription and is reporting a decrease in pain relief. Which change is the patient experiencing that would lead the nurse to discuss an increase in opioid dose with the health care provider?
Tolerance
when can a nurse start helping a patient train ileostomy to produce stool at certain times?
Training is not possible because of the frequent drainage from the site
Which interventions are included to decrease the patients risk for respiratory complications when planning care for a patient with multiple rib fractures sustained in a motor vehicle accident? Select all that apply.
Turn and position every 2 hours Coughing and deep breathing every 2 hours
The licensed practical nurse is caring for an immobile patient and is attempting to prevent respiratory complications from developing. Which task can be safely assigned to a certified nursing assistant (CNA)
Turn and reposition the patient every 2 hours
The nurse is planning care for a patient who is at risk for impaired gas exchange related to immobility. Which interventions would the nurse include in the patients care? Select all that apply
Turn the patient every 2 hours Instruct the patient to cough and deep breathe every 2 hours
The nurse observes a reddened area over the sacrum of a patient. Which action should the nurse implement? Select all that apply
Turn the patient every 2 hours Place a moist dressing over the site
A patient is admitted to the unit with a stage 3 sacral pressure ulcer. Which pressure ulcer prevention protocols should be implemented by the nurse ? Select all that apply
Turn the patient every 2 hours and PRN Keep bed linens dry smooth and free of wrinkles Use pillows or foam wedges to separate knees and ankles Place the patient on a specialty mattress to help reduce pressure.
A patient is admitted with a concussion and contusions after falling from his roof. Which exercises should the nurse instruct the patient to do in bed to help prevent future health problems due to immobility? Select all that apply
Unilateral leg lifts and foot dorsiflexion Raising the head in prone and supine positions Turning, coughing, and deep breathing every 2 hours Pelvic tilts (on back , knees bent, feet flat, tuck in tummy, relax ) Neck rolls (neck foward flex, backward extend, lateral flex, rotate)
Which interventions can the nurse implement to help prevent pressure ulcers in patients who are unable to leave there beds? Select all that apply
Use moisturizers Frequently change positions Keep bed linens dry and smooth
Which technique will the nurse use to test a patien for postvoid residual?
Using an ultrasound device
Which definition of pain is most accurate?
Whatever the person experiencing it says it is.
During a focused data collection , which comment would the nurse expect from a patient with stress incontinence?
When I pick up a bag of groceries, I leak some urine
which signs and symptoms indicate small bowel obstruction after surgery to create an ileoanal reservoir ? select all that apply
abdominal distention nausea and vomiting changes in bowel patterns
When is the best time to have an ostomy patient participate in the care of the ostomy?
When the patient begins to watch
Nonverbal communication
Without words ex: gesture, body posture, intonation, general appearance
The nurse enters the room of a patient who is 2 days postoperative after having a colostomy. Which response is appropriate when the patient is visibly upset and tearful
You seem upset whats going on
Analgesics
are drugs that relieve pain without producing loss of consciousness or loss of reflexes
which location of an ostomy is expected to have the most liquid effluent?
ascending colon
the LPN is assisting with the irrigation of the patients colostomy. which action would the nurse perform first?
ask the patient to choose the time of day that is most conventient
A patient has been experiencing loose stools for the past week. The nurse suggests increasing intake of which foods t decrease stool frequency
bananas , rice , potatoes
The nurse expects a new intestinal stoma to appear which color?
beefy red
a young woman suspects she has a urinary tract infection because she has been experiencing pain and urination. The LPN informs her that which laboratory test will be performed
clean catch urinalysis with a culture and sensitivity test
Which food would the patient with fecal incontinence be instructed to avoid? select all that apply
coffee nd chocolate
which procedure involves creating an internal pouch from a loop of ileum for storing fecal matter?
continent ileostomy
which ostomies are forms of urinary diversions? select all that apply
cystostomy ileal conduit ureterostomy
a patient who had a colostomy 5 days ago is refusing to look at the stoma or participate in care. The patient appears to be in which stage of the grieving process?
denial
Nociceptive
described by patients as dull and aching
which factor is considered an advantage of a kock pouch over a plain ileostomy ?
drainage of liquid stool at intervals
which method is most effective in the management of urge and reflex incontincence
drug therapy
Which finding indicates that a patient with an ileoanal reservoir has developed peritonitis ?
elevated white blood cell count
Which findings indicate that a patient with an ileoanal reservoir has developed peritonitis ?
elevated white blood cell count
Which term describes a person who voids inappropriately because of an inability to get to the toilet or to manage the mechanics of the toilet?
functional incontinence
visceral pain
if it originates from the abdominal and thoracic organs.
somatic pain
if it originates from the skin, bones, joints, muscles, or connective tissue (e.g., arthritis pain)
Which type of ileostomy allows for nearly normal bowel evacuation?
ileal j pouch- anal anastomies
Which part of the intestine is used for creating a urinary diversion
ileum
which part of the intestine is used for creating a urinary diversion?
ileum
bloody diarrhea loss of appetite and pain are indicative of which complications of an ileoanal resevoir?
inflammation
which conditions would the necessitate a perment urinary diversion rather than a temporary diversion? select all that apply
irremovable obstruction in the bladder malignant carcinoma of the bladder congential malformation of the bladder damaged sphincters of the bladder and detrusor muscle
Which conditions would necessitate a permanent urinary diversion rather than a temporary diversion? select all that apply
irremovable obstruction in the bladder Malignant carcinoma of the bladder congenital malformation of the bladder Damaged sphincters of the bladder and detrusor muscle
which interventions would the nurse implement for a patient with urge incontinence?
limits fluids 2 hours before bedtime
Which task may be delegated to the unlicensed assistive personnel (UAP) when determining the cause of a patients incontinence
measuring output
Which conditions are indications for ileostomy placement? select all that appy
multiple polyposis inflammatory bowel disease
which conditions are indications for ileostomy placement? select all that apply
multiple polyposis inflammatory bowel disease
Enemas are appropriate for which type of fecal incontinence?
overflow
which type of fecal incontinence is caused by constipation that includes fecal matter in the entire colon?
overflow
The three terms used in relationship to the pain experience
pain perception, pain threshold, and pain tolerance.
In preconference a nursing instructor quizzes a student on the definition of dysuria. What should be the students response?
painful urination
The nurse is collecting data on the appearance of the stoma of a patient with an ileostomy 2 days postoperatively. Which finding needs to be reported to the health care provider?
pale pink color
The nurse is collecting data on the appearance of the stoma of a patient with an ileostomy 2 days postoperatively. which finding needs to be reported to the health care provider?
pale pink color
which foods will produce thicker stools through an ileoanal resevoir ? select all that apply
pasta boiled rice low fat cheese
The licensed practical nurse is contributing to a discharge plan for a patient who will be taking bethanechol chloride to treat urinary incontinence. The nurse would alert the patient to be aware of which signs or symptoms that need to be reported to the health care provider?
patient develops a headache and nausea and is short of breath
Which deficit is the patient at risk for as a result of the placement of a ureterosigmoidostomy?
potassium
which deficit is the patient at risk for as a result of the placement of a ureterosigmoidostomy?
potassium
A patient has been prescribed bethanechol chloride for the treatment of urinary incontinence. The patient tells the licensed practical nurse (LPN) that she has a history of asthma. The nurse would notify which member of the health care team first?
provider
How should the stoma appear for a patient who had a colostomy 3 months ago
rose red
When can a nurse start helping a patient train the ileostomy to produce stool at certain times?
training is not possible because of the frequent drainage from the site.
what are the four basic types of urinary incontinence? Select all that apply
urge stress overflow functional
The family of a patient on the medical unit calls for the nurse urgently and reports that their loved one fainted while having a bowel movement. Which description accurately describes what has happened to this patient?
vasovagal reflex
CH 18 which ostomy is located in the urinary tract?
vesicostomy
Which ostomy is located in the urinary tract?
vesicostomy
Which initial response is appropriate when a patient with an ostomy expresses concerns regarding sexuality
what is concerning you about your sexuality since having the ostomy ?
which initial response is appropriate when a patient with an ostomy expresses concerns regarding sexuality?
what is concerning you about your sexuality since having the ostomy?
