Module 5

Hydrogen ions are transferred from blood into the urine during which of the following processes? A. Secretion B. Filtration C. Reabsorption D. All of the above

A. Secretion

The enzyme amylase begins the conversion of which of the following? A. Starches to sugars B. Sugars to starches C. Proteins to amino acids D. Fatty acids and glycerol to fats

A. Starches to sugars

Thrush is: A. caused by a type of yeast B. seen sometimes by adults who are immunosuppressed C. also known as oral candidiasis D. all of the above

D. all of the above

The portion of the tooth that is covered with enamel is the: A. pulp cavity B. neck C. root D. crown E. none of the above is correct

D. crown

The liver is an: A. enzyme B. endocrine organ C. endocrine gland D. exocrine gland

D. exocrine gland

Cholelithiasis is the term used to describe: A. biliary colic B. jaundice C. portal hypertension D. gallstones

D. gallstones

A general term for infection of the gums is: A. dental caries B. leukoplakia C. Vincent angina D. gingivitis

D. gingivitis

Which task would be assigned to a nurse rather than to unlicensed assistive personnel (UAP)? O Perineal cleaning and care O Urinary catheter irrigation O Obtaining a clean urine sample O Urinary output measurement

O Urinary output measurement Rationale The task of irrigating an indwelling urinary catheter requires the skill of a nurse and should not be delegated to a UAP Perineal cleaning and care, obtaining a clean urine sample, and measuring urinary output are tasks that can be delegated to UAP

A patient with a terminal diagnosis has been awake for 2 days and has pressed the call bell several times requesting the nurse to sit at the bedside and talk. Which assumption can the nurse make about the patient's behavior? O The patient feels abandoned by family members. O The patient is bored and needs diversional activity O The patient is self-centered and is seeking attention O The patient may be afraid to go to sleep for fear of dying

The patient may be afraid to go to sleep for fear of dying Rationale Patients with advanced cancer or chronic illnesses are often afraid to go to sleep for fear that they might dic. There is no indication that the family has abandoned the patient or that the patient is bored or seeking attention. The patient is terminal and has not slept in 2 days, which indicates that the patient is most likely afraid to go to sleep because of fear of dying. and has not slept in 2 days, which indicates that the patient is moRationale Patients with advanced cancer or chronic illnesses are often afraid to go to sleep for fear that they might dic. There is no indication that the family has abandoned the patient or that the patient is bored or seeking attention. The patient is terminalst likely afraid to go to sleep because of fear of dying.

The postsurgical patient has a Salem sump tube for decompression of the stomach. The nurse observes fluid leaking out of the pigtail. What should the nurse do? (379) 1. Remove the tube and reinsert it. 2. Introduce 30 mL of air into the pigtail. 3. Pull the tube back a few centimeters. 4. Increase the pressure of the wall suction.

2. Introduce 30 mL of air into the pigtail.

Which patient statement indicates further discharge teaching is needed for a patient with hemorrhoids? O "I should use witch hazel pads daily." O "I will drink fluid only when i am thirsty." O will add fiber enriched food to my diet." O "I can sit in a bathtub of warm water twice a day."

"I will drink fluid only when i am thirsty." Rationale The goal for patients with hemorrhoids is to decrease pain, prevent elimination problems, and prevent damage to the already swollen tissues. To facilitate this, it is necessary for the patient to maintain a proper diet high in fiber, ensure adequate fluid intake, and participate in regular exercise. If the hemorrhoids are particularly bothersome, localized heat such as from a sitz bath and witch hazel pads can be used. If the patient limits fluid intake, it is an indication of lack of understanding and the need for additional teaching,

Which statement by the patient demonstrates a clear understanding of how to use the patient-controlled analgesia (PCA) drug delivery system prior to surgery? O "I am going to push the button every 10 minutes." O "If I push the button, I will receive medication as long as it is not too soon." O I will stop breathing ifl push the button too much O I will only push the button when I am awake, and the nurse will push it when lam asleep."

"If I push the button, I will receive medication as long as it is not too soon." Rationale The patient should be taught to use the PCA before surgery. The nurse should have the patient demonstrate use of the PCA delivery button. The most effective method to assess whether the patient understands how to use the machine is through return demonstration. Immediately after surgery the patient may not be capable of verbalizing pain relief, therefore this is not an effective option. Stating that the button can be pushed as often as needed for pain control demonstrates an accurate understanding of the system. The patient should understand and be able to verbalize that he or she should push the button any time that pain is felt. It is good for the patient to know the lockout time as well. There is a time frame in which the patient can press the button for pain meds. If the patient tries too soon, then the medication will not be dispensed. This will prevent the patient from having to keep track of the availability of pain medication. The patient does not understand the purpose of a PCA If he or she believes that the nurse will push the button when the patient is asleep. The patient can push the button every 10 minutes, but that is not using the PCA to full benefit. The patient should assess his or her own pain and hit the button as much as needed, prior to the pain becoming too high. The PCA is programmed and has a lockout mechanism that will not allow the patient to overdose.

Which information would be provided to a patient being discharged with a new colostomy? Select all that apply. O Insert the cone into the stoma during ostomy care." O "Sit in a chair to change the ostomy appliance. O "Measure the stoma opening before cutting the wafer." O "Change the ostomy appliance every 3 to 7 days O "Notify the health care provider of stoma color changes."

"Measure the stoma opening before cutting the wafer." "Change the ostomy appliance every 3 to 7 days "Notify the health care provider of stoma color changes." Rationale Ostomy appliances should be changed every 3 to 7 days to prevent accidental dislodgment from the skin. The stoma will decrease in size over the first 6 to 8 weeks as inflammation subsides, therefore patients should measure the stoma opening before cutting the wafer. The nurse should instruct the patient to notify the health care provider of stoma color changes. The cone and sitting in the chair are steps in colostomy irrigation

How does the nurse properly use a tourniquet when performing a venipuncture? (682) 1. Ties it into a single knot 2. Leaves it in place for no more than 1-2 minutes 3. Places it 6-8 inches above the selected site 4. Ties it tight enough to occlude the distal pulse

2. Leaves it in place for no more than 1-2 minutes

A patient requires venipuncture to obtain a blood sample for diagnostic testing. Which laboratory result is the greatest concern related to the venipuncture? (680) 1. High blood glucose level 2. Low platelet count 3. Elevated blood urea nitrogen 4. Low sodium level

2. Low platelet count

The nurse is talking to a patient who wants to try transcutaneous electric nerve stimulation. Which condition is most important to bring to the attention of the provider? (595) 1. The patient has a cardiac pacemaker device. 2. The patient uses an older model of hearing aid. 3. The patient has a metallic hip joint. 4. The patient has a history of a broken back

1. The patient has a cardiac pacemaker device.

Which patient is likely to have the most complex discharge plan? (273) 1. A 73-year-old man with chronic disease who has no family in the area 2. A 23-year-old mother who just delivered her first healthy baby 3. A 17-year-old adolescent who broke his leg during a ski trip 4. A 35-year-old woman who had an emergency appendectomy

1. A 73-year-old man with chronic disease who has no family in the area

The patient reports that the prescribed opioid dose does not seem to provide the same relief for his acute pain compared to 4 weeks ago. Based on the nurse's knowledge of pharmacology, what does the nurse recognize? (598) 1. The patient has developed a physical tolerance. 2. The patient has a psychological dependence. 3. The patient probably has an addiction. 4. The patient is experiencing chronic pain.

1. The patient has developed a physical tolerance.

A patient had a diagnostic study with a contrast medium 4 hours ago. Now he has swelling and itching around the eyes, a rapid pulse, and mild dyspnea. What should the nurse do first? (650) 1. Administer an as-needed (PRN) dose of diphenhydramine and call the provider. 2. Call the Rapid Response Team and bring resuscitation equipment to the bedside. 3. Contact the health care team member who administered the contrast medium. 4. Apply a cool compress to reduce the swelling and instruct the patient to rest.

1. Administer an as-needed (PRN) dose of diphenhydramine and call the provider.

The nurse needs to perform venipuncture to obtain a blood sample for blood chemistries. What factors influence the nurse's choice of sterile needles? Select all that apply. (685) 1. Age of patient 2. Condition of veins 3. Nurse's familiarity with the product 4. Syringe method versus vacuum tube method 5. Type of blood chemistry test ordered 6. Color of the collection tube

1. Age of patient 2. Condition of veins 4. Syringe method versus vacuum tube method

The nurse is teaching the patient how to col-lect a specimen for blood glucose monitoring. Which patient action demonstrates correct technique? (671) 1. Allows the blood specimen to drop onto the test strip 2. Uses the center of the finger for the punc-ture 3. Holds the finger upright after puncture 4. Vigorously squeezes the fingertip after puncture

1. Allows the blood specimen to drop onto the test strip

The nurse is supervising a nursing student who will perform venipuncture to obtain a blood sample for blood chemistries. The nurse will intervene if the student performs which action? (682) 1. Applies a warm compress to the arm on the side of a mastectomy 2. Obtains a vacutainer and different colors of collection tubes 3. Applies a tourniquet 3 inches above the elbow and palpates the antecubital space 4. Releases the tourniquet after 2 minutes of trying to locate a vein

1. Applies a warm compress to the arm on the side of a mastectomy

Shortly after the patient returns from having a liver biopsy, he reports chest pain and trouble breathing. He seems restless and anxious. The RN says that he might have a pneumothorax. What will the nurses do before calling the provider? Select all that apply. (660) 1. Assess rate, rhythm, and depth of respirations. 2. Check pulse oximeter reading. 3. Assess blood coagulation profile. 4. Listen to breath sounds. 5. Apply oxygen if needed.

1. Assess rate, rhythm, and depth of respirations. 2. Check pulse oximeter reading. 4. Listen to breath sounds. 5. Apply oxygen if needed.

Before the digital removal of a fecal impaction, the nurse checks the medical record. Which part of the patient's history alerts the nurse to be especially observant during the procedure? (382) 1. Cardiac disease 2. Hysterectomy 3. Urinary infection 4. Diabetes mellitus

1. Cardiac disease

The nurse notes purulent drainage from a wound and decides to obtain an order for a wound culture. Prior to contacting the surgeon, what other data will the nurse obtain? Select all that apply. (673) 1. Check oral temperature. 2. Look at trends of white blood cell count. 3. Ask about subjective symptoms such as chills or fatigue. 4. Assess for pain at the wound site. 5. Review the previous documentation about the wound.

1. Check oral temperature. 2. Look at trends of white blood cell count. 3. Ask about subjective symptoms such as chills or fatigue. 4. Assess for pain at the wound site.

The student nurse is obtaining a urine specimen from a patient who has had an indwelling catheter for several days. Which action(s) require(s) correction? Select all that apply. (362, 364) 1. Disconnects the catheter from tubing and collects urine in a sterile container 2. Obtains the urine from the collection bag using the drainage tube on the bag 3. Draws urine directly from the catheter by using a sterile small-gauge needle 4. Applies clean gloves and scrubs the drain-age port with an alcohol swab 5. Uses a sterile needle and syringe and col-lects 10 mL from the drainage port

1. Disconnects the catheter from tubing and collects urine in a sterile container 2. Obtains the urine from the collection bag using the drainage tube on the bag 3. Draws urine directly from the catheter by using a sterile small-gauge needle

The nurse hears in report that a patient receiving tube feedings has been having trouble with dumping syndrome. Based on the report, which action is the nurse most likely to perform? (375) 1. Ensure that the feeding is administered very slowly. 2. Auscultate bowel sounds before and after the feeding. 3. Stay with the patient while the feeding is infusing. 4. Offer the feeding through a straw instead of the tube.

1. Ensure that the feeding is administered very slowly.

The UAP made two attempts to test a patient's blood glucose but was unable to get enough blood to adequately cover the test strip. What factors will nurses assess that could interfere with getting an adequate drop of blood? Select all that apply. (665, 671) 1. Environmental temperature of the room 2. Technique used to obtain the sample 3. Position of the patient's arm 4. Improper calibration of the glucometer 5. Problems with peripheral circulation 6. Condition of the skin on hands and fingers

1. Environmental temperature of the room 2. Technique used to obtain the sample 3. Position of the patient's arm 4. Improper calibration of the glucometer 5. Problems with peripheral circulation 6. Condition of the skin on hands and fingers

For a patient who is having an acute myocardial infarction, the nurse anticipates that the provider will order morphine to relieve pain. Which harmful physical effect of unrelieved pain is the greatest concern for this patient? (595) 1. Increased oxygen demand 2. Decreased gastric motility 3. Depressed immune response 4. Increased mental confusion

1. Increased oxygen demand

What is the most important thing for the nurse to assess for in caring for an older patient who has a condom catheter? (362) 1. Inspect the skin underneath the catheter. 2. Monitor for a urinary tract infection. 3. Measure the daily urinary output. 4. Assess for urinary retention.

1. Inspect the skin underneath the catheter.

An older adult patient diagnosed with osteoarthritis suffers from chronic pain. Based on the patient's age and condition, which pain medications will the provider most likely avoid? Select all that apply. (598, 602) 1. Meperidine 2. Acetaminophen 3. Morphine sulfate 4. Nonsteroidal antiinflammatory drugs 5. Combinations of opioid drugs

1. Meperidine 3. Morphine sulfate 4. Nonsteroidal antiinflammatory drugs 5. Combinations of opioid drugs

The nurse is supervising a new nurse who must collect gastric secretions from a nasogastric (NG) tube. When would the supervising nurse intervene? (675) 1. New nurse uses an alcohol swab to scrub the NG tube prior to inserting a sterile needle. 2. New nurse assists the patient to a high Fowler's position and places a towel underneath the NG tube. 3. New nurse disconnects the NG tube from the suction or the gravity drainage. 4. New nurse verifies NG tube placement to ensure aspiration of gastric contents.

1. New nurse uses an alcohol swab to scrub the NG tube prior to inserting a sterile needle.

A rational patient wishes to leave the hospital against medical advice (AMA), despite the nurse's best attempt at therapeutic communication. What is the nurse's first responsibility? (274) 1. Notify the provider. 2. Document the incident. 3. Detain the patient. 4. Obtain an AMA form.

1. Notify the provider.

Which tasks related to admitting a new patient can be delegated to the UAP? Select all that apply. (262, 265) 1. Obtain personal care items, such as water pitchers or packaged cleansing cloths. 2. Position the bed for transfer from stretcher or wheelchair. 3. Hang signs above the bed related to care, such as "nothing by mouth." 4. Ask the patient if he/she needs special equipment, such as a walker. 5. Store belongings, such as jewelry, watch, or wallet, on the bedside table. 6. Assist the patient to arrange desired items, such as eyeglasses, within reach

1. Obtain personal care items, such as water pitchers or packaged cleansing cloths. 2. Position the bed for transfer from stretcher or wheelchair. 6. Assist the patient to arrange desired items, such as eyeglasses, within reach

The nurse is planning care for several patients who will need postprocedural care. Which patient will require serial neurovascular assessments on bilateral extremities? (654) 1. Patient having cardiac catheterization 2. Patient having a bone scan 3. Patient having electrocardiography 4. Patient having paracentesis

1. Patient having cardiac catheterization

The nurse identifies that the patient with coronary insufficiency is having referred pain. Which finding substantiates the nurse's interpretation? (593) 1. Patient reports she is having pain in her left jaw. 2. Patient demonstrates grimacing when pain starts. 3. Patient reports that chest hurts during exercise. 4. Patient reports that symptoms are relieved with rest.

1. Patient reports she is having pain in her left jaw.

The nurse sees that several patients require stool specimens for diagnostic testing. Which patient's stool specimen must be taken immediately to the laboratory after it has been obtained? (669) 1. Patient traveled to a foreign country and reports abdominal cramping with diarrhea. 2. Patient saw a very dark black stool several days ago, but now the stool seems normal. 3. Patient (small child) is suspected of swallowing a plastic marble 3 days ago. 4. Patient saw stool floating in the toilet and there was an oily film in the water.

1. Patient traveled to a foreign country and reports abdominal cramping with diarrhea.

Which nursing intervention demonstrates the application of the gate control theory of pain? (593) 1. Performs a back massage using warmed lotion 2. Administers acetaminophen as needed 3. Elevates a patient's sprained ankle to prevent swelling 4. Repositions the patient every 2 hours

1. Performs a back massage using warmed lotion

The postoperative patient demonstrates some mild dizziness and mild shortness of breath when moving from sitting to standing position. Which laboratory value would the nurse check first? (692) 1. Red blood cell count 2. White blood cell count 3. Blood urea nitrogen 4. Creatinine level

1. Red blood cell count

The patient had a colonoscopy 2 hours ago and reports that abdominal pain seems to be increasing. What assessments would the nurse perform if colon perforation is suspected? Select all that apply. (655) 1. Take vital signs and compare with baseline. 2. Gently palpate abdomen for tenderness and distention. 3. Perform digital rectal examination to check for blood. 4. Observe for tolerance of clear oral fluids. 5. Observe stools for bleeding and note color and amount.

1. Take vital signs and compare with baseline. 2. Gently palpate abdomen for tenderness and distention. 5. Observe stools for bleeding and note color and amount.

The patient tells the home health nurse that he is doing fine and has been irrigating his colostomy 5-6 times a week with 2000 mL each time. What is the immediate concern that needs to be followed up? (388, 389) 1. The patient needs to have blood drawn for possible low electrolyte levels. 2. The patient needs review of teaching points about colostomy care. 3. The patient needs to have laboratory studies to rule out peritonitis. 4. The patient needs to have psychological evaluation for failure to cope.

1. The patient needs to have blood drawn for possible low electrolyte levels.

When performing a Hemoccult slide test to determine the presence of occult blood in a stool specimen, the nurse would be correct in per-forming which action? (674) 1. Use two separate areas of the stool when obtaining the specimen 2. Obtain the specimen from the toilet bowl. 3. Perform the test control before obtaining the specimen. 4. Take the specimen immediately to the laboratory to prevent hemolysis.

1. Use two separate areas of the stool when obtaining the specimen.

Prior to a paracentesis, which assessments should be performed? Select all that apply. (662) 1. Weight 2. Height 3. Abdominal girth 4. Baseline vital signs 5. Peripheral pulses

1. Weight 2. Height 3. Abdominal girth it 4. Baseline vital signs 5. Peripheral pulses

lubricate catheter for men and women

1.5 to 2 inches for female patient and 6 to 7 inches for male patient.

Catheterization is performed within how long after the patient voids?

10 Mins

How much sterile water is instilled in the balloon when preparing to insert an indwelling urinary catheter? O 3 mL O 5 mL O 10 mL O 15 mL

10 mL Rationale The balloon used to hold a routine indwelling urinary catheter in place should be filled with 10 mL of sterile water. Using 3 mL and 5 mL would not anchor the catheter in place: 15 ml may cause the balloon to burst

HOW HIGH SHOULD THE CLEANSING ENEMA BE RAISED?

12 TO 18 INCHES

The nurse has just informed the patient that he should collect a sputum specimen in the morning. Which additional instruction will the nurse give? (673) 1. "Brush your teeth and use mouthwash just prior to collecting the specimen." 2. "Drink extra water the day before collection to decrease the thickness of mucus." 3. "Inhale and cough deeply and then spit the clear saliva into the sterile cup." 4. "Do not eat any red meat or drink any caffeinated beverages."

2. "Drink extra water the day before collection to decrease the thickness of mucus."

The nurse is placing an identification band on a patient who was admitted through the emergency department. What is best to say as the band is applied? (261) 1. "This is your assigned hospital identification number." 2. "The primary purpose of the band is to maintain safety." 3. "All patients have to wear these; it's standard procedure." 4. "We don't want to lose you while you are in the hospital."

2. "The primary purpose of the band is to maintain safety."

The nursing student reports to the nurse that a postoperative patient is asking for pain medication. What is the most important question that the nurse will ask the student to answer? (594) 1. "Can you give the medication yourself?" 2. "What did the patient tell you about his pain?" 3. "Did you try any non pharmacological interventions?" 4. "What do you know about the prescribed medication?"

2. "What did the patient tell you about his pain?"

A patient with Alzheimer's disease is being transferred from a long-term care facility to an acute care hospital for possible sepsis and change in mental status. Which question is the most important to ask the nurse who is giving the report? (268, 269) 1. "Has the family been advised about the reason for the transfer?" 2. "What is the patient's baseline mental status and behavior?" 3. "When is the patient scheduled to be transferred?" 4. "Will the patient be accompanied by a nurse or family member?"

2. "What is the patient's baseline mental status and behavior?"

The patient requests information about a scheduled magnetic resonance imaging study. What should the nurse tell the patient to expect? (661) 1. "You shouldn't eat or drink for 4 hours before the test." 2. "You will hear humming and loud thumping sounds." 3. "You will have minor discomfort in the area being tested." 4. "You will be assisted to make frequent position changes."

2. "You will hear humming and loud thumping sounds."

Which laboratory blood test is more likely to require written informed consent? (649) 1. Complete blood count 2. Human immunodeficiency virus test 3. Platelet count 4. Blood glucose testing

2. Human immunodeficiency virus test

Which nursing action empowers the patient to become an active partner in managing pain? (592) 1. Administers prescribed pain medication in a timely fashion 2. Acknowledges the patient as expert in his own experience of pain 3. Advocates for therapies that provide sufficient relief of pain 4. Assesses the pain before and after giving pain medication

2. Acknowledges the patient as expert in his own experience of pain

The nurse is suctioning a patient to obtain a sputum specimen. Which occurrence is expected? (676) 1. As the suction catheter is inserted into the tracheostomy, there is resistance. 2. As the suction catheter is inserted into the trachea, the patient begins to cough. 3. As suction is applied, oxygen saturation drops below normal for several minutes. 4. As the suction catheter is withdrawn, the patient begins to exhale very deeply.

2. As the suction catheter is inserted into the trachea, the patient begins to cough.

The nurse has just inserted a nasogastric tube. The patient is coughing and gagging. The nurse takes a small amount of clear aspirated material and tests it with color-coded pH pa-per and the pH is 8. What should the nurse do first? (377) 1. Call the provider to obtain an order for an x-ray to confirm placement. 2. Ask the patient to speak his name and state his full address. 3. Pull the tube out and tell the patient it was probably down his airway. 4. Ask the RN to come and verify the tube placement before use.

2. Ask the patient to speak his name and state his full address.

The patient is being transferred from the medical-surgical unit to a long-term care center. What tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. (269) 1. Change soiled dressings. 2. Bathe an incontinent patient. 3. Assist to collect personal items. 4. Take a final set of vital signs. 5. Review transfer details with family.

2. Bathe an incontinent patient. 3. Assist to collect personal items. 4. Take a final set of vital signs.

A patient is newly admitted for pneumonia with possible early sepsis. The nurse is reviewing the admission orders. Which order should be done first? (681) 1. Intravenous antibiotics 2. Blood cultures from two sites 3. Chest x-ray 4. Blood chemistries

2. Blood cultures from two sites

The patient has an old head injury and demonstrates occasional intermittent episodes of belligerence and confusion interspersed with appropriate behavior. He is currently angry and wants to leave AMA. The nurse is unable to reach the provider. What should the nurse do first? (275) 1. Explain the AMA form and consequences to the patient. 2. Call the supervising RN, because the patient now has acute needs. 3. Notify the family and ask them to take responsibility. 4. Contact the risk manager and ask for permission to detain.

2. Call the supervising RN, because the patient now has acute needs.

An older adult resident in a long-term care facility is incontinent of urine. The nurse observes that the resident always asks for assistance to go to the toilet after eating breakfast. Based on this observation, what would the nurse do first? (373) 1. Instruct UAP to apply incontinence pants before breakfast. 2. Note times that the resident asks for help to the bathroom or requires changing of underwear. 3. Suggest that the health care team plan and initiate a bladder training program. 4. Obtain an order for a condom catheter or an indwelling urinary catheter.

2. Note times that the resident asks for help to the bathroom or requires changing of underwear.

The charge nurse delegates the removal of an indwelling urinary catheter to a new staff member. Which action requires correction? (364) 1. Explaining the burning sensation with the first voiding 2. Obtaining a final urine specimen from the drainage bag 3. Deflating the balloon and pinching the catheter 4. Using clean gloves and performing perineal care

2. Obtaining a final urine specimen from the drainage bag

A patient tells the nurse that he has been sleeping in a recliner chair for the past several months because "It is easier to fall asleep and stay asleep." What is the nurse most likely to suspect and assess for? (607) 1. Back or spinal problems 2. Problems with breathing 3. Headaches with visual problems 4. Restless leg syndrome

2. Problems with breathing

The nurse must perform catheter care. Prior to starting the procedure, the nurse raises the bed and lowers one side rail. What is the best rationale for this action? (360) 1. Ensures patient safety and comfort 2. Promotes good body mechanics 3. Facilitates visualization of the patient's body 4. Adheres to standard procedure

2. Promotes good body mechanics

An older patient had a bronchoscopy several hours ago and now seems restless and con-fused compared to baseline behavior. Which assessment is the most important? (654) 1. Orientation to person, place, and time 2. Pulse oximeter reading and respiratory rate 3. Use of antianxiety medications during the procedure 4. Time of last food and fluid ingestion

2. Pulse oximeter reading and respiratory rate

What is the physiologic rationale for avoiding use of meperidine for patients with sickle cell disease? (598) 1. There is a direct action that causes sickling of blood cells. 2. Renal insufficiency will be present to some degree. 3. Underlying respiratory distress results in respiratory depression. 4. Patients with sickle cell disease are more prone to seizures.

2. Renal insufficiency will be present to some degree.

The patient had a surgical procedure this morning and is requesting pain medication. The nurse assesses the patient's vital signs and decides to withhold opioid medication. Which finding supports this decision? (597) 1. Pulse = 90/min 2. Respirations = 10/min 3. Blood pressure = 130/80 mm Hg 4. Temperature = 99o F rectally

2. Respirations = 10/min

The student nurse is looking at nursing jobs to consider after graduation. Which shift is most likely to cause sleep-wake cycle disruption? (608) 1. Straight night shift 2. Rotating day to night shift 3. Weekends-only evening shift 4. Monday to Friday day shift

2. Rotating day to night shift

The patient reports lower back pain that is dull and intermittent. Which description most strongly suggests that the patient is having chronic pain? (593) 1. Sometimes the pain interferes with sleep or work. 2. The pain has been off and on for about 11 months. 3. Over-the-counter medications give temporary relief. 4. Prolonged sitting seems to make the pain worse.

2. The pain has been off and on for about 11 months.

Which patient is most likely to need extra teaching about how to protect the skin around an ostomy? (383) 1. The patient has a colostomy of the trans-verse colon. 2. The patient has an ileostomy. 3. The patient has a colostomy of the descending colon. 4. The patient has a urostomy

2. The patient has an ileostomy.

The home health nurse is assessing whether a patient with a spinal cord injury would be a candidate for intermittent self-catheterization. Which criteria would support this choice for this patient? Select all that apply. (364) 1. The patient and family understand the use and cost of sterile supplies. 2. The patient understands how to recognize signs/symptoms of infection. 3. The patient has the manual dexterity to perform the cleaning and insertion. 4. The patient and family are seeking ways for the patient to maintain independence. 5. The family wants noninvasive and natural methods to maintain bodily functions.

2. The patient understands how to recognize signs/symptoms of infection. 3. The patient has the manual dexterity to perform the cleaning and insertion. 4. The patient and family are seeking ways for the patient to maintain independence.

What is the greatest concern with patient-controlled analgesia (PCA) by proxy? (600) 1. It's more difficult for the nurse to monitor the dosage and assess response. 2. There is a greater chance of oversedation and opioid toxicity. 3. The patient becomes a passive recipient in the pain management process. 4. The patient's pain is more likely to be unrelieved or undertreated.

2. There is a greater chance of oversedation and opioid toxicity.

The postsurgical patient has chills, fever, and malaise. The provider has instructed the nurse to report the laboratory results as soon as they are available. Which laboratory result is defini-tive for confirmation of infection and effective treatment? (673) 1. White blood cell count 2. Wound culture and sensitivity 3. Red blood cell count 4. Electrolyte levels

2. Wound culture and sensitivity

Which newly admitted patient is most likely to need and benefit from an individualized explanation of the bathroom facilities? 1. A 75-year-old woman with advanced Alzheimer's disease 2. A 20-month-old child who has just started toilet training 3. A 65-year-old man who is from a rural farming region of China 4. A 50-year-old woman who has stress in-continence

3. A 65-year-old man who is from a rural farming region of China

The patient reports seeing black, tarry stool. Which question is the nurse most likely to ask? (673) 1. "Are you straining or noticing discomfort with bowel movements?" 2. "Have you eaten a lot of red meat in the past few days?" 3. "Are you having any pain or discomfort in the upper mid-abdomen?" 4. "Have you ever had a problem with hemorrhoids?

3. "Are you having any pain or discomfort in the upper mid-abdomen?"

The nurse is interviewing a patient who needs to be scheduled for colonoscopy. Which patient comment would cause the nurse to contact the provider before giving instructions for the usual oral bowel preparation? (655) 1. "I take insulin for my diabetes." 2. "I have heard the bowel prep is awful." 3. "I think I might have acute diverticulitis." 4. "My father died of colon cancer."

3. "I think I might have acute diverticulitis."

The patient agrees to try guided imagery as a noninvasive method of pain relief. Before they begin the therapy, which instruction is the nurse most likely to give? (595) 1. "I'll use a combination of firm and light strokes during the therapy." 2. "The skin will be stimulated with a mild electric current that reduces pain." 3. "Tell me about a place and time where you felt relaxed and peaceful." 4. "We have to use specialized equipment to identify your biologic responses."

3. "Tell me about a place and time where you felt relaxed and peaceful."

The nurse is talking to a patient who reports feeling tired and not getting enough sleep. Which question related to the patient's medication is most relevant to designing interventions for the patient's problem? (608) 1. "Which antiinflammatory medication has the provider suggested?" 2. "Has there been a recent increase in the dosage of your opioid medication?" 3. "What time of the day do you usually take your diuretic medication?" 4. "Are you taking your antiemetic medication before or after meals?"

3. "What time of the day do you usually take your diuretic medication?"

The nurse is caring for several patients who are receiving morphine. Which patient is most likely to have problems with respiratory depression? (599) 1. A patient with a history of chronic back pain who is receiving epidural morphine for an acute exacerbation 2. An older patient who is postoperative for a fractured hip and is receiving patient-controlled analgesia 3. A child who received an intramuscular injection prior to having fracture reduction of the forearm 4. An older patient with end-stage uterine cancer who is receiving an oral form of morphine

3. A child who received an intramuscular injection prior to having fracture reduction of the forearm

The patient reports that pain medication used to help, but now is less effective. The patient also reports fatigue, sleep disturbance, and depression. The nurse suspects a synergistic effect. Based on the nurse's interpretation of the data, which intervention would the nurse try first? (593) 1. Advocate for a change of medication or an increase of dose. 2. Tell the patient that this is an expected side effect that will pass. 3. Assess sleep patterns and control environment to facilitate rest. 4. Ask the provider to prescribe an antidepressant medication.

3. Assess sleep patterns and control environment to facilitate rest.

An older female patient is supposed to have diagnostic testing that requires nothing by mouth for 12 hours prior to the test and bowel preparation. The test has been canceled 2 days in a row; once for a large amount of retained stool and once because of equipment problems. Which intervention is the priority? (652) 1. Explain the cancellations to the patient us-ing terms that she can easily understand. 2. Call the diagnostic technician to ensure that the test gets done. 3. Assess the patient for dehydration and fluid and electrolyte imbalances. 4. Call the provider and ask if the test can be postponed for a few days.

3. Assess the patient for dehydration and fluid and electrolyte imbalances.

Which nursing action demonstrates that the nurse is complying with the Joint Commission standards of pain management? (594) 1. Documents that medication is given after the patient receives it 2. Incorporates knowledge of the patient's culture in pain management 3. Assesses the patient's pain and reassesses pain after interventions 4. Stays current with the latest information about pain therapies

3. Assesses the patient's pain and reassesses pain after interventions

The provider prescribes 1000 mg acetaminophen every 4 hours as needed for pain. What should the nurse do? (596) 1. Assess the patient every 4 hours and give the medication as needed. 2. Give the medication as needed during the daytime hours only. 3. Call the provider and ask for clarification of the order. 4. Call the pharmacy and ask if the medication comes in 1000-mg tablets.

3. Call the provider and ask for clarification of the order.

The patient will be catheterized for residual urine. What is the correct technique for this procedure? (667) 1. Catheterize the patient when the bladder is full. 2. Obtain an order for an indwelling catheter. 3. Catheterize the patient within 10 minutes of voiding. 4. Use clean technique to obtain the sample.

3. Catheterize the patient within 10 minutes of voiding.

The nurse is admitting a new patient to the diagnostic and surgical center. What should the nurse do first? (262) 1. Assess immediate needs. 2. Take vital signs. 3. Check identification band. 4. Orient patients to the facility routines.

3. Check identification band.

The student nurse is obtaining a urine specimen from a patient with an existing indwelling catheter. When would the supervising nurse intervene? (667) 1. Performs hand hygiene and applies clean gloves for the procedure. 2. Clamps the drainage tubing for 30 minutes before specimen collection begins. 3. Disconnects the catheter from the drainage tubing and collects the urine in a specimen cup. 4. Unclamps the drainage tube after collection and observes for urine flow.

3. Disconnects the catheter from the drainage tubing and collects the urine in a specimen cup.

The nurse has inserted the urinary catheter into the patient and while the balloon is being inflated, the patient expresses discomfort. What should the nurse do? (367) 1. Remove the catheter and begin the procedure again. 2. Pull back on the catheter to determine tension. 3. Draw fluid out of the balloon and move the catheter forward. 4. Continue to inflate the balloon since dis-comfort is expected.

3. Draw fluid out of the balloon and move the catheter forward.

The nurse is caring for a patient who has arthritis. Which medication does the nurse anticipate the provider will prescribe? (602) 1. Naloxone 2. Gabapentin 3. Ibuprofen 4. Morphine

3. Ibuprofen

What is the best rationale for drawing at least two blood cultures from two different sites? (681) 1. This is the standard method used to detect bacteremia. 2. If only one culture shows bacteria, techni-cian error is assumed. 3. If both cultures show an infecting agent, bacteremia is confirmed. 4. If both cultures show different infecting agents, skin contamination is assumed.

3. If both cultures show an infecting agent, bacteremia is confirmed.

The nurse has tried several times to obtain a throat culture on a patient, but the patient has gagged, moved, and contaminated the tip of the swab during each attempt. What should the nurse do first? (679) 1. Have the patient look in the mirror, give him the swab, and coach him through the procedure. 2. Inform the provider that several unsuccessful attempts have been made. 3. Instruct the patient to open their mouth and say a very long "ahhhhh" and avoid using a tongue blade. 4. Obtain an order for a mild local anesthetic that will temporarily suppress the gag re-flex.

3. Instruct the patient to open their mouth and say a very long "ahhhhh" and avoid using a tongue blade.

The nurse has just removed a urinary catheter from a postsurgical patient. What is the most important instruction to give the UAP? (361) 1. Be especially gentle when performing perineal care, because the area is likely to be irritated. 2. Report the amount of food and fluids that the patient consumes for the remainder of the shift. 3. Measure the amount of the first voiding and report the time and amount to the nurse. 4. Assist the patient to ambulate because the patient is likely to be sore and uncomfortable.

3. Measure the amount of the first voiding and report the time and amount to the nurse.

The patient is to have a thoracentesis per-formed. The nurse assists the patient to which position for this test? (664) 1. Dorsal recumbent 2. Supine with the arms held above the head 3. Sitting up and leaning over a table 4. Side-lying with the knees drawn up

3. Sitting up and leaning over a table

The patient is receiving an epidural opioid. What is a complication of this treatment? (601) 1. Diarrhea 2. Hypertension 3. Urinary retention 4. Increased respiratory rate

3. Urinary retention

What is included in the instructions to the patient for collection of a midstream urine sample? (668) 1. Use a clean specimen cup and try not to touch the inside of the cup. 2. Collect at least 200 mL of urine into the specimen cup. 3. Void into the toilet, stop urinating, and then urinate into the cup. 4. Bathe or shower the perineal area before collection.

3. Void into the toilet, stop urinating, and then urinate into the cup.

Most patients require a pain level of ____ or less to function well

4

Crede maneuver

applying manual pressure over the lower abdomen to express urine from the bladder at regular intervals.

The patient is suspected of having a urinary tract infection (UTI). The provider has ordered a urine specimen for culture and sensitivity testing. The patient asks, "Can't I just get a prescription for antibiotics?" What is the best response? (673) 1. "This is just a routine test for any patient suspected of having a UTI." 2. "Your provider feels this test is necessary in determining your diagnosis." 3. "I can contact your provider if you would like to ask for a prescription." 4. "Different bacteria can cause a UTI and the test results will indicate the best antibiotic."

4. "Different bacteria can cause a UTI and the test results will indicate the best antibi-otic."

The clinic nurse sees that the provider has ordered a sputum specimen for acid-fast bacillus. What is the nurse most likely to clarify with the provider? (673) 1. "Shall I instruct the patient to collect the specimen in the early morning?" 2. "If the patient cannot expectorate a specimen, is nasotracheal suction allowed?" 3. "Is the patient allowed to smoke, drink, and eat after the sputum is collected?" 4. "Should the patient be placed in a negative pressure isolation room?"

4. "Should the patient be placed in a negative pressure isolation room?"

The patient is newly admitted and seems anxious, but also appears very hesitant to ask questions. Which statement by the nurse best demonstrates empathy? (263) 1. "Call me if you need anything; I'll be happy to help you." 2. "There's nothing to worry about; we'll take good care of you." 3. "I know you must have a lot of questions; I know I would." 4. "You seem a little uncertain; do you have some questions?"

4. "You seem a little uncertain; do you have some questions?"

The patient tells the nurse that he would like to be transferred to hospital X, because his cardiologist doesn't come to hospital Y. What should the nurse do? (269) 1. Obtain an AMA form and have the patient sign it. 2. Call hospital X and advise that the patient desires transfer. 3. Advise the patient that the cardiologists in hospital Y are good. 4. Advise the patient that a transfer requires an order from the provider

4. Advise the patient that a transfer requires an order from the provider

The nurse has orders for voided midstream urine specimens for several patients. Which patient is most likely to require an order for a straight catheterized specimen rather than avoided midstream specimen? (668) 1. A 25-year-old female who finished her menstrual period yesterday 2. A 55-year-old female diabetic patient who is very overweight 3. A 63-year-old male who has difficulty with urination due to prostate problems 4. An 18-year-old male who has a Glasgow coma score of 4 after a head injury

4. An 18-year-old male who has a Glasgow coma score of 4 after a head injury

The provider has ordered blood pressure, pulse, and respirations every 2 hours for 12 hours. It is currently 8:00 pm and the nurse knows that the patient has been having a lot of problems sleeping in the hospital. What strategy should the nurse try first? (609) 1. Clarify the necessity of the order with the provider. 2. Explain to the patient that vital signs will only be taken every 2 hours for 12 hours. 3. Tell the unlicensed assistive personnel to quietly take vital signs every 2 hours. 4. Apply an automatic blood pressure cuff that can be programmed for every 2 hours.

4. Apply an automatic blood pressure cuff that can be programmed for every 2 hours.

The nurse enters the patient's room at 3:00 am and finds that the patient is awake and sitting up in a chair. The patient tells the nurse that she is not able to sleep. What should the nurse do first? (609) 1. Obtain a prescription for a hypnotic. 2. Instruct the patient to return to bed. 3. Provide a glass of warm milk with honey. 4. Ask about methods that have helped her sleep.

4. Ask about methods that have helped her sleep.

Nurse A is aware that Nurse B, who is not very skilled at venipuncture, is sticking her patients more than the recommended two times as stated by hospital policy. What should Nurse A do first? (686) 1. Report Nurse B to the nurse manager for violating hospital policy. 2. Watch Nurse B and offer to perform venipunctures after two attempts. 3. Assess Nurse B's understanding and skill in performing venipuncture. 4. Ask the charge nurse to assess Nurse B's understanding of hospital policy.

4. Ask the charge nurse to assess Nurse B's understanding of hospital policy.

Although placebos are rarely used, what is the best physiologic explanation for how they relieve pain? (593) 1. Action of a placebo mimics "fight or flight," which is triggered by epinephrine. 2. Placebos partially close the "gate," so the passage of pain impulses is blocked. 3. Chemically, placebos inhibit the synthesis of prostaglandins that mediate pain. 4. Placebos cause the release of endorphins, which attach to opioid receptor sites

4. Placebos cause the release of endorphins, which attach to opioid receptor sites

The nurse is giving instructions to a family caregiver of an older patient who will need help after discharge from the hospital. The nurse senses tension, resentment, and unwillingness from the caregiver. What should the nurse do first? (273) 1. Continue to give the instructions and ask for feedback from the caregiver. 2. Notify the provider for an order for home health nursing. 3. Get a social service consult to resolve family tensions and problems. 4. Assess the caregiver's attitude toward the patient and the circumstances.

4. Assess the caregiver's attitude toward the patient and the circumstances.

The nurse is suctioning the patient to obtain a sputum specimen. During the 10 seconds of suctioning, the cardiac monitor shows bradycardia and the patient becomes very diaphoretic. What is the best explanation for this occurrence? (673) 1. Patient demonstrated anxiety due to the procedure. 2. Nurse caused hypoxia by suctioning for a prolonged time. 3. Cardiac changes are unrelated to the procedure. 4. Catheter caused direct stimulation of vagal nerve fibers.

4. Catheter caused direct stimulation of vagal nerve fibers.

The patient has an indwelling urinary catheter. The UAP reports that no new urine is collecting in the bag since it was measured and discarded at the beginning of the shift. What should the nurse do first? (362) 1. Irrigate the system using sterile closed technique. 2. Call the provider for an order to discontinue the catheter. 3. Give the patient oral fluid to flush the bladder and catheter. 4. Check for kinks in the tubing system and reposition the patient.

4. Check for kinks in the tubing system and reposition the patient.

The nurse has just received laboratory results for an unfamiliar test, so he is unsure if the results are within normal limits. What should the nurse do first? (650) 1. Call the provider and read the results exactly as they are shown. 2. Ask the patient if he is having any unusual symptoms or complaints. 3. Call the laboratory technician and ask for an explanation of the results. 4. Check the facility's laboratory manual for information about the test.

4. Check the facility's laboratory manual for information about the test.

The nursing student has the opportunity to perform urinary catheterization on a patient. What should the student do first? (360) 1. Perform hand hygiene and don gloves. 2. Explain the procedure to the patient. 3. Obtain the necessary equipment. 4. Check the provider's order.

4. Check the provider's order.

Which instruction will the nurse give to the unlicensed assistive personnel (UAP) about catheter care for the patient? (368) 1. Maintain continuous tension on the external catheter tubing. 2. Empty the drainage bag once a day or sooner if necessary. 3. Attach the drainage bag to the side rails, below the level of the bladder. 4. Clean the urinary meatus and 2 inches down the catheter.

4. Clean the urinary meatus and 2 inches down the catheter.

As the nurse is performing an electrocardiogram (ECG), the patient reports very mild left anterior chest pain. What should the nurse do first? (656) 1. Stop the procedure and obtain the crash cart and other emergency equipment. 2. Continue the procedure, and tell the patient to relax and not to worry. 3. Stop the procedure and obtain an order for pain medication. 4. Continue the procedure and make a notation of pain on the request slip or ECG strip.

4. Continue procedure and make notation of pain on the request slip or ECG strip.

The nurse is using a commercially prepared tube for the collection of an aerobic wound specimen for culture. After collecting the specimen with the swab, what should the nurse do? (679) 1. Place the swab into the collection tube, close it tightly, and keep the specimen warm. 2. Take the swab and mix it with the special color-changing reagent in the collection tube. 3. Place the swab into the collection tube and add the liquid culture medium. 4. Crush the ampule at the end of the tube and put the tip of the swab into the solution.

4. Crush the ampule at the end of the tube and put the tip of the swab into the solution.

The nurse hears in report that the patient with diabetes has reported a tingling, burning sensation in the lower extremities. Which drug is the nurse most likely to administer for this type of discomfort? (599) 1. Ketorolac tromethamine 2. Tramadol 3. Acetaminophen 4. Duloxetine

4. Duloxetine

For a patient on a bladder retraining program, which dietary/fluid intervention is the best? (364) 1. Encourage black coffee for breakfast. 2. Help the patient identify high-fiber foods. 3. Restrict fluid intake to control bladder. 4. Encourage at least 2000 mL of fluid each day.

4. Encourage at least 2000 mL of fluid each day.

What is the greatest advantage of using non-pharmacologic pain management techniques as an adjunct to pain medication? (595) 1. Inexpensive and easy to perform 2. Based on the gate control theory 3. Low risk and few side effects 4. Gives patients some control over pain

4. Gives patients some control over pain

The nurse is trying to explain the bed controls and the call button and other items related to hospitalization, but the older adult patient keeps telling the nurse to "wait for my son to get here." What should the nurse do first? (263) 1. Go find the son or other available family members. 2. Leave written information at the bedside. 3. Give brief information using very simple language. 4. Offer comfort measures and ensure patient safety.

4. Offer comfort measures and ensure patient safety.

An experienced LPN/LVN is working on a medical-surgical unit. The LPN/LVN sees that a new RN has not completed the admission assessment on a patient who arrived 20 hours ago. What should the LPN/LVN do first? (265) 1. Wait to see if the new RN completes the admission assessment. 2. Mention the incomplete admission assessment to the nurse manager. 3. Remind the RN that the Joint Commission requires admission assessment within 24 hours. 4. Offer to collect data so that the new nurse can complete the admission assessment.

4. Offer to collect data so that the new nurse can complete the admission assessment.

According to the bloodborne pathogen standards of Occupational Safety and Health Administration, health care facilities are required to make a written exposure control plan. Which health care worker has sustained a major significant exposure? (681) 1. Nursing student injures self while recapping a needle used to draw up the patient's insulin. 2. UAP picks up blood-stained linen without donning gloves. 3. Nurse sustains a deep cut with profuse bleeding while trying to raise a patient's side rails. 4. Phlebotomist sustains a deep puncture caused by a needle used to collect blood.

4. Phlebotomist sustains a deep puncture caused by a needle used to collect blood.

The patient begins to cough and gag when the nurse inserts a nasogastric tube. The nurse in-structs the patient to breathe easily and take a few sips of water, but the patient continues to cough. What should the nurse do first? (377) 1. Remove the tube and let the patient rest before reinsertion. 2. Attach a syringe to the tube and aspirate for stomach contents. 3. Use a flashlight and tongue blade to look at the throat. 4. Pull the tube back just slightly and instruct the patient to breathe slowly

4. Pull the tube back just slightly and instruct the patient to breathe slowly

The patient begins to cough and gag when the nurse inserts a nasogastric tube. The nurse in-structs the patient to breathe easily and take a few sips of water, but the patient continues to cough. What should the nurse do first? (377) 1. Remove the tube and let the patient rest before reinsertion. 2. Attach a syringe to the tube and aspirate for stomach contents. 3. Use a flashlight and tongue blade to look at the throat. 4. Pull the tube back just slightly and instruct the patient to breathe slowly.

4. Pull the tube back just slightly and instruct the patient to breathe slowly.

What is an expected assessment finding that demonstrates the action of epinephrine on the body during an episode of acute pain? (593) 1. Blood glucose is lower than normal. 2. Description of pain is disproportionate. 3. Pain medication quickly relieves the pain. 4. Pulse and respiratory rates are increased.

4. Pulse and respiratory rates are increased.

The home health nurse sees an order for meperidine for a 63-year-old patient with cancer who requires long-term opioid treatment. What is the best rationale for the nurse to question this medication order? (598) 1. Meperidine is an older drug that is now rarely prescribed for any condition. 2. The patient cannot be continuously monitored for adverse effects in the home setting. 3. The patient is not young nor healthy and is therefore more likely to suffer side effects. 4. Repeated administration of meperidine increases the risk of accumulation.

4. Repeated administration of meperidine increases the risk of accumulation.

Which evaluation statement indicates that the polystyrene sulfonate enema was a successful therapy? (382) 1. The patient evacuated 300 mL of light-brown fluid after the third enema. 2. Removal of hard fecal mass was followed by a small, soft, brown stool. 3. The patient reports resumption of normal bowel pattern after enema. 4. The patient's serum potassium level is within normal limits.

4. The patient's serum potassium level is within normal limits.

When providing routine indwelling catheter care, the nurse should be most diligent in cleaning which areas? 1. The perineal area 2. The area surrounding the urinalysis meatus 3. The labia majora and the labia minora 4. The perineal area and 2 inches of the catheter

4. The perineal area and 2 inches of the catheter

The nurse needs to perform venipuncture on an older patient whose veins are very fragile. What is the best strategy for the nurse to use? (661) 1. Gently tap over the vein. 2. Apply a warm compress. 3. Use a vacutainer. 4. Use a small-gauge needle.

4. Use a small-gauge needle.

How many inches should an indwelling catheter be lubricated before inserting in a male patient? O 1.5 O 4.5 O 3 O 6

6 Rationale Because the urinary tract of a male is longer than that of a female, approximately 6 to 7 inches of the catheter will need to be lubricated. In a female patient, 1.5 to 2.0 inches of the urinary catheter should be lubricated. Lengths of 3 and 4.5 inches are too short for a male patient. Inadequate lubrication leads to friction and trauma to the tissue.

normal range for blood glucose

80-120

Esophagus

A muscular tube that connects the mouth to the stomach.

rectum

A short tube at the end of the large intestine where waste material is compressed into a solid form before being eliminated

During the process of digestion, stored bile is poured into the duodenum by which of the following? A. Gallbladder B. Liver C. Pancreas D. Spleen

A. Gallbladder

What is the middle portion of the small intestine called? A. Jejunum B. Ileum C. Duodenum D. Cecum

A. Jejunum

The union of the cystic duct and hepatic duct forms the: A. common bile duct B. major duodenal papilla C. minor duodenal papilla D. pancreatic duct

A. common bile duct

Incisors are used during mastication to: A. cut B. pierce C. tear D. grind

A. cut

Obstruction of the __________ will lead to jaundice. A. hepatic duct B. pancreatic duct C. cystic duct D. none of the above

A. hepatic duct

The triangular divisions of the medulla of the kidney are known as: A. pyramids B. papillae C. calyces D. nephrons

A. pyramids

The ducts of the ____________ glands open into the floor of the mouth. A. sublingual B. submandibular C. parotid D. carotid

A. sublingual

Urostomy

the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin

two layers of the glomerular capsule are ____

a visceral layer and a parietal layer

Older adult considerations

the effect of aging on the pain process may be compounded in an older adult who has a chronic illness that affects the nervous system

ascending colon

the part of the large intestine that ascends from the cecum to the transverse colon

large intestine

Absorbs water & some other nutrients, & collects food residue for excretion

______ and ____ - the nonopioid analgesics - are the most widely available and frequently used analgesic groups.

Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDS)

non-rapid eye movement (NREM)

the stage of sleep during which the eyes move very little and the body gradually reaches its state of deepest relaxation

Which essential nursing problem would the nurse add to the nursing care plan to address the common side effects of opioid pain medication? O Disturbed body image O Risk for impaired skin integrity O Alteration in bowel elimination O Fluid and electrolyte imbalance

Alteration in bowel elimination Rationale Opioids often delay gastric emptying, slow bowel motility, and decrease peristalsis. They also tend to reduce secretions from colonic mucosa. The result is a slow-moving, hard stool that is difficult to pass. Constipation is the most common side effect of opioids and the only one for which an individual does not develop tolerance. Body image disturbances, impaired skin integrity, and fluid and electrolyte imbalance are not common side effects of opioid use.

Which instruction would be included when teaching patients how to change an ostomy pouch? Select all that apply. Cut the skin barrier a quarter inch larger than the stoma. Rub the skin around the stoma with cold water. Apply the protective skin barrier one-sixteenth of an inch from the stoma, Attach the pouch to the flange by compressing the two parts together. Cover the stoma with toilet tissue to prevent leaking during bag change

Apply the protective skin barrier one-sixteenth of an inch from the stoma, Attach the pouch to the flange by compressing the two parts together. Cover the stoma with toilet tissue to prevent leaking during bag change Rationale When providing teaching on care for ostomy pouches, the nurse should instruct patients to apply a protective skin barrier one-sixteenth of an inch from the stoma to create a good seal from the bag apply the pouch to the flange by compressing the faceplate to the bag, and cover the stoma with toilet tissue to prevent leaking during bag changes. The skin barrier should be cut one-sixteenth of an inch larger than the stoma; any larger allows stool to come in contact with the skin. Patients should gently cleanse the skin around the stoma with warm water, but never rub.

How should the nurse verify placement when inserting a nasogastric tube? Select all that apply. O Aspirate contents O Measure pH of contents. O Auscultate bowel sounds. O Irrigate tube with normal saline. O Listen for swoosh when injecting air.

Aspirate contents Measure pH of contents. Listen for swoosh when injecting air. Rationale Ways to determine the placement of the nasogastric tube include aspirating gastrointestinal contents, testing the pH of these contents, and listening for a swoosh when injecting air through the nasogastric tube. Auscultating bowel sounds determine bowel function. Normal saline is used to irrigate the tube, not determine tube placement

Which of the following processes is used by the artificial kidney to remove waste materials from blood? A. Pinocytosis B. Hemodialysis C. Catheterization D. Active transport

B. Hemodialysis

Which of the following statements about ADH is not correct? A. It is stored by the pituitary gland B. It makes the collecting ducts less permeable to water C. It makes the distal convoluted tubules more permeable D. It is produced by the hypothalamus

B. It makes the collecting ducts less permeable to water

What is an extension of the peritoneum that is shaped like a giant pleated fan? A. Omentum B. Mesentery C. Peritoneal cavity D. Ligament

B. Mesentery

Which one of the following substances does not contain any enzymes? A. Saliva B. Bile C. Gastric juice D. Pancreatic juice E. Intestinal juice

B. Bile

The crown of the tooth is covered externally with which of the following? A. Cementum B. Enamel C. Dentin D. Pulp

B. Enamel

Voluntary control of micturition is achieved by the action of which of the following? A. Internal urethral sphincter B. External urethral sphincter C. Trigone D. Bladder muscles

B. External urethral sphincter

What are the capillary loops contained within the Bowman capsule called? A. Convoluted tubules B. Glomeruli C. Henle loop limbs D. Collecting ducts

B. Glomeruli

Which one of the following structures does not increase the surface area of the intestine for absorption? A. Plicae B. Rugae C. Villi D. Brush border

B. Rugae

What is the layer of tissue that forms the outermost covering of organs found in the digestive tract called? A. Mucosa B. Serosa C. Submucosa D. Muscularis

B. Serosa

Duodenal ulcers appear in which of the following? A. Stomach B. Small intestine C. Large intestine D. Esophagus

B. Small intestine

Fats in chyme stimulate the secretion of the hormone: A. lipase B. cholecystokinin C. protease D. amylase

B. cholecystokinin

The wall of the pulp cavity is surrounded by: A. enamel B. dentin C. cementum D. connective tissue E. blood and lymphatic vessels

B. dentin

Bile is responsible for the: A. final digestion of fats B. emulsification of fats C. chemical breakdown of fats D. chemical breakdown of cholesterol

B. emulsification of fats

Which one of the following substances is secreted by diffusion? A. Sodium ions B. Certain drugs C. Ammonia D. Hydrogen ions E. Potassium ions

C. Ammonia

Glucose reabsorption begins in the: A. Henle loop B. proximal convoluted tubule C. distal convoluted tubule D. glomerulus E. none of the above

B. proximal convoluted tubule

Another name for the third molar is: A. central incisor B. wisdom tooth C. canine D. lateral incisor

B. wisdom tooth

If it is necessary to reuse catheters teach the patient and primary caregiver to

Boil rubber catheters 20 minutes and wrap in clean cloth.

Which factor would be assessed before inserting a rectal tube into a patient with diarrhea? Skin integrity Peristomalarea Bowl sounds Level of orientation

Bowl sounds Rationale The patient's bowel sounds should be assessed before inserting a rectal tube as a baseline assessment before treatment. Skin integrities and level of orientation are parts of a routine physical assessment but are not needed before inserting a rectal tube. A peristomal area is found only in patients with an ostomy.

Which one is not part of the small intestine? A. Jejunum B. Ileum C. Cecum D. Duodenum

C. Cecum

Which of the following conditions would be expected in an infant less than 2 years of age? A. Retention B. Cystitis C. Incontinence D. Anuria

C. Incontinence

Which of the following functions is not performed by the kidneys? A. Help maintain homeostasis B. Remove wastes from the blood C. Produce ADH D. Remove

C. Produce ADH

The enzyme pepsin is concerned primarily with the digestion of which of the following? A. Sugars B. Starches C. Proteins D. Fats

C. Proteins

Which of the following steps involved in urine formation allows the blood to retain most body nutrients? A. Secretion B. Filtration C. Reabsorption D. All of the above

C. Reabsorption

Which of the following teeth is missing from the deciduous arch? A. Central incisor B. Canine C. Second premolar D. First molar E. Second molar

C. Second premolar

Which portion of the alimentary canal mixes food with gastric juice and breaks it down into a mixture called chyme? A. Gallbladder B. Small intestine C. Stomach D. Large intestine

C. Stomach

What is the structure that carries urine from the kidney to the bladder called? A. Urethra B. Bowman capsule C. Ureter D. Renal pelvis

C. Ureter

After food has been chewed, it is formed into a small, rounded mass called a: A. moat B. chyme C. bolus D. protease

C. bolus

The largest of the papillae on the surface of the tongue are the: A. filiform B. fungiform C. circumvallate D. taste buds

C. circumvallate

Fats are broken down into: A. amino acids B. simple sugars C. fatty acids D. disaccharides

C. fatty acids

The largest gland in the body is the: A. pituitary B. thyroid C. liver D. thymus

C. liver

The volume of saliva secreted per day is about: A. one-half pint B. one pint C. one liter D. one gallon

C. one liter

Most of the digestion of carbohydrates takes place in the: A. mouth B. stomach C. small intestine D. large intestine

C. small intestine

Protein digestion begins in the: A. esophagus B. small intestine C. stomach D. large intestine

C. stomach

Cane sugar is the same as: A. maltose B. lactose C. sucrose D. glucose E. none of the above

C. sucrose

Dumping syndrome

Caused by too rapid an infusion of highly concentrated feedings

The nurse is assessing the insertion site of the patient's indwelling urinary catheter and notices exudate. What other assessments is the nurse most likely to perform before notifying the provider? (369) 1. Look at the trends of intake and output for the past several days. 2. Gently palpate the patient's suprapubic area to assess for bladder distention. 3. Check the patient's temperature and draw fresh urine from the drainage port. 4. Observe the clarity, odor, and color of urine in the collection bag.

Check the patient's temperature and draw fresh urine from the drainage port.

Which order of effective cleansing of the perineal area of a male patient would the nurse follow? O Cleansing the area around the meatus and then moving down the penis O Cleansing the top of the penis and then moving down in a circular motion OCleansing the right end of the meatus and then moving left and down the penis O Cleansing the bottom portion of the penis and then moving up over the meatus

Cleansing the top of the penis and then moving down in a circular motion Rationale The nurse uses forceps and cotton balls soaked in antiseptic solution while cleansing the external genitalia. The nurse first cleanses the top of the penis, and then moves down in a circular motion. The nurse also retracts the foreskin to cleanse the area properly. This is the standard procedure followed to promote effective cleansing of the perineal area. The meatus is the last part of the male genitalia to be cleansed. The nurse cannot start cleaning the male external genitalia by cleansing the area around the meatus. The sequence for cleansing the female perineal region is right of the meatus, left of the meatus, and then center over the meatus. The bottom portion of the penis is not the first part to be cleansed.

The nurse is caring for an elderly patient who is in the room beside the intensive care unit and reports difficulty sleeping. Which interventions should the nurse take to ensure that the patient gets proper sleep? Select all that apply. O Consider changing the room O Provide a back rub before sleep. O Switch off the lights in the room. O Administer a sedating medication. O Encourage ambulation in the early morning

Consider changing the room Provide a back rub before sleep. Rationale Providing a soothing back rub can improve the patient's condition and promote sleep. Because intensive care units are very noisy, the nurse can consider shifting the patient to a quieter room. Sedating medications should not be given before attempting nonmedicated interventions. Early morning ambulation does not have any significant effect on the patient's sleep pattern. Switching off the lights in an older patient's room is not advisable because the patient is likely to fall in a dark room; dimming the lights is advised

Which type of catheter would the nurse use for an adult patient with prostate enlargement? O Mushroom (de Pezzer) catheter O Coude catheter O whistle-tip catheter O Robinson catheter

Coude catheter Rationale The curved stylet of the Coudé catheter is used to assist the health care provider in the insertion of a urethral catheter in a male patient with prostate enlargement. Malecot and de Pezzer (mushroom) catheters are used to drain urine from the renal pelvis of the kidney, and the Robinson catheter has multiple openings in its tip to facilitate intermittent drainage. In patients with blood in their urine, a whistle-tip catheter may be used because it has a slanted, larger orifice at its tip.

The first baby tooth, on average, appears at: A. 2 months B. 1 year C. 3 months D. 1 month E. 6 months

D. 1 month

The third molar appears between the ages of: A. 10 and 14 B. 5 and 8 C. 11 and 16 D. 17 and 24 E. none of the above

D. 17 and 24

The permanent central incisor erupts between the ages of: A. 9 and 13 B. 5 and 6 C. 7 and 10 D. 7 and 8 E. none of the above

D. 7 and 8

Which of the following statements about aldosterone is not correct? A. It is secreted by the adrenal cortex B. It is a water-retaining hormone C. It is a salt-retaining hormone D. All of the above are correct

D. All of the above are correct

Remove electrolytes from the blood 1. Which of the following is true of urinary catheterization? A. It can be used to treat retention B. It requires aseptic technique C. It can lead to cystitis D. All of the above are true

D. All of the above are true

Which one of the following is a simple sugar? A. Maltose B. Sucrose C. Lactose D. Glucose E. Starch

D. Glucose

Failure of the kidneys to remove wastes from the blood will result in which of the following? A. Retention B. Anuria C. Incontinence D. Uremia

D. Uremia

Morphine and other opioid analgesics have a potenital to cause what

Depression of the nervous system-reversed with Narcan Injection

In a child reporting stomach pain, which findings would indicate that the child has severe pain? Select all that apply. O Diaphoresis O Dilated pupils O High respiration rate O Hyperthermia O Hands over the stomach

Diaphoresis Dilated pupils High respiration rate Hands over the stomach Rationale During assessment the nurse should first observe the child's behavioral characteristics. Excessive sweating (diaphoresis) may occur when the child is going through unbearable pain. If a person feels any pain or discomfort, the pupils are dilated. A respiratory rate usually increases as a response to pain but can decrease as well: Children may place their hands over the area that hurts. Change in body temperature does indicate discomfort, but it is not an indicator of pain.

Which action should the nurse take while using a straight catheter to empty a distended bladder? O Collect a urine specimen O Drain the bladder too quickly! O Withdraw the catheter slowly. O Wash and dry the perineum.

Drain the bladder too quickly Rationale If a distended bladder is drained too rapidly, the bladder may collapse in spasm. Collecting a specimen, slowly withdrawing the catheter, and washing and drying the perineal area are appropriate.

The nurse is caring for a patient who has severe postoperative pain and is prescribed fentanyl (Actiq) and psyllium (Metamucil). Which instructions would the nurse give the patient to enhance the effectiveness of psyllium (Metamucil)? Select all that apply. Meditate. Rest more Drink more water. Eat a fiber-rich diet. Exercise regularly.

Drink more water. Eat a fiber-rich diet. Exercise regularly. Rationale Fentay (Actiq) is an opioid drug used for analgesia. Constipation is the most common side effect of opioids. Therefore the health care provider prescribed psyllium (Metamucil) to facilitate bowel moment. These laxatives alone will not be sufficient to prevent constipation. Therefore the nurse should instruct the patient to drink more water, eat a proper fiber-rich diet and exercise regularly. These strategies would further assist in bowel movement Meditation is usually done to relieve stress. Excessive rest would further aggravate constipation due to the lack of movement.

_________ % of the glomerular filtrate is reabsorbed. A. 20 B. 40 C. 75 D. 85 E. 99

E. 99

Which one of the following is not a part of the roof of the mouth? A. Uvula B. Palatine bones C. Maxillary bones D. Soft palate E. All of the above are part of the roof of the mouth

E. All of the above are part of the roof of the mouth

The renal corpuscle is made up of the: A. Bowman capsule and the proximal convoluted tubule B. glomerulus and the proximal convoluted tubule C. Bowman capsule and the distal convoluted tubule D. glomerulus and the distal convoluted tubule E. Bowman capsule and the glomerulus

E. Bowman capsule and the glomerulus

The outermost portion of the kidney is known as the: A. medulla B. papilla C. pelvis D. pyramid E. cortex

E. cortex

The middle third of the duodenum contains the: A. islets B. fundus C. body D. rugae E. major duodenal papilla

E. major duodenal papilla

The saclike structure that surrounds the glomerulus is the: A. renal pelvis B. calyx C. Bowman capsule D. cortex E. none of the above

E. none of the above

Hardest substance in the body

Enamel

Which interventions would stimulate a patient to void after the removal of a urinary catheter? Select all that apply. O Running water in the sink O Having the patient drink cold milk O Encouraging the male patient to stand O Placing the patient's hands in warm water O Instructing the patient to void every 6 hours

Encouraging the male patient to stand Placing the patient's hands in warm water Running water in the sink Rationale If the patient complains of urinary retention, the nurse should try running water placing the patient's hands in water and pouring warm water on the perineum. The female patient should be encouraged to sit on a commode and the male patient encouraged to stand during urination. Drinking cold milk and having the patient void every 6 hours will not help a patient experiencing urinary retention

The nurse is caring for a patient who receives nasogastric (NG) tube feedings after a gastric surgery. What nursing interventions are required in order to ensure patient safety during feedings? Select all that apply. Ensure patency of the tube. Provide mouth care at least every 2 hours. Advance the tube further by repositioning Instruct the patient to avoid drinking water. Lubricate the patient's nostrils and the tube with a water-soluble jelly.

Ensure patency of the tube. Provide mouth care at least every 2 hours. Lubricate the patient's nostrils and the tube with a water-soluble jelly. Rationale When a patient is inserted with an NG tube, the patient breathes through the mouth because of nasal occlusion by the tube. As a result, the patient's lips and tongue often become dry and cracked. The nurse should therefore provide mouth care at least every 2 hours to prevent discomfort. The nurse should ensure that the tube is free of any blockages to maintain patency of the tube. Lubricating the patient's nostrils and the tube with a water-soluble jelly helps prevent crusting of secretions. The patient is allowed to drink water to ease the gag reflex Repositioning of the NG tube can be done only by the health care provider if the patient has had gastric or esophageal surgery

Pancreas

Enzymes are released into the small intestine. Amylase breaks down starch. Stepsin breaks down fats. Pancreatic proteases break down proteins

To provide proper documentation of pain, which type of pain scale would the nurse use to assess the level of pain of a 6-year-old child? O 0 to 5 O 1 to 10 O FACES O Intensity

FACES Rationale The FACES pain scale applies a facial description to a pain rating, of which children have a better understanding. A 0-to-5 scale and the 0-to-10 scale are more difficult for a child to comprehend. The intensity should be evaluated, but there is not a specific scale

The combination of _____,____, and_____ has the potential to markedly change a person's perception of pain.

Fatigue sleep Disturbance Depression

A patient is experiencing acute pain due to surgery. Which physiologic processes of the patient should the nurse monitor on a regular basis? Select all that apply. O Heart rate O Anxiety O Respiratory rate O Blood glucose O Blood pressure

Heart rate ♡ Respiratory rate Blood pressure Rationale Acute pain may be accompanied by an increase in heart rate, respiratory rate, and blood pressure. Hence, the nurse may monitor it regularly. Pain may cause anxiety, but that is not a physiologic process. Blood glucose level generally does not change in patients experiencing pain.

robinson catheter

Has multiple openings in its tip to facilitate intermittent drainage

If there is presence of bright red blood in the stool indicates the the blood is fresh and that the sit of bleeding is?

In the lower GI (Gastrointestinal) tract

Which toxic side effect would the nurse monitor for in a patient who has arthritis and receives a daily dose of acetaminophen, 4000 mg? O Nausea O Tinnitus O Hepatotoxicity O Photosensitivity

Hepatotoxicity Rationale The maximum recommended dose of acetaminophen is 4000 mg in a 24-hour period. Its toxic side effect, a basic consideration of all analgesic regimens, is hepatotoxicity or liver failure. Therefore the patient must be assessed for nausea, vomiting, weakness, jaundice, and yellow eyes and skin. Tinnitus is commonly associated with high aspirin doses. Nausea is one of the side effects of acetaminophen but is usually not toxic. Photosensitivity usually does not occur as a side effect of acetaminophen intake.

Which finding indicates effective intermittent suctioning for a patient with a nasogastric tube? O pH of aspirate of 3.5 O Hissing sound at air vent O Bowel sounds in all four quadrants O Gurgling sounds when injecting air

Hissing sound at air vent Rationale After connecting a nasogastric tube to intermittent suction, the nurse should be able to hear a hissing sound at the air vent. This determines the suction's patency. The pH of the solution and gurgling sounds auscultated when injecting air are signs used to verify tube placement. Bowel sounds present in all four quadrants indicates good bowel function, suctioning would not be required.

For a patient with excessive gastric bleeding, cold or iced solutions for a gastric lavage may cause which condition? Dumping syndrome Aspiration and gastric reflux Impaired platelet production Excessive blood clotting

Impaired platelet production Rationale Cold/iced solutions, if used for gastric lavage in patients with gastric bleeding, may cause impaired platelet production. This lowers the rate of blood coagulation and thereby increases the rate of bleeding. Thus the use of cold/iced solutions is contraindicated for gastric lavage in this case Dumping syndrome is caused by rapid infusion of concentrated solutions. Aspiration and gastric reflux are seen when the patient receives feeding through nasogastric tubing. Cold/iced solutions impair platelet production and therefore impair the clotting process

Epidural Analgesia

Insertion of an epidural catheter and the infusion of opiates into the epidural space -it beings medication close to the action site 3 Methods of Adiminstering -Bolus Doses -Continuous Infusion -Patient-Controlled Epidural Analgesia (PCEA)

Which route of drug delivery would be used to administer analgesic to a patient who has just had a corn-removal procedure of the foot? Oral Epidural Intravenous Intramuscular

Intravenous Rationale The intravenous route of administration is useful in cases in which rapid onset of drug action is required. In the intravenous coute, the analgesic drug directly enters the bloodstream and reaches the site of action, The intramuscular route is not preferable in this case because it may cause pain due to muscle trauma. Moreover, it also has a delayed onset of action. The epidural route is not preferable in this case because it acts on a larger body surface and does not have a rapid onset of action. The oral route is also not useful for this patient because this route has a delayed onset of action.

Which action should the nurse take if no urine return is visualized after inserting a urinary catheter in a female patient? Obtain an order for an external female catheter Remove the catheter and attempt to reinsert the same catheter. Remove the catheter and obtain a new insertion kit. Leave the catheter in place and insert a secand catheter

Leave the catheter in place and insert a secand catheter Rationale If the nurse inserts a urinary catheter into a female patient and does not see urine return, the balloon should be inflated and left in place. This action marks that the catheter is in the vagina and provides a landmark, thus helping avoid inserting the catheter again in the same opening. A new catheter should be obtained and Inserted into the urinary meatus. The nurse should not obtain an order for an external female catheter. The same catheter should not be reinserted after removal because this increases the risk of infection

The nurse is administrating a cleansing enema. Before administrating the enema, the nurse assists the patient into which position? 1. Supine 2. On the right side 3. Left sims position 4. Left side with head of bed elevated 45 degrees

Left sims position

cardiac sphincter

Located at the base of the esophagus and functions to prevent food materials from entering the esophagus from the stomach

What is the term for the cleanest part of the voided specimen and is collected in a sterile container?

Midstream urine specimen

Inflammation of the abdominal cavity

Peritonitis

How should the nurse determine the length of the nasogastric tube be inserted? O Insert the tube until resistance is felt. O Measure from the nose to the earlobe to the xiphoid process. O Insert the tube nasally until the patient feels discomfort O Have the patient swallow some water, and insert the tube to the third premarked line.

Measure from the nose to the earlobe to the xiphoid process. Rationale In an effort to determine the distance to which the tube should be inserted, the total distance from the tip of the nose to the earlobe and from there to the xiphoid process of the sternum should be measured. Inserting the tube until resistance is felt or until the patient feels discomfort is inappropriate. Although the tube is premarked, the third line may or may not be the correct indication of how far the tube should be inserted for a given patient.

Which behavioral signs would the nurse expect pain? Select all that apply. O High blood pressure O Moaning O Restlessness O Low respiratory rate O Irritability

Moaning Restlessness Irritability Rationale Behavioral indications of pain that can be observed in a patient are moaning, restlessness, and irritability, Moaning is a low sound made by a person experiencing physical suffering. A patient experiencing acute pain usually cannot sit or lie quietly. A patient having acute pain may have high blood pressure and a low or high respiratory rate, but these are physiologic signs and not behavioral signs.

Which order does the nurse anticipate from the health care provider for a patient with abdominal distention, nausea, vomiting, and absent bowel sounds who had abdominal surgery 3 days ago? Suppository Rectal tube insertion Enteral tube feedings Nasogastric tube insertion

Nasogastric tube insertion Rationale The patient is exhibiting signs of a bowel obstruction that requires gastric decompression via a nasogastric tube Insertion. A suppository treats constipation, not an obstruction. rectal tube prevents skin breakdown in patients with diarrhea. Enteral tube feedings will not move through the gastrointestinal tract when an obstruction is present

HOW CAN THE NURSE PROVIDE PATENCY OF THE NG TUBE?

O 30cc bolus of air for "whoosh test" O X-ray for placement O check ph balance of gastric content O flush to make sure nothing is clogged

Which recommendation will help promote normal bowel function in a patient with a history of constipation? Select all that apply. O Activity O High-fiber diet O Taking a laxative every day O Fluid intake 1000 mL/day O Establishing a routine schedule

O Activity O High-fiber diet O Establishing a routine schedule Activity, a high-fiber diet, and a normal elimination schedule help promote normal bowel movements. The daily use of laxatives can lead to dependence and is not recommended for most patients. Recommended fluid intake is between 2000 and 3000 mL/day, not 1000 mL/day, to help promote regular bowel elimination

Which statement by the nurse is appropriate while discussing acute pain management with the family of a terminally ill cancer patient? O "Such type of pain is caused due to damage to the tissues." O "Guided imagery and distraction may be effective for such pains." O "Drugs that block neurotransmitter uptake are used for such pains." O Analgesics and opioids alone usually might not relieve such pains,"

O Analgesics and opioids alone usually might not relieve such pains," Rationale Analgesics and opioids alone usually do not relieve such pains. Patients can use patient-controlled analgesia (PCA) pumps or epidurals to help with continuous pain control related to cancer. It is sometimes managed with common analgesics such as thoce in the nonsteroidal antiinflammatory drug (NSAID) family, Damage to tissues is not the reason the cancer patient is having pain Drugs that block neurotransmitter uptake are not used for cancer pain. Guided imagery and distraction are nonpharmacologic treatments that may be effective for minor pains or in conjunction with medications:

patient-controlled analgesia (PCA) device is being used after surgery. The patient has been pressing the button as instructed, but the nurse knows that an adverse reaction to narcotics is oversedation. Which measure should the nurse take to assess whether the patient is experiencing this adverse reaction? O Assess the patient's level of orientation frequently O Ask the family if the patient is able to converse with them. O Check the dosage and the functioning of the pump every 4 hours. O Determine whether the patient feels drowsy during assessment of vital signs.

O Assess the patient's level of orientation frequently Rationale The patient's level of orientation should be evaluated to determine whether the patient is experiencing oversedation. In caring for the patient with a PCA, the nurse should monitor the intravenous site and the PCA for proper functioning and correct dosage, but not every 4 hours. Asking the family to give input on this assessment is not appropriate; the nurse should communicate with the patient. It is normal for the patient to be drowsy because this is a normal side effect of the medication. The patient's perception may not be accurate; therefore, objective data such as the level of orientation are needed to verify the oversedation

Which clinical manifestation in a patient using nonsteroidal antiinflammatory drugs (NSAIDs) would the nurse classify as a common adverse effect? O Headaches O Drowsiness O Hematemesis O Blurred vision

O Hematemesis Rationale NSAID use increases a patient's risk a for gastrointestinal (GI) bleeding, including hematemesis. Loss of blood from the Gl tract is considered an adverse effect of NSAID therapy and must be assessed for and managed NSAIDs are commonly used to treat headaches, sa this finding is not considered an adverse effect of this class of drugs. NSAIDs are non-sedating, so drowsiness would not be expected. Vision changes are not associated with NSAID use.

A registered nurse is assisting a health care provider in performing epidural analgesia to a patient. Which interventions should the nurse take to prevent infection in the patient? Inspect the catheter for breaks. Observe the external dressing for dampness. Use gauze dressing to secure the catheter. Avoid frequently changing the dressing over the site. Change the infusion tubing at a 24-hour time interval.

O Avoid frequently changing the dressing over the site. O Change the infusion tubing at a 24-hour time interval. Rationale Frequent dressing of the site would frequently expose the site to the external environment. This may lead to infection of the site and thus should be avoided. The tube that is inserted for delivering analgesic is moist from within and would serve as a breeding ground for microorganisms, therefore the tube should be changed on a daily basis. Inspecting for breaks is a routine assessment by the nurse to ensure that the catheter is not blocked it does not prevent infection. If breaks are present, the analgesic drug would leak out. Transparent dressing, not gauze, should be used to secure the catheter so that it is easy to check for any cerebrospinal fluid (CSA) leakage. If the external dressing is damp. this would indicate CSF leakage, not infection

Which action would the priority intervention be for the nurse who is caring for a patient with decreased kidney function and is ordered an opioid metabolized in the kidneys for pain control? O Assess urine output frequently to monitor for changes O Give preference to using a nonopioid analgesic if prescribed. O Call the health care provider to clarify the prescription O Give the medication as prescribed because it is commonly prescribed for patients with decreased renal function.

O Call the health care provider to clarify the prescription Rationale Because drugs such as normeperidine are metabolized in the kidneys, they should be given with extreme caution in patients with decreased kidney function A nurse should clarify the prescription with the health care provider before administering the drug Administering the medication as prescribed could lead to a potential toxicity because of the inability of the kidneys to eliminate the drug. A nonopioid analgesic may not address the patient's pain, so the prescription needs to be clarified to provide best patient care Assessing urine output frequently should be standard of care of a patient with decreased kidney function but will not assess for toxicity of the drug

During colostomy irrigation, the nurse finds that the patient has a pressure sore in the area around the colostomy. Which intervention would be best? O Avoid giving colostomy care to this patient O Change the irrigation solution for the colostomy, O Change the size of the ostomy appliance in the patient. O Avoid cleansing the skin with the irrigation sleeve on the stoma.

O Change the size of the ostomy appliance in the patient. Rationale The nurse must change the size of the ostomy appliance because an ill-fitting colostomy appliance can cause a pressure sore, which can lead to gangrene. Colostomy care should be done on a regular basis to prevent complications such as infection. Changing the irrigation solution for a pressure sore is not required because the pressure sore is not caused by the irrigation solution. It is necessary to cleanse the skin before placing the irrigation sleeve on the stoma. This reduces the risk for skin damage.

Which internal symptoms does the nurse look for in the patient who is not expressing signs of pain? Select all that apply. O High blood pressure O Rigid posture O Insomnia O Profuse perspiration O Nausea

O High blood pressure O Profuse perspiration O Nausea Rationale If the patient does not show any observable indication of pain, then the nurse must assess for other detectable signs of pain. Blood pressure, heart rate, and respiratory rate may be elevated in such patients. The patient may sweat profusely, the symptom is called diaphoresis. Nausea or an involuntary urge to vomit is another detectable sign that the nurse may find in the patient. Rigid body posture and inability to sleep are observable indications of pain.

Which action when performing colostomy irrigation requires correction? O Placing irrigation cone inside the stoma O Priming tubing with solution to expel air O Filling irrigation bag with 1000 ml tepid water O Holding the irrigation bag 1 ft above patient

O Holding the irrigation bag 1 ft above patient Rationale The irrigation bag should be held at the patient's shoulder level when performing colostomy irrigation. Any higher level can cause abdominal cramping, increased pressure, and bowel damage. Placing the irrigation cone inside the stoma, priming the tubing to expel air, and filling the irrigation bag with 1000 mil tepid water are correct steps when performing colostomy irrigation

Which analgesic is a particularly poor choice for pain control in older adults? O Ibuprofen (Motrin) O Meperidine (Demerol) O Acetaminophen (Tylenol) O Morphine (morphine sulfate) O Media 3 Case Study

O Ibuprofen (Motrin) O Meperidine (Demerol) O Acetaminophen (Tylenol) O Morphine (morphine sulfate) O Media 3 Case Study Rationale Meperidine (Demerol) should not be used in those who have decreased renal function. In general, older adults have some degree of decreased renal function. Acetaminophen (Tylenol) and ibuprofen (Motrin) work at the peripheral receptor level, and they are widely used for pain management. Morphine has the potential for nervous system depression and can be used in elderly patients

A nurse is teaching about preventing constipation in older adults. Which information would the nurse include? Select all that apply. O Limit lactose. O Increase fluids. O Increase activity O Decrease dietary fiber. O Keep daily meal journal.

O Increase fluids. O Increase activity O Keep daily meal journal. Rationale Increasing activity, increasing fluids, and keeping a daily meal journal are interventions that can prevent constipation in the older adult. Dietary fiber should be increased. Limiting lactose does not prevent constipation

Which action by a patient performing intermittent straight catheterization could lead to repeated urinary tract infections? O Using a new disposable catheter each time O Taking prescribed antibiotics on a daily basis O Irrigating catheters with sterile saline after use O Performing hand hygiene before and after procedure

O Irrigating catheters with sterile saline after use Rationale If supplies must be reused, patients should be instructed to boil rubber catheters for 20 minutes and wrap in a clean cloth. Irrigating catheters with sterile saline will not eliminate microorganisms that can cause urinary tract infections. Using new disposable catheters, taking prescribed antibiotics, and performing hand hygiene diminish the risk for infection

Which action should be performed when a patient reports abdominal cramping while receiving an enema? O Lower the container O Administer an analgesic. O Remove the enema tube. O Notify the health care provider.

O Lower the container Rationale If a patient reports abdominal cramping during enema administration, the nurse should lower the container and instruct patient to perform deep breathing. The nurse does not need to administer pain medication. It is not necessary to notify the health care provider. The nurse should not remove the tubing tip from the rectum

Medication for Pain Managment

O Nonopioids O Acetaminophen O Nonsteroidal O Anti-Inflammatory O Drugs-Asprin-Ibuprofen-Naproxen-Sodium

A patient has just returned to the unit from surgery. The patient's skin color is pink; the dressing is intact with no drainage noted to be coming through, but the patient is moaning and showing facial grimacing and is restless. Which sign will be a priority for the nurse to assess related to these findings? O Pain O Pulse O Respirations O Blood pressure

O Pain Rationale Pain should be assessed along with pulse, respirations, and blood pressure. Because the patient's wound and skin color are normal, the nurse would need to address the moaning and restlessness, which is a sign of pain The other vital signs may be changed as well when the patient is experiencing pain.

Which statement best describes the characteristic of pain? O Responses to pain vary. O Pain is objective in nature. O Pain is a situation that is not demanding. O Pain is a warning sign of actual or potential tissue damage.

O Pain is a warning sign of actual or potential tissue damage. Pain is an unpleasant sensation caused by the stimulation of the sensory nerve endings. It serves as a warning to the body and often occurs where there is actual or potential tissue damage. Pain responses do vary, but the best description is that pain often occurs where there is actual or potential tissue damage. When a patient experiences pain, the situation is usually demanding. Pain is subjective in natur

Which finding in a patient with an indwelling urinary catheter needs correction? O Loose-fitting clothing worn O Leg bag used during the day O Powder noted in perineal area O Drainage bag below bladder level in

O Powder noted in perineal area Rationale Powders and lotions should not be used in the perineal area because they can lead to infection Patients with an indwelling utinary catheter should wear loose-fitting clothing to prevent catheter kinking The leg bag should be used during the day. The drainage bag should be below bladder level.

Which finding does the nurse expect while assessing a patient who has been practicing meditation for the last 2 years? Select all that apply. O Elimination of pain O Relaxation of body O Reduction in blood pressure O Change in mental alertness O Stimulation of nerves

O Relaxation of body O Reduction in blood pressure Rationale During meditation the person focuses on an image, thought, breath, or awareness. This induces profound physical relaxation and reduction in blood pressure and respiratory rate. Meditation focuses the attention away from the pain or a painful situation but does not eliminate the pain. It neither changes the mental alertness of the patient nor does it stimulate the nerves.

Which evaluation of interventions indicates the patient has not met the goal of pain management? O On a scale of D to 10, the patient's pain level decreased from 8 to 3 O Sometimes the patient's pain level decreases when pain medication is administered O Patient slept 3 hours after pain medication was given but was guarded on awakening. O The pain level decreases only when patient is given pain medication as prescribed.

O Sometimes the patient's pain level decreases when pain medication is administered Rationale Pain that is controlled only sometimes after pain medication administration indicates that the goal of pain management has not been met. A patient receiving relief after pain medication administration, sleeping 3 hours after pain medication (even with guarding on awakening), and having a decreased pain level from 8 to 3 on a scale of 0 to 10 indicates that the goal has been met

Which statements by a physical therapist assistant indicate effective learning regarding the use of transcutaneous electrical nerve stimulation (TENS)? Select all that apply. O "TENS therapy is effective in the treatment of psychosocial pain. O The use of TENS requires an order from the health care provider." O "TENS can produce stimulation in high as well as low frequencies O "The use of TENS is effectively taught to the patients after surgery." O Low-level current between the electrodes blocks the pain sensation."

O The use of TENS requires an order from the health care provider." O "TENS can produce stimulation in high as well as low frequencies O Low-level current between the electrodes blocks the pain sensation." Rationale TENS therapy can be used to manage pain only when the health care provider orders it. This therapy is available in high-frequency and low-frequency stimulation. Electrical stimulation is created by a small electrical stimulator attached to electrodes. These low-level currents block the pain. TENS therapy uses high frequency to manage acute pain and law frequency to control chronic pain. TENS is generally controlled by the patient as per need. TENS for the relief of postoperative pain is generally most effective when the patient has received instructions on the use of the device before surgery. Postoperative pain and analgesic medications make teaching more difficult after the surgery. TENS is not used in the treatment of psychosocial pain

Which analgesic method may lead to serious complications in a patient who has severe back pain and an artificial pacemaker? O Heat or cold application O Progressive muscle relaxation O Nonsteroidal antiinflammatory drugs (NSAIDs) O Transcutaneous electric nerve stimulation (TENS)

O Transcutaneous electric nerve stimulation (TENS) Rationale TENS uses electrical impulses for relief of pain in patients with back pain. The patient in this case already has a pacemaker device. The electrical impulses from TENS may interact with the pacemaker activity and may cause dysrhythmia in the patient. Thus TENS should be avoided in this patient. The nurse initially performs a back rub to reduce the pain. Progressive muscle relaxation is a technique for learning to monitor and control muscular tension. It does not interact with pacemaker activity. Similarly, superficial application of heat or cold to the back would relieve muscle spasms and reduce back pain. It would not interfere with the pacemaker activity. Therefore the nurse can also perform hot therapy if a back rub is not useful. NSAIDs may cause severe adverse effects, such as constipation, liver toxicity, and renal impairment. Therefore the nurse could use analgesic drugs only if prescribed by the health care provider. These medications do not interact with pacemaker signals

Which nursing action could interfere with the ostomy appliance's ability to adhere to the skin? O Changing the ostomy appliance every 3 days O Washing the peristomal skin with soap and water O Applying the protective skin barrier around the stoma O Pressing ostomy appliance against the skin for 1 to 2 minutes

O Washing the peristomal skin with soap and water The peristomal skin should only be cleansed with warm water and patted dry. Soap can leave a residue that will affect the pouch's ability to properly adhere to the skin. Changing the ostomy appliance every 3 days, applying to protect skin barrier around the stoma, and pressing the ostomy appliance against the skin for 1 to 2 minutes are accurate steps to promote ostomy appliance adherence to the skin

Which intervention is most effective to prevent skin breakdown in a patient with incontinence? O Providing bladder training O Inserting a Foley catheter O Using the Crede maneuver O changing undergarments and pads frequently

O changing undergarments and pads frequently Rationale Urine and feces are highly irritating to the skin. Skin that is continuously exposed becomes inflamed and irritated quickly. To help prevent skin impairment, the patient's undergarments or underpants should be changed frequently and the area washed with soap and water after each episode of incontinence. Inserting a Foley catheter is not a nursing function and places the patient at risk for infection. Bladder training may take some time and is not an immediate method of preventing skin impairment. The Crede maneuver is used to promote bladder elimination and is not appropriate,

Which instruction would be given to patient beginning colostomy irrigation? Select all that apply. O instill 500 to 1000 ml slowly over 15 minutes!! O "Allow the fluid to sit in the bowel for 15 to 20 minutes." O "Insert the entire length of the lubricated cone into the stoma." O instruct the patient to sit on the toilet or in front of the toilet." O "Fill the irrigation container with 1000 ml of cold water.

O instill 500 to 1000 ml slowly over 15 minutes!! O instill 500 to 1000 ml slowly over 15 minutes!! O instruct the patient to sit on the toilet or in front of the toilet." Rationale Colostomy irrigation should include instilling 500 to 1000 mL slowly over 15 minutes. The fluid should be kept in the bowel for 15 to 20 minutes for maximum effect. Colostomy irrigation should be performed with the patient in the sitting position-either on the toilet or in front of the toilet. The cone should only be inserted part of the way into the stoma. The fluid used to irrigate should be tepid

Pain is most effectively controlled through a combination of .....

Pain is most effectively controlled through a combination of .....

transverse colon

Part of the colon that passes across the interior abdomen. Turns posteriorly at the spleen and inferiorly at the splenic flexure to become the descending colon.

Which pain method would be best for a postsurgical patient with a low tolerance for pain? O Oral medication O Rectal suppositories O A short-acting patch O Patient-controlled analgesia (PCA)

Patient-controlled analgesia (PCA) Rationale The intravenous (IV) method is the best route of administration for an opioid analgesic after major surgery and is accomplished via the use of a PCA device. An opioid is used to treat escalating pain. The PCA allows the ability to administer a dose when it is needed and places the patient in control while eliminating the wait for medication to be given. Intravenous therapy from the PCA provides a continuous, more effective method of pain control than oral administration, rectal suppositories, or a short-acting patch. Oral medication would not be enough for a postoperative patient with a low pain tolerance. Rectal suppositories and short-acting patches do not work as fast as IV medications, and the patient is not able to control the medication to use the least amount of medication needed to meet the pain goal.

Which treatment is used to reduce pain from hemorrhoids? Select all that apply. O Enemas O Laxatives O Sitz baths O Witch hazel pads O Narcotic analgesics

Sitz baths Witch hazel pads Rationale Sitz baths and witch hazel pads can provide localized relief for patients with hemorrhoids. Enemas can cause the hemorrhoids to bleed. Laxatives can lead to dependence. Narcotic analgesics are stronger than is necessary to alleviate hemorrhoidal pain.

Which would the nurse observe for in a patient with fecal incontinence? O Diarrhea O Rectocele O Sensory deficits O Skin breakdown

Skin breakdown Rationale The nurse should routinely examine an incontinent patient's skin, as fecal matter is very irritating and can lead to skin breakdown Diarrhea, a rectocele, and sensory deficits can lead to fecal incontinence but are not potential complications the nurse should observe for

Which data collection related to monitoring is necessary before applying an external condom catheter on a patient? Skin damage Blood infection Prostate trauma Abdominal distension Injury to pelvic veins

Skin damage Blood infection Rationale A condom catheter contains an adhesive that could damage the skin and increase the risk of blood infection (sepsis) in elderly patients. The nurse should monitor for both skin damage and blood infection. Prostate trauma is seen with use of internal catheters, not with external condom catheters. Abdominal distension is not a problem with the use of urinary catheters. Catheter condoms are helpful in preventing the effects of prostatic obstruction; they do not cause prostate trauma, Condom catheters do not affect the integrity of the pelvic veins.

Self catheterization is an option for

Someone who has had a spinal cord injury or other neurologic disorders that interfere with urinary elimination.

Which sleep stage is described? • Lightest level of sleep • Lasts a few minutes • Decreased physiologic activity, beginning with a gradual fall in vital signs and metabolism • Person is easily aroused by sensory stimuli such as noise • If person awakes, feels as though daydreaming has occurred • Reduction in autonomic activities (e.g., heart rate) 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

Stage 1

Which sleep stage is described? • Period of sound sleep • Lasts 10 to 20 minutes • Relaxation progresses • Arousal is still easy • Body functions are still slowing 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

Stage 2

Which sleep stage is described? • Initial stage of deep sleep • Lasts 15 to 30 minutes • Arousal is difficult, movement is rare • Muscles are completely relaxed • Vital signs decline but remain regular • Hormonal response includes secretion of growth hormone 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

Stage 3

Which sleep stage is described? • Deepest stage of sleep • Lasts approximately 15 to 30 minutes • Arousal is very difficult • If sleep loss has occurred, the sleeper spends most of the night in this stage • Restores and rests the body • Vital signs are significantly lower than during waking hours • Sleepwalking and enuresis are possible • Hormonal response continues • Stage of vivid, full-color dreaming consistent with sensory experiences (less vivid dreaming sometimes occurs in other stages) • First occurs approximately 90 minutes after sleep has begun, thereafter occurs at end of each NREM cycle • Duration increasing with each cycle and averaging 20 minutes • Typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased or fluctuating blood pressure • Loss of skeletal muscle tone • Responsible for mental restoration • Stage in which sleeper is most difficult to arouse 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

Stage 4

At which stage of non-rapid eye movement (NREM) sleep are sleepwalking and enuresis most likely to occur? Stage 1 Stage 2 Stage 3 Stage 4

Stage 4 Rationale Stage 4 is the deepest stage of sleep, and it is difficult to arouse a sleeper in this stage. Sleepwalking and enuresis are most likely to occur at this stage. Stage 1 is the lightest stage of sleep, and a person in this stage is easily aroused. Stage 2 is the relaxation phase, but a person in this stage is still aroused easily. Stage 3 is the initial stage of deep sleep, and the sleeper rarely move

cleansing enema

Stimulates Peristalsis through the infusion of a large volumes of fluid to distend the bowel. helps empty colon completely (used before gi diagnostic procedures)

Which response is the nurse's priority when a patient begins to cough and gag during a nasogastric tube insertion? O Assess the oropharynx. O Withdraw the tube. O Pull the tube slightly back. O Stop advancing the tube.

Stop advancing the tube. Rationale If a patient begins to cough or gag during a nasogastric insertion, the first thing the nurse should do is to stop advancing the tube. If the symptoms continue when tube insertion resumes, the nurse should pull the tube back slightly. The oropharynx should then be assessed with a flashlight. If the patient is exhibiting respiratory distress, the tube should be removed,

Gallbladder

Stores bile & releases it into small intestines to emulsify fats

Which interventions should be incorporated into the nursing care plan for a patient admitted with chronic pain? Select all that apply. Assess pain once a day Teach relaxation exercises. Promote the use of guided imagery Encourage the patient to report pain or discomfort Encourage the patient to use adjunct herbal remedies.

Teach relaxation exercises. Promote the use of guided imagery Encourage the patient to report pain or discomfort Rationale Teaching relaxation exercises, promoting the use of imagery, and encouraging the patient to report pain and discomfort are interventions that should be incorporated into the patient's care plan. Pain should be assessed frequently in patients with chronic pain, and the standard of care is more frequently than once a day for all patients. The patient should not explore herbal remedies without discussing it with health care provider first

bicuspids

Teeth also called premolars, used to grind food

Accessory organs and structures of digestion

Teeth, tongue, salivary glands, pancreas, liver, gallbladder, and appendix

Duodenum

The first section of the intestines

peritoneal

The lining of the abdominal cavity

amylase

The pancreatic enzyme that breaks down starches to glucose is called:

Which teaching would the nurse provide to a patient about the use of enemas? Alternate between enemas and suppository use. Enemas are as safe to use as a stool softener. The urge to defecate may become dependent on enema use. A soapsuds enema is better than an enema using an over-the-counter product

The urge to defecate may become dependent on enema use. Rationale: No matter what type of enema fluid is used, the patient must be cautioned to limit the number of enemas used. With repeated use of enema, the defecation reflex may become dependent on it, which may cause constipation. It is better to determine the cause of bowel irregularity and treat the cause rather than relying on enemas, Alternating between enemas and suppository use also causes the defecation reflex to become dependent. Enemas are not as safe as a stool softener, and a soapsuds enema used on a regular basis is not better than enema using an over-the-counter product. Therefore the patient should not be educated about these practices

Which type of catheter would be used to maintain continuous bladder irrigation for a patient after urinary surgery? O Coudé O Three-way O Mushroom O Winged tip

Three-way Rationale A three-way indwelling catheter is used for continuous bladder irrigation. One lumen is attached to the irrigating fluid, one to the drainage bag, and the third is for the retention balloon. The Coudé catheter is angled at the tip and used in patients with obstructions, such as enlarged prostates, A mushroom catheter is used for suprapubic catheterization. A winged-tip catheter is rarely used in practice today.

Which advice would the nurse give to the patient on diuretics and having trouble sleeping? O Urinate before going to sleep. O Administer the drug in the morning O Ask for a change of the diuretic drug O Drink fewer fluids during the night.

Urinate before going to sleep. Rationale Patients on diuretic drugs tend to urinate frequently. If the patient takes the drug at night, the patient will have to urinate frequently and thus will have disturbed sleep. Thus, the nurse should ask the patient to take the drug earlier. Even if the patient urinates before sleep, the patient would urinate frequently during the night due to the effect of the diuretic. This effect would be seen regardless of the type of diuretic; therefore the nurse should not ask the patient to have the medication changed. The nurse should not advise the patient to lower fluid consumption because this may lead to dehydration

Which statement by a patient indicates a need for teaching about ostomy self-care? I must monitor my skin every time change my colostomy pouches.. The skin around the colostomy must be washed and dried carefully! "I must change the colostomy bag immediately if I notice or feel a leak." When applied correctly, should feel pressure from the ostomy appliance."

When applied correctly, should feel pressure from the ostomy appliance." Rationale When the skin barriers are cut to fit the stoma, the nurse ensures that the ostomy appliance opening is small enough to form a proper seal, 1/16 inch larger than the stoma, and does not cause pressure on the stoma because there is blood and nerve supply in the stoma but no sensation. An ill-fitting appliance can cause a pressure sore and lead to gangrene. If the patient is feeling pressure from the appliance, this is an indication that the appliance has been incorrectly applied

What would be the correct explanation of catheter care? a. Cleansing the first 2 in of the catheter with soap and water every shift b. Disinfecting the entire catheter with alcohol every shift c. Lubricating the catheter with antiseptic lotion every 24 hours d. Cleansing the meatal-catheter junction every 24 hours

a. Cleansing the first 2 in of the catheter with soap and water every shift The first 2 in of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift.

Nonopioids

acetaminophen, for milk to moderate pain and some severe pain

When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy? a. It is always permanent. b. It drains semiliquid stool. c. It has a much larger stoma. d. It does not need a pouch.

b. It drains semiliquid stool.The ileostomy is higher in the GI tract and drains semiliquid stool. The ileostomy is very similar in appearance to the colostomy, may not be permanent, and needs a pouch.

WHAT TYPE OF PATIENT WOULD REQUIRE A NASOGASTRIC TUBE?

bowel obstructed decompressing of stomach feedings unable to eat

After a Foley catheter has been removed, the nurse should assess the patient for: a. hemorrhage. b. constipation. c. urinary retention. d. bladder spasm.

c. urinary retention.

when irrigating stoma

cleanse the skin around stoma, place irrigation sleeve over the stoma, fill irrigation container with 1000 ML of tepid water, attach the cone to tubing, lubricate cone and insert into stoma through the top of the sleeve, use gentle pressure

ileostomy

creation of an artificial opening into the ileum (needed when the entire colon must be removed or bypassed.

Two examples of noninvasive pain relief measures

cutaneous stimulation, distractions

The small intestine

duodenum, jejunum, ileum

provide oral care for NG tube patients

every two hours,due to them breathing through mouth causing tongue and lips to dry. rinse mouth with cool water or oral swabs making sure they dont swallow any water.

Nephron

functional unit of the kidney

Appropriate pain management typically brings about.....

quicker recoveries, shorter hospital stays , fewer readmissions, and improved quality of life.

the organs of the urinary system are ____

kidneys, ureters, urinary bladder, and urethra

Opioids

morphine, action higher centers of the brain to modify perception and reaction to pain Severe to Acute Pain-Morphine-Meperidine (Demerol)-Codeine Releived pain mainly by action in the CNS, binding to opioid receptor sites in the brain and spinal cord

McCaffery's discription of pain

nurse must believe every patient who says he or she has pain

cecum

the cavity in which the large intestine begins and into which the ileum opens

electrocardiography ECG

process of recording the electrical activity of the heart, non invasive, records the activity of the myocardium

gastric lavage

often used in cases of poisoning or to stop GI bleeding. it involves instilling room-temperature medications or solutions into the stomach and then suctioning it back out500mL

In older adults, avoid the combinations of ________

opioids

The _____ is often the optimal route, especially for chronic pain treatment, bc if its convenience, its flexibility, and the relatively steady blood levels produced. Takes long to kick in and last longer.

oral route

transmission of pain

peripheral structures and central structures

why do patients have difficulty voiding after catheter removal?

sphincter muscles are weakened.

rectal tube

stimulates peristalsis and the movement of flatus thus eliminating discomfort. assist pt in sims position, lubricate and insert tube 4 to 6 inches, leave the tube in NO longer than 30 min.

the function of the bladder is ____

store urine

colostomy

surgical creation of a stoma on the abdominal wall to where the colon is normal attached. (performed for patients with cancer of the colon,intestinal trauma, inflammatory disease of the colon.)

gate control theory

the brain cannot acknowledge the pain while it is interpreting the other stimuli bombardment of sensory impulses, such as those from the pressure of a backup, the heat or a warm compress, or the cold from ice applications, WILL CLOSES THE GATES TO PAINFUL STIMULI some patients can be distracted from pain by removing the sensation of pain from the center of attention. auditory or visual stimuli can distract patients and help make pain more to reable gating mechanisms can also be altered by thoughts, feelings, and memories

A ________ is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.

urostomy A urostomy is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.

cleaning for women

use non dominant hand to spread labia(do not use this hand anymore since it is considered unsterile) cleanse right meatus the left meatus then down the center over meatus make sure vagina does not fold back as that will be considered non sterile

oil retention enema

used to soften stool and lubricate the bowel to make defecation easier. (used when fecal impaction is suspected)

if urinary retention is present. How can you stimulate urination?

you can try to stimulate urination by running water, running hands under warm water and pouring warm water over the perineum.