Prep U- Basic care and comfort
A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. Palliative care Radiation Angiogenesis Respite care TAKE ANOTHER QUIZ
Palliative care Explanation: In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers.
A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? crust around the pin insertion site a small amount of yellow drainage at the left pin insertion site a slight reddening of the skin surrounding the insertion site pain at the insertion site TAKE ANOTHER QUIZ
a small amount of yellow drainage at the left pin insertion site Explanation: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.
While reviewing a client's chart, the nurse notes the client has been experiencing enuresis. To assess whether this remains an ongoing problem for the client, the nurse asks which question? "Do you have a strong desire to void?" "Do you urinate while sleeping?" "Does it burn when you urinate?" "Is it painful when you urinate?" TAKE ANOTHER QUIZ
"Do you urinate while sleeping?" Explanation: Enuresis is defined as involuntary voiding during sleep. The remaining questions do not relate to this problem associated with changes in the client's voiding pattern.
A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response?
"The operating table is a firm surface; we need to be sure your skin looks okay." Explanation: The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred. The client would not be told that his covers looked messy, or that the nurse was concerned about sponges or syringes underneath. The client's skin should be assessed on admission; after surgery would not be the time to do this initial assessment to document skin breakdown.
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? "Are you having pain?" "Is the pain constant?" "How does the pain medication make you feel?" "What does the pain feel like?" TAKE ANOTHER QUIZ
"What does the pain feel like?" Explanation: An open-ended question (one that cannot be answered with a simple "yes" or "no") provides more information than a closed-ended question, which limits the client's response. The other options are closed-ended questions. Having the client describe how the pain medication makes them feel does not address the issue of the client's present statement of pain.
A nurse is performing an intake assessment for a client admitted to the hospital with hypertension. The client informs the nurse that she drinks alcohol in the evening to help her sleep. What does the nurse know about the induction of sleep through alcohol intake? Alcohol will help induce a deep sleep that the client will awaken from refreshed in the morning. Alcohol induces sleep initially and disrupts and fragments sleep. Alcohol is a stimulant and will cause a delay in the induction of sleep. Alcohol along with the concurrent use of melatonin in moderation will help with acute insomnia. TAKE ANOTHER QUIZ
Alcohol induces sleep initially and disrupts and fragments sleep. Explanation: Although alcohol initially may induce sleep, it often causes disrupted and fragmented sleep. Sleep also is disrupted in people undergoing alcohol- or sleep-medication withdrawal. Alcohol also can lead to poor quality sleep and is related to insomnia.
A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to:
Apply ice and tell the patient to keep his head elevated Explanation: Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated. Saline lavage, warm compresses, and nebulizers are not common treatment modalities for nasal fractures.
A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care? "You must consume a diet rich in protein, such as chicken, fish, and beans." "You must consume a diet low in calories, such as skim milk, fresh fruits, and vegetables." "You must consume a diet high in carbohydrates, such as bread, potatoes, and pasta." "You must consume a diet low in fat by limiting dairy products and concentrated sweets." TAKE ANOTHER QUIZ
Correct response: "You must consume a diet rich in protein, such as chicken, fish, and beans." Explanation: The nurse encourages a client with a lung abscess to eat a diet that is high in protein and calories in order to ensure proper nutritional intake. A carbohydrate-dense diet or diets with limited fats are not advisable for a client with a lung abscess.
The nurse likes to use humor to help clients deal with pain. What guidelines should the nurse follow when using humor to foster pain relief?
Humor should take into account the client's personality and circumstances. Explanation: Humor should be used only with clients who are responsive to it and wish to use it. Consequently, the nurse must assess the client's personality and circumstances carefully. It should not normally be used in the presence of moderate or severe pain, though it can be used, if appropriate, when caring for older clients or those from other cultures.
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? Irrigates the wound to remove debris Administers an oral analgesic for pain Administers acetaminophen (Tylenol) for headache Shaves the hair around the wound TAKE ANOTHER QUIZ
Irrigates the wound to remove debris Explanation: Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.
What is the highest nursing priority in the plan of care for a client with peripheral vascular problems?
Promote arterial and venous circulation. Explanation: Maslow's hierarchy defines priorities with physiological needs as the highest priority. In the case of a client with peripheral vascular disease, the highest priority would be tissue perfusion. Once this is established, the nurse can address the problems of pain and skin integrity. It is also important to educate the client and provide a self-care program. However, the client's physiological needs must be met first.
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?
Participate in a regular walking program.
What begins the digestive process? Esophagus Saliva Stomach Tongue TAKE ANOTHER QUIZ
Saliva Explanation: Saliva, which contains water and digestive enzymes, is secreted from the salivary glands to begin the digestive process and to facilitate swallowing by making the bolus slippery.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine TAKE ANOTHER QUIZ
applying ice Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
To assess subjective data related to a client's elimination pattern, the nurse:
asks the client about changes in elimination patterns.
When assessing a child for impetigo, the nurse expects which assessment findings?
honey-colored, crusted lesions Explanation: In impetigo, honey-colored, crusted lesions develop once the pustules rupture. Small, brown, benign lesions are common in children with warts. Linear, threadlike burrows are typical in a child with scabies. Circular lesions that clear centrally characterize tinea corporis.
Inversion
is movement that turns the sole of the foot inward.
Eversion
is the return movement from flexion.
A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position? right lateral left lateral supine semi-Fowler's TAKE ANOTHER QUIZ
left lateral Explanation: The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.
Rotation of the forearm so that the palm of the hand is down is termed inversion. supination. pronation. eversion. TAKE ANOTHER QUIZ
pronation. Explanation: Pronation is the rotation of the forearm so that the palm of the hand is down.
A client from a minority culture has been hospitalized for 6 days for postoperative infection. The client's weight is decreasing each day, and the nutritional intake is declining. Which nutritional assessment question is most appropriate?
"What type of food do you eat at home?" Explanation: Cultural food preferences often put the client at risk for inadequate nutrition. By exploring what foods the client eats at home, the nurse can assess the client's cultural dietary preferences and work to incorporate these foods into the meal plan. The other choices are judgmental and indicate that the client should eat what is presented regardless of cultural preference.
Diagnostic testing has resulted in a diagnosis of small cell lung cancer (SCLC) in an older adult client. When exploring the etiology of the client's disease, what assessment question is most relevant?
"Have you ever been a smoker?" Explanation: Most cases of SCLC are attributable to smoking, and it is rare among nonsmokers. Family history and radiation exposure are relevant risk factors, but smoking exceeds their importance. Smoking also causes COPD, but COPD is not an independent risk factor for smoking.
Which is an inappropriate use of traction?
Decrease space between opposing structures Explanation: Traction is done to increase the space between opposing surfaces. Traction is used to minimize muscle spasms, to reduce, align, and immobilize fractures, and to reduce deformity.
A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?
Independent showering
Supination is
rotation of the forearm so that the palm of the hand is up.
An older adult client in a long-term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"? stool consistency and client comfort one bowel movement daily one bowel movement every other day two bowel movements daily TAKE ANOTHER QUIZ
stool consistency and client comfort Explanation: Normal bowel patterns range from three bowel movements per day to three bowel movements per week. In differentiating normal from abnormal, the consistency of stools and the comfort with which a person passes them are more reliable indicators than is the frequency of bowel elimination.
What position should the nurse use for the client with venous insufficiency to enhance blood supply? prone with head turned to one side Fowler with lower extremities in neutral position dorsal recumbent with legs separated supine with lower extremities elevated TAKE ANOTHER QUIZ
supine with lower extremities elevated Explanation: For clients with venous insufficiency, blood return to the heart needs to be enhanced; therefore, the nurse should position them in a position with lower extremities elevated. Prone with head turned to one side and Fowler with lower extremities in neutral position does not elevate the extremities and, therefore, does not increase blood supply. Dorsal recumbent with legs separated is used for special situations, not to enhance blood supply in venous insufficiency.
A client with diabetes mellitus has a blood glucose level of 40 mg/dL. Which rapidly absorbed carbohydrate would be most effective? 1/2 cup fruit juice or regular soft drink 4 oz of skim milk 1/2 tbsp honey or syrup three to six LifeSavers candies
1/2 cup fruit juice or regular soft drink Explanation: In a client with hypoglycemia, the nurse uses the rule of 15: give 15 g of rapidly absorbed carbohydrate, wait 15 minutes, recheck the blood sugar, and administer another 15 g of glucose if the blood sugar is not above 70 mg/dL. One-half cup fruit juice or regular soft drink is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Eight ounces of skim milk is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. One tablespoon of honey or syrup is equivalent to the recommended 15 g of rapidly absorbed carbohydrate. Six to eight LifeSavers candies is equivalent to the recommended 15 g of rapidly absorbed carbohydrate.
The nurse at a long-term care facility encourages the older adults to drink even though they may not feel thirsty at the time. Which statement supports the nurse's action? Older adults often experience a decrease in the sensation of thirst, even when serum sodium levels are high. The metabolic needs for both fluid and sodium in older adults differ from those of younger individuals. Regulation and maintenance of effective circulating volume by the kidneys is less effective in older adults. The renin-angiotensin-aldosterone system (RAAS) is less able to facilitate sodium clearance in older adults. TAKE ANOTHER QUIZ
Older adults often experience a decrease in the sensation of thirst, even when serum sodium levels are high. Explanation: Older adults are prone to hypodipsia even when osmolality and serum sodium levels are elevated, a fact that is compounded by sensory and/or neurologic deficits. Hypodipsia in older adults is not related to differing metabolic needs, ineffective kidney function, or compromise of the RAAS.
The nursing students have learned in class that causes of urinary obstruction and urinary incontinence include which of the following? Select all that apply.
Structural changes in the bladder Impairment of neurologic control of bladder function Structural changes in the urethra Urinary obstruction and urinary incontinence can be caused by several factors, including structural changes in the bladder, structural changes in the urethra, and impairment of neurologic control of bladder function. Changes in the gallbladder or pancreas do not cause urinary obstruction or incontinence.
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? Take a mild laxative such as magnesium citrate when necessary. Take a stool softener such as docusate sodium daily. Administer a tap-water enema weekly. Administer a phospho-soda enema when necessary. TAKE ANOTHER QUIZ
Take a stool softener such as docusate sodium daily. Explanation: Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.
The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority?
The nurse verifies the position of the feeding tube. Explanation: Verifying the position of the tube to ensure that the tube is in the stomach by aspirating stomach contents is the highest priority. This is a top priority because of the danger of aspiration if the tube is not in the stomach but rather in the esophagus or the lung.
When the bladder contains 400 to 500 mL of urine, this is referred to as anuria. specific gravity. functional capacity. renal clearance. TAKE ANOTHER QUIZ
functional capacity. Explanation: A marked sense of fullness and discomfort with a strong desire to void usually occurs when the bladder contains 400 to 500 mL of urine, referred to as the "functional capacity." Anuria is a total urine output less than 50 mL in 24 hours. Specific gravity reflects the weight of particles dissolved in the urine. Renal clearance refers to the ability of the kidneys to clear solutes from the plasma.
A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will
palpate the bladder above the symphysis pubis. Eight hours is a long time not to have voided. The kidneys typically produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder would be full of urine and palpable above the symphysis pubis.
When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches him how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?
The client keeps the drainage bag below the bladder at all times. Explanation: To maintain effective drainage, the client should keep the drainage bag below the bladder; doing so allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because the bag could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.
A client who's 2 months pregnant complains of urinary frequency and says she gets up several times at night to go to the bathroom. She denies other urinary symptoms. How should the nurse intervene? Advise the client to decrease her daily fluid intake. Refer the client to a urologist for further investigation. Explain that urinary frequency isn't a sign of urinary tract infection (UTI). Explain that urinary frequency is expected during the first trimester. TAKE ANOTHER QUIZ
Explain that urinary frequency is expected during the first trimester. Explanation: Urinary frequency is expected during the first trimester as the growing uterus exerts pressure on the client's bladder. Although the client should increase fluid intake during pregnancy, she should avoid drinking fluids after 6 p.m. to reduce the need to get up at night. Because urinary frequency is a normal discomfort of pregnancy and the client has no other signs or symptoms of UTI, referral to a urologist is unnecessary. Urinary frequency, dysuria, and voiding of small amounts of urine indicate UTI.
The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next? Chart the data. Validate the data. Ignore the client's answer. Ignore the client's nonverbal behavior. TAKE ANOTHER QUIZ
Validate the data. Explanation: Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior.
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? Body aligned opposite to line of traction pull Weights hanging and touching the floor Pulleys without evidence of the obstruction Ropes freely moving over pulleys TAKE ANOTHER QUIZ
Weights hanging and touching the floor Explanation: When checking traction equipment, the weights should be freely hanging. Weights that touch the floor require the nurse to intervene. The body should be aligned in an opposite line to the pull of the traction. The ropes should be freely moving over unobstructed pulleys.
