Advance Fund- Exam 2
The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history?
- When did the edema start? - Can you describe the edema? - What were you doing just before you notice the edema? - Do you have any recent history of surgery or illness? - What are your usual daily activities? - Do you stand a lot? - What medications do you take? Do you have heart disease or blood vessel disease?
The nurse has an order to check a patient's post-void residual urine. How would the nurse carry out this order? A. Measure the amount of urine in the bladder using a bladder scanner. B. Insert a straight catheter and measure the urinary output in two hours. C. Calculate the difference between the patient's intake and output. D. Palpate the bladder for distention and record findings in the chart.
A
The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg? A. Dark discoloration of the skin surrounding the wound site. B. Scaly rash between the toes with itchiness. C. Shiny skin with hair loss over legs, feet, and toes. D. Pale, white toes with decreased sensation.
A
The nurse is caring for a patient who is unable to urinate voluntarily since a gunshot injury. Patient data associated with which intervention will provide information regarding the patient's kidney function? A. Daily serum creatinine levels B. Urinary output over eight hours C. Number of times the patient requests oxybutynin over a 24-hours period D. Results of precatheterization bladder scans
A
The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse? A. Call for a co-worker to help hold the patient's legs in position. B. Instruct the patient to turn over on her side. C. Ask a family member to assist you with the catheterization. D. Notify the provider that the procedure could not be completed because the patient is paralyzed.
A
The nurse is preparing to irrigate a wound. Which statement, if made by the nurse, indicates an understanding of the procedure? A. I will gently direct a stream of fluid into the wound, keeping syringe tip at least one inch from the upper tip of the wound. B. I will use a sterile specimen cup to slowly pour irrigation solution over the entire wound bed. C. In order to debride the wound, I will use a moderate amount of force to instill the solution. D. I will make sure the tip of the syringe touches the wound bed while performing the irrigation.
A
The nurse is providing patient education on self-catheterization. What statement by Ms. Johnson indicates the need for additional teaching? A. I can use either an indwelling or intermittent catheter. B. I should report signs and symptoms of potential complications to the provider immediately. C. I may be eligible for free catheters through Medicare. D. I should store my reusable catheters in a clean, dry container.
A
Which diagnostic test is used as a screening tool for the possible diagnosis of colon cancer? A. Occult blood B. Stool pinworms C. Timed stool specimen D. Stool culture
A
Which statement made by the patient indicates an understanding of diet progression after surgery? A. I'll start drinking water as soon this nausea subsides. B. I know it is important to get my strength back, so I will ask for a milkshake after surgery. C. I can't tolerate a soft diet so I'll simply go back to drinking clear liquids. D. I love coffee, so I'll have some as soon as I get back from surgery.
A
While inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. What is the appropriate action by the nurse? A. Leave the catheter in the vagina as a landmark and begin the procedure again with new supplies. B. Allow the patient a period of rest and attempt the procedure at a later time. C. Carefully remove the catheter and reinsert it into the urethra. D. Remove the catheter and re-start the procedure using a new sterile kit.
A
After completing an intermittent catheterization, what information concerning the procedure will the nurse include in Ms. Johnson's medical record? (Select all that apply.) A. Time procedure was performed B. Size of catheter used C. Description of the patient's tolerance of the procedure D. Characteristics of the urine obtained E. Description of the cleansing process preceding the procedure
A, B, C, D
The nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this patient? (Select all that apply.) A. Assist with range of motion exercises to lower extremities. B. Provide meticulous skin care. C. Monitor patient for signs of skin breakdown. D. Perform neurovascular checks to look for changes. E. Maintain strict bed rest.
A, B, C, D
The nurse is preparing discharge education for a patient with a permanent colostomy. What information concerning diet and nutrition will the nurse include? (Select all that apply.) A. Avoid high fiber foods for eight weeks after surgery. B. Gradually add new foods into the diet. C. Drink at least two quarts of water daily. D. Avoid foods that previously caused diarrhea. E. Be aware that colostomies are prone to develop food blockages.
A, B, C, D
The nurse is completing an admission assessment on a patient admitted for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition? (Select all that apply) A. Poor circulation B. Poor hygiene C. Obesity D. Hypertension E. Diabetes mellitus
A, B, C, E
The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? (Select all that apply.) A. Do you have any sores on your body? B. Have you used pads or special pants because you can't control your urine? C. Do some areas of your skin seem warmer or colder than others? D. What kind of activities cause you to be fatigued? E. Have you noticed any swelling on your feet, ankles, or fingers?
A, B, C, E
Which interventions will the nurse implement to help minimize a postoperative patient's risk for surgical site complications? (Select all that apply.) A. Providing sufficient fluids to maintain hydration. B. Monitoring for elevation in body temperature. C. Advancing diet as appropriate to provide adequate nutrition. D. Encouraging deep, sustained breathing and supported coughing. E. Following strict aseptic techniques when changing surgical dressing.
A, B, C, E
Which statements best support the nurse's evaluation that a patient who recently experienced a sigmoid colostomy has begun to accept the body change? (Select all that apply.) A. I'm anxious to get a bathing suit that accommodates my colostomy. B. My ostomy nurse always has helpful suggestions about daily care routine. C. Having a colostomy is a small price to pay for being healthy. D. I really hope no one else I know has to ever deal with a colostomy. E. My stoma continues to be red and moist.
A, B, C, E
Which statements indicate that a patient who recently required a colostomy has achieved the outcomes set for regular bowel elimination? (Select all that apply.) A. I've learned to implement the techniques I learned in stress management. B. My routine includes about 30 minutes of exercise daily. C. I've gotten accustomed to drinking at least two quarts of water a day. D. Getting a short nap each afternoon makes me feel so much better. E. I know that what I eat has a large impact on my bowel function.
A, B, C, E
Which statements will guide the nurse when preparing to educate a patient whose condition requires a permanent colostomy? (Select all that apply.) A. Help the patient get accustomed to looking at the ostomy. B. Encourage the patient to take part in the care process. C. If the patient is accepting, include family members in the teaching. D. Schedule the teaching two to three days after the surgery. E. Assess the patient for sign of depression.
A, B, C, E
The nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. What questions would the nurse include when assessing the patient? (Select all that apply.) A. How often do you urinate? B. Is there anything that you do that helps you urinate? C. When was your last menstrual period? D. Have you noticed any change in you usual voiding pattern? E. Do you ever leak urine?
A, B, D, E
The nurse is providing discharge education on complications associated with intermittent self-catherteization. Which possible complications should the nurse include in the teaching session? (Select all that apply.) A. Urinary tract infections B. Bladder perforation C. Nephrotic syndrome D. Urethral strictures E. Bladder spasms
A, B, D, E
What assessment data will the nurse expect to find to support the assumption that Mr. Hayes's surgical incision is in the inflammatory phase of wound healing? (Select all that apply.) A. Redness surrounding the incision. B. Increased white blood cell count. C. Signs of scabbing are noted at the incision site. D. Incisional site pain. E. Incision is slightly edematous.
A, B, D, E
The nurse had received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patient's specimen? (Select all that apply.) A. Sediment B. pH C. Clarity D. Odor E. Color
A, C, D, E
The nurse is completing documentation following the insertion of an intermittent urinary catheter. What should be included in the documentation? (Select all that apply.) A. Size of the catheter. B. The length of time for completion of the procedure. C. Date the procedure was performed D. Patient's tolerance of the procedure E. Time the procedure was performed
A, C, D, E
The nurse is performing an assessment of Ms. Morrow's wound. What should be included in the documentation? (Select all that apply.) A. Location B. Turgor C. Odor D. Tunneling E. Drainage
A, C, D, E
What information should the nurse include in the documentation associated with the changing of a patient's colostomy pouch? (Select all that apply.) A. Condition of the skin around the stoma. B. How often the process will be done. C. Description of the stoma. D. Characteristics of the fecal matter. E. Patient's response to the process.
A, C, D, E
What information will the nurse include when providing education for a patient who is scheduled for a sigmoid colostomy? (Select all that apply.) A. The term ostomy refers to an opening from the inside of an organ to the outside of the body. B. The fecal matter that will pass through the stoma will be liquid in form. C. A stoma is the portion of intestinal mucosa that is secured to the skin of the abdomen. D. A health stoma is bright read, moist and rounded. E. When a ostomy is needed, intestinal mucosa is through through the abdominal wall
A, C, D, E
Which nursing interventions are implemented primarily to prevent respiratory complications in a patient after abdominal surgery? (Select all that apply.) A. Education on incentive spirometer use B. Providing pain medication as required C. Assisting in early ambulation D. Encouraging deep breathing E. Prompting to cough
A, C, D, E
The need for a sigmoid colostomy is generally a result of cancer at what point in the intestinal tract? A. Anywhere in the descending colon B. Near the rectum C. Anywhere in the transverse colon D. Near the ileocecal value
B
The nurse is caring for a patient experiencing the effects of paraplegia. What urinary condition is sccociated with this diagnosis? A. Chronic cystitis B. Neurogenic bladder C. Stress incontinence D. Oliguria
B
The nurse is preforming a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? A. Remove gloves and go to the supply room to obtain more supplies. B. Ask the patient to press the call bell to summon a co-worker to obtain another dressing. C. Pick up the dressing and use the side that did not touch the bed. D. Reapply the original dressing until a new one can be obtained.
B
The nurse is providing education to Ms. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing? A. Whole grain bread B. Baked chicken C. Green leafy vegetables D. Baked potato
B
Which statement by the nurse indicates a thorough understanding of the purpose of postoperative nursing care? A. The goal is well-managed postoperative pain. B. The goal is to ensure uneventful recovery from surgery. C. The goal is to prevent infection. D. The goal is frequent assessment of the surgical incision site.
B
The nurse is preparing to catheterize a female patient and is positioning the patient. Which position(s) would be appropriate for this procedure? (Select all that apply.) A. Semi-Fowler's B. Side lying C. Dorsal recumbent D. Lithotomy E. Supine
B, C
The nurse is recording fluid intake for Ms. Johnson. Which items on the dinner tray should the nurse include when completing this documentation? (Select all that apply.) A. Applesauce B. Ice-Cream C. Tomato Soup D. Iced Tea E. Creamed corn
B, C, D
Which patients have an increased risk for developing colorectal cancer? (Select all that apply.) A. A 40-year-old with a history of lupus. B. A 50-year-old whose diet includes red meat daily. C. A 63-year-old who is healthy. D. A 70-year-old who has been diagnosed as obese. E. A 30-year-old with a 13-year history of Crohn's disease
B, C, D, E
What information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure? (Select all that apply.) A. The scan produces an image of the patient's bladder and the amount of urine it contains. B. The scanner is moved over the skin of the patient's lower abdomen. C. The procedure is necessary when a patient experiences difficulty voiding. D. The scan typically does not cause the patient any pain E. The patient's body is draped to promote modesty.
B, D, E
A postoperative patient is receiving enoxaparin sodium therapy. Which assessment data would the nurse report immediately to the patient's health care provider? A. A platelet reading of 260,000 per mcL B. Patient reports no bowel movements for two days. C. Patient has reported self-medicating with aspirin three times since surgery. D. Small amount of gum bleeding after completing oral hygiene.
C
Ms. Johnson asks: Why do I need to self-catheterize at regular intervals? What would be the appropriate response by the nurse? A. Self-catheterization helps reduce your risk of infection. B. You will only need to self-catheterize once daily. C. This helps prevent your bladder from becoming over distended. D. This allows you to accurately measure your urine.
C
Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse? A. Irrigation helps to sterilize the wound. B. The application of fluid helps hydrate the surrounding tissue. C. The procedure helps remove drainage and debris from the wound. D. The irrigation fluid contains medication for the wound.
C
The nurse has created a sterile filed and is preparing to catheterize a patient. While using sterile cotton balls to clean the patient prior to the procedure, the nurse drops a contaminated cotton ball in the middle of the sterile field. What is the correct action of the nurse at this time? A. Remove the contaminated cotton ball from the field with the non-dominant hand. B. Ask a co-worker to remove the contaminated cotton ball from the field. C. Obtain a new catheter kit and restart the procedure. D. Continue with the procedure while avoiding the contaminated cotton ball.
C
The nurse is irrigating a patient's wound when the patient complains of pain. What is the appropriate action by the nurse? A. Discontinue the irrigation and notify the provider. B. Administer the ordered analgesic when the procedure is finished. C. Stop the procedure and administer the ordered analgesic. D. Complete a pain assessment and finish the procedure.
C
The nurse is providing Ms. Johnson discharge education about intermittent self-catheterization. What statement, if made by the patient, would indicate the need for further instruction? A. There are risks associated with self-catheterization, such as bleeding and infection. B. It is important that I self-catheterize at regular intervals. C. I should maintain sterile technique throughout the procedure. D. If I do not catheterize myself, I may develop urinary problems.
C
The nurse is providing education to Ms. Morrow and her daughter on management of venous stasis in the lower extremities. What would be appropriate for the nurse to include in the teaching session? A. Avoid ambulating as this may aggravate your condition. B. Keep skin surrounding the would dry and inspect it at least once a week. C. Put on anti embolism stockings as soon as you get up in the morning and wear them all day. D. Sit with your legs in the development position so that blood will drain to lower extremities.
C
The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? A. Iron B. Albumin C. Prealbumin D. Calcium
C
The nurse removes a dressing assesses yellow, foul smelling drainage. How would the nurse document this finding? A. Serous B. Serosanguineous C. Purulent D. Sanguineous
C
What instruction should the nurse provide to a patient concerning how often the colostomy pouch should be emptied? (Select all that apply.) A. When the pouch isn't well attached to the skin. B. At least four to five times daily. C. Whenever the pouch is one-third of fecal drainage. D. After each meal.
C
Which intervention takes priority when the nurse determines that a postoperative patient has hypoactive bowel sounds? A. Assess the patient for indications of hypotension. B. Advance the patient's diet to soft, solid foods. C. Assess the abdomen for signs of distention. D. Notify the surgeon of this assessment finding.
C
A patient is placed on omeprazole 20 mg daily. When will the nurse administer the medication? A. At bedtime B. With breakfast C. On hour after any meal D. One hour before breakfast
D
Ms. Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session? A. You may have to urinate more frequently while taking this medication. B. You may experience excess saliva production while taking this medication. C. Your urine may appear reddish-orange. D. This medication helps reduce bladder spasms.
D
The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed? A. Full-thickness tissue loss with exposed bone, tendon, or muscle. B. Intact skin with nonblanchable redness of a localized area. C. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. D. Full-thickness tissue loss, possibly with visible subcutaneous fat.
D
The nurse has received an order to apply a hydrocolloid dressing to Ms. Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education? A. It will help protect the wound form contamination. B. I can leave this dressing in place for three to seven days. C. Hydrocolloid dressings help to maintain a moist wound environment. D. This dressing will need to be held in place by surgical tape.
D
The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12? A. Not a risk B. Low risk C. Moderate risk D. High risk
D
The nurse is preparing to irrigate a patient's wound. Upon assessment, the wound appears to be healing and the wound bed is beefy red. Which solution should the nurse select for this procedure? A. Tap water B. Isopropyl alcohol C. Dakin's solution D. Normal saline
D
What information will the nurse include when providing education for a patient scheduled for a colostomy as treatment for rectal cancer? A. Once the inflammation in the colon subsides, the ostomy will be reversed. B. The surgeon will determine whether the ostomy can be temporary once surgery has begun. C. Permanency will depend on how much colon function has been affected by the surgery. D. The ostomy will be permanent because of the nature of the illness.
D
When should the nurse caring for a patient with a new colostomy plan to change the pouching system? A. Before the patient showers. B. Right before bed. C. After any meal. D. Before breakfast.
D
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