Cont unit 7/8

A nurse is carrying out a prescription to remove an indwelling catheter. Which explanation should the nurse use with the client prior to removing an indwelling catheter? "I am going to remove the catheter after cutting the tubing and deflating the balloon." "I will need you to take several deep breaths when I withdraw the tubing." "I want to warn you that intense burning may initially occur." "I am going to remove the catheter after withdrawing the fluid from the balloon."

"I am going to remove the catheter after withdrawing the fluid from the balloon."

A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information? "I understand these will help me control stress incontinence." "I know this is also called pelvic floor muscle training." "I will do these 30 to 80 times a day for 2 months." "I will contract the muscles in my abdomen and thighs."

"I will contract the muscles in my abdomen and thighs."

The nurse is flushing a client's feeding tube with 50 mL of water after giving medications through it. When the client asks, "Why are you doing that?" what is the appropriate nursing response? "This fluid will help your medication to dissolve." "Water helps keep the feeding tube free from obstruction." "I'm providing water through the tube to keep you hydrated." "It appears that you are concerned about this procedure."

"Water helps keep the feeding tube free from obstruction."

The nurse should assess the patient for signs of lethargy, increasing intracranial pressure, and seizures when the serum sodium reaches what level? 115 mEq/L 130 mEq/L 145 mEq/L 160 mEq/L

115

The nurse assesses a cardiac patient's urinary output. The patient weighs 175 pounds. Based on the normal daily range of urine volume, the nurse expects a 4-hour output of: 40 mL to 80 mL. 80 mL to 160 mL. 120 mL to 240 mL. 160 mL to 320 mL.

160 mL to 320 mL.

A client has just returned from surgery with a Foley catheter in place. The nurse anticipates that the catheter will be removed within what time frame after the operation? 24 hours 36 hours 48 hours 72 hours

24 hours

A nurse is checking the placement of a nasogastric tube and aspirates fluid to test the pH. Which result would the nurse interpret as indicating that the tube is in the stomach? 3 6 7 9

3

A nurse will be removing a client's nasogastric tube. Which action will the nurse perform to reduce the risk for aspirating gastric fluid during these procedure? Remove the tube from the nose gently and slowly. Ask the client to take a deep breath and hold it. Enclose the tube within the towel or glove firmly. Ask the client to clear the nose of mucus and debris.

Ask the client to take a deep breath and hold it.

The nurse is caring for a patient with a diagnosis of hyponatremia. What nursing intervention is appropriate to include in the plan of care for this patient? (Select all that apply.) Assessing for symptoms of nausea and malaise Encouraging the intake of low-sodium liquids Monitoring neurologic status Restricting tap water intake Encouraging the use of salt substitute instead of salt

Assessing for symptoms of nausea and malaise Monitoring neurologic status Restricting tap water intake

A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence.

Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection.

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing what electrolyte imbalance? Hypernatremia Hypomagnesemia Hypophosphatemia Hypercalcemia

Hypercalcemia

spironolactone

It is used to get rid of extra fluid and and raise blood pressure. It lowers BP

Flurosemide (Lasix)

It is used to get rid of extra fluid and lowers BP watch for potassium lowering give medication slow can cause tintus

The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. What assessment finding would suggest that the client's potassium levels are too low? Diarrhea Large amounts of dilute urine Increased muscle tone Joint pain

Large amounts of dilute urine

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Monitor the client's heart rhythm. Prepare for gastric lavage. Obtain a urine specimen for drug screening.

Prepare to assist with ventilation.

A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs continuous bladder irrigation. Which intervention should the nurse perform when providing continuous bladder irrigation? Place the sterile solution on the bed. Purge air from the tubing. Empty the balloon with a syringe. Clean the urinary meatus.

Purge air from the tubing.

The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include? Tighten the internal muscles used to prevent or interrupt urination. Keep muscles contracted for at least 30 seconds. Relax muscles for at least 1 minute between contractions. Perform these exercises 10 times daily for 1 month.

Tighten the internal muscles used to prevent or interrupt urination.

A nurse is caring for a client whose nasogastric tube drainage holes are adhering to the gastric mucosal wall. Which intervention can solve the problem? Instill a bolus of air into the vent. Turn the suction off momentarily. Resecure the lid to the container. Increase the suction pressure momentarily.

Turn the suction off momentarily.

The physician added the condition "hypervolemia" to a client's list of medical ailments. What could put the client at risk for hypervolemia? Select all that apply. altered cardiac function taking prednisone eating large amounts of bananas drinking too much coffee

altered cardiac function taking prednisone

A nurse caring for a patient with metabolic alkalosis knows to assess for the primary, compensatory mechanism of: a. Increased serum HCO3. b. Increased PaCO2. c. Decreased serum HCO3. d. Decreased PaCO2.

b. Increased PaCO2.

The nurse is educating a new colostomy client on gas-producing foods. Which food is a gas-producing food the client may choose to avoid? lettuce rice brussels sprouts green peppers

brussels sprouts

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

dehydration

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement? Encourage fluid intake. Restrict fluid intake. No action is required. Alert the health care provider of possible infection.

encourage fluid intake

A client with dysphagia has been experiencing weakness and nausea after the introduction of enteral feedings. The care team recognizes that the client is likely experiencing dumping syndrome. Dumping syndrome results from which physiologic processes? fluid shifts from circulation to the intestines sudden release of pancreatic amylase and gastric lipase sudden conversion of glycogen to glucose in the small intestines spasms of the pyloric sphincter due to osmotic changes

fluid shifts from circulation to the intestines

A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality? free water loss diuretic use overhydration hyponatremia

free water loss

A client with nonhealing wounds requires a feeding tube. Which type of formula does the nurse anticipate will be ordered? high-protein standard isotonic fiber-containing partially hydrolyzed

high-protein

A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client's laboratory values:Sodium 134 mEq/L (134 mmol/L)Potassium 3.2 mEq/L (3.2 mmol/L)Chloride 111 mEq/L (111 mmol/L)Magnesium 1.1 mg/dL (0.45 mmol/L)Calcium 8.4 mg/dL (2.1 mmol/L)What fluid and electrolyte imbalance would the nurse relate to the client's findings? hyponatremia hypokalemia hypocalcemia hypomagnesemia

hypomagnesemia

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? increased bowel sounds abdominal tenderness areas of distention muscular resistance

increase bowel sounds

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs? water soap normal saline oil

oil

The nurse is administering a rectal suppository. How far will the nurse insert the suppository? past the internal sphincter just past the opening of the anus far enough to still visualize the end of the suppository until the client reports feelings of discomfort

past the internal sphincter

What is the most critical component of an enteral feeding formula? carbohydrates fat protein fiber

protein

A 71-year-old woman sought care because of recurrent constipation. The client stated that she had tried an array of pharmacologic and dietary approaches to managing her problem, yet it persisted. The nurse suggested that the woman keep a "stool diary" for a few weeks and this documented the fact that the woman typically has six to seven formed bowel movements each week. What type of constipation is this client most likely experiencing? primary constipation secondary constipation iatrogenic constipation pseudoconstipation

pseudoconstipation primary- lifestyles secondary- partial bowel obstruction iatrogenic- narcotic use pseudoconstipation- concerned about bowel movements, overuse laxative

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

pus

A client is admitted with dehydration. In client education, the nurse reinforces how much oral fluid an adult needs daily. Balancing fluid intake with fluid output helps to keep the body healthy. What type of fluid loss is an insensible loss? sweating breathing perspiration bowel elimination

sweating breathing perspiration