EAQ's Unit 3:2

During a colonoscopy, the health care provider finds a single polyp in the patient. The nurse anticipates which intervention will be performed? Select all that apply. One, some, or all responses may be correct. 1 Removal of the growth 2 Cauterization of the growth 3 Institution of cryotherapy 4 Sample collection for a biopsy 5 Waiting and watching the single lesion

1 Removal of the growth 4 Sample collection for a biopsy

What can a nurse use to measure the postvoid residual (PVR) volume in a patient with urinary retention? Select all that apply. One, some, or all responses may be correct. 1 Ultrasound 2 Bladder scanner 3 Cystoscopy 4 Straight catheterization 5 Axial computed tomographic scan

1 Ultrasound 2 Bladder scanner 4 Straight catheterization

Upon auscultating the abdomen of a patient with a stethoscope, the nurse hears high-pitched and hyperactive bowel sounds. The nurse identifies that the assessment findings correspond with which condition? 1 Small intestine obstruction 2 Normal bowel activity 3 Fluid or gas within the abdomen 4 Effects of abdominal surgery

1 Small intestine obstruction

A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be most beneficial in assisting the patient to void? 1 Suggest he stand at the bedside. 2 Stay with the patient. 3 Give him the urinal to use in bed. 4 Tell him that if he does not urinate he will be catheterized.

1 Suggest he stand at the bedside.

A patient reports having the urge to void, but urine starts leaking before the patient reaches the bathroom. Which treatment strategy would be helpful for this patient? Select all that apply. One, some, or all responses may be correct. 1 Scheduled toileting 2 Absorbent products 3 Electrical stimulation 4 Clothing modification 5 Antimuscarinic agents

1 Scheduled toileting 2 Absorbent products 4 Clothing modification

The nurse is caring for a patient with urinary incontinence. Which action would the nurse perform to promote comfort for the patient? Select all that apply. One, some, or all responses may be correct. 1 Change dressings and linens when wet. 2 Limit fluid intake. 3 Use absorbent pads. 4 Increase coffee intake. 5 Catheterize the patient.

1 Change dressings and linens when wet. 3 Use absorbent pads. 5 Catheterize the patient.

The nurse reviews the procedure for inserting and maintaining a small-bore nasogastric tube. The nurse identifies that which step is included to increase patient comfort? Select all that apply. One, some, or all responses may be correct. 1 Change the tape on the fixation device. 2 Apply a lubricant to the nares. 3 Provide mouth care once daily. 4 Use gargles with topical Xylocaine jelly. 5 Provide lozenges for the patient to suck.

1 Change the tape on the fixation device. 2 Apply a lubricant to the nares. 4 Use gargles with topical Xylocaine jelly. 5 Provide lozenges for the patient to suck.

A 55-year-old man is admitted to the hospital with urinary retention. The patient is catheterized to relieve retention. Which action is necessary to prevent infection in the patient? Select all that apply. One, some, or all responses may be correct. 1 Ensure a closed drainage system. 2 Monitor the patency of the catheter. 3 Hang the drainage bag on the bedrail. 4 Ensure that the bag's drain does not touch any contaminated surfaces. 5 Follow good hand-hygiene techniques

1 Ensure a closed drainage system. 2 Monitor the patency of the catheter. 4 Ensure that the bag's drain does not touch any contaminated surfaces. 5 Follow good hand-hygiene techniques

The nurse observes the presence of a tympanic note when percussing the abdomen of a patient and suspects which cause? 1 Gas 2 Fluid 3 Tumor 4 Thick pus

1 Gas

A patient who presents with dribbling of urine is diagnosed with stress incontinence. Which datum would the nurse include in the assessment of this patient? Select all that apply. One, some, or all responses may be correct. 1 Height and weight 2 History of osteoarthritis 3 Menopausal status 4 Number of live births 5 Alcohol use

1 Height and weight 3 Menopausal status 4 Number of live births

A male patient is admitted to the hospital with urinary retention. Which intervention would the nurse perform to stimulate the micturition reflex? Select all that apply. One, some, or all responses may be correct. 1 Help the patient relax and void in a standing position. 2 Encourage the patient to run water while trying to void. 3 Stroke the outer aspect of the thigh. 4 Pour warm water over the patient's perineum. 5 Obtain a prescription to catheterize the patient.

1 Help the patient relax and void in a standing position. 2 Encourage the patient to run water while trying to void. 4 Pour warm water over the patient's perineum.

The nurse receives a prescription to obtain a postvoid residual for a patient via catheterization. Which method to obtain this measurement is best? 1 Intermittent catheterization 2 Long-term indwelling catheterization 3 Short-term indwelling catheterization 4 Medium-term indwelling catheterization

1 Intermittent catheterization

A health care provider instructs the nurse to insert an indwelling urinary catheter in a patient for 3 weeks. Which type of catheter is the best choice for this patient to prevent infection and promote comfort? 1 Latex catheter 2 Silicon catheter 3 Teflon catheter 4 Plastic catheter

1 Latex catheter

A patient undergoes surgery on the pharynx and has a small-bore nasogastric tube in place. The nurse understands that the tube is inserted for which purpose? Select all that apply. One, some, or all responses may be correct. 1 Medication administration 2 Enteral feeding 3 Gastric decompression 4 Removal of gastric secretions 5 Preparation for barium enema

1 Medication administration 2 Enteral feeding

After assessing a patient, a nurse suspects that the patient has overflow urinary incontinence. Which finding supports the nurse's conclusion? Select all that apply. One, some, or all responses may be correct. 1 Nocturia 2 Frequency 3 Distended bladder on palpation 4 Leakage of urine on the way to the bathroom 5 Diminished or absent awareness of bladder filling and the urge to void

1 Nocturia 2 Frequency 3 Distended bladder on palpation

The nurse is caring for a patient who has a colostomy. When assessing the stoma, which color indicates that the stoma is healthy? Select all that apply. One, some, or all responses may be correct. 1 Pink 2 Red 3 Blue 4 Brown 5 Black

1 Pink 2 Red

A nurse is caring for an elderly patient who has recently started taking an antimuscarinic medication to treat urinary continence. Which nursing intervention is most important in this situation? 1 Teaching pelvic muscle exercises 2 Assessing the patient for mental status changes 3 Reminding the patient to drink adequate amounts of water 4 Instructing the patient to restrict fluid intake 2 hours before bedtime

2 Assessing the patient for mental status changes

Which event may occur because of vagus nerve stimulation during removal of a fecal impaction? 1 Atelectasis 2 Bradycardia 3 Hypertension 4 Cardiac tamponade

2 Bradycardia

During a home health visit after a patient's recent surgery, the nurse assesses that a patient is experiencing acute pain related to constipation. The nurse reviews the potential causes of the pain and recognizes that the patient is at risk of intestinal obstruction if which condition is unresolved? 1 Incisional pain 2 Fecal impaction 3 Use of opioid medication 4 Impaired physical mobility related to surgery

2 Fecal impaction

When mucus is noted in a patient's feces, the nurse suspects which cause? 1 Constipation 2 Intestinal infection 3 Increased peristalsis 4 Malabsorption of fat

2 Intestinal infection

A nurse is caring for a patient with an indwelling catheter. Which nursing action may increase the risk of a catheter-associated urinary tract infection? 1 Collecting specimens via a port in the tubing 2 Keeping the drainage bag above the level of the bladder 3 Allowing the patient to wear a leg bag while ambulating 4 Monitoring the drainage system to prevent backflow of urine

2 Keeping the drainage bag above the level of the bladder

An obese patient reports leaking urine while coughing. Which management strategy should be included in the patient's treatment plan? Select all that apply. One, some, or all responses may be correct. 1 Adequate fluid intake 2 Kegel exercises 3 Heavy weight lifting 4 Weight-control measures 5 Caffeinated beverages

2 Kegel exercises 4 Weight-control measures

Which symptom would the nurse anticipate in a patient with urge urinary incontinence? Select all that apply. One, some, or all responses may be correct. 1 Distended bladder on palpation 2 Leaks on the way to the bathroom 3 Leaks without awareness 4 Strong urge or leaks upon hearing water running 5 Loss of a small volume of urine while coughing or laughing

2 Leaks on the way to the bathroom 4 Strong urge or leaks upon hearing water running

A nurse is caring for a patient with a spinal cord injury who reports an absence of awareness of bladder filling and the urge to void. A family member adds that the patient also sometimes has leakage of urine without awareness. Which nursing intervention is most important for the patient? 1 Placing an indwelling catheter 2 Monitoring for autonomic dysreflexia 3 Encouraging the patient to perform pelvic muscle exercises 4 Monitoring the postvoid residual volume according to the health care provider's direction

2 Monitoring for autonomic dysreflexia

The nurse notices pus in the catheter of a patient who had an indwelling catheter inserted 4 days ago. Which nursing measure is appropriate for this patient? 1 Irrigating the catheter with 10 mL of water 2 Replacing the catheter with a new one 3 Irrigating the catheter with antiseptic solution 4 Milking the catheter from proximal end to distal end

2 Replacing the catheter with a new one

A patient who is a smoker complains of involuntary passage of urine after a strong sense of urgency to void. Which nursing intervention would be helpful to this patient? Select all that apply. One, some, or all responses may be correct. 1 Credé method 2 Smoking cessation 3 Intermittent catheterization 4 Antimuscarinic agents 5 Behavioral interventions

2 Smoking cessation 4 Antimuscarinic agents 5 Behavioral interventions

What is the daily recommended volume of fluid intake for a woman? Record your answer using one decimal place. _______ L

2.7

A nurse is teaching a 55-kg patient about the promotion of normal micturition by maintaining optimal fluid intake. The nurse is aware that the patient has normal renal function and no heart disease or alterations that require fluid restriction. What is the approximate amount of fluid that the nurse should instruct the patient to drink per day? Record your answer using a whole number. ____ mL

2300

A nurse is educating a patient who has altered urinary elimination on how to maintain a healthy bladder. Which statement by a patient indicates a need for further education? Select all that apply. One, some, or all responses may be correct. 1 "I'll drink six to eight glasses of water a day." 2 "I'll avoid drinking beverages that contain caffeine." 3 "I'll avoid drinking fluids 4 hours before bedtime to decrease nocturia." 4 "I'll immediately tell my doctor if I experience pain when voiding." 5 "After each voiding and bowel movement, I'll cleanse my perineum from back to front."

3 "I'll avoid drinking fluids 4 hours before bedtime to decrease nocturia." 5 "After each voiding and bowel movement, I'll cleanse my perineum from back to front."

Which patient is most likely to exhibit symptoms such as dysuria, urgency, frequency, and nocturia? 1 A patient with kidney failure 2 A patient receiving diuretic therapy 3 A patient with a urinary tract infection 4 A patient with uncontrolled diabetes mellitus

3 A patient with a urinary tract infection

Which bowel elimination problem is most likely the result of improper diet, reduced fluid intake, and lack of exercise? 1 Diarrhea 2 Flatulence 3 Constipation 4 Incontinence

3 Constipation

What should the nurse include in the plan of care for a patient with urge urinary continence? 1 Helping the patient learn efficient and safe toilet transfers 2 Helping the patient with leg-strengthening exercises 3 Helping the patient strengthen the pelvic floor muscles and learn fluid and food modifications 4 Helping the patient obtain assistive devices for the home that are covered by insurance

3 Helping the patient strengthen the pelvic floor muscles and learn fluid and food modifications

A nurse is caring for an elderly patient who is receiving treatment for urinary incontinence. After reviewing the patient's prescription, the nurse knows to observe the patient for cognitive impairment. Which medication is the patient most likely taking? 1 Atropine 2 Diuretics 3 Oxybutynin 4 Phenazopyridine

3 Oxybutynin

What is the recommended daily fluid intake for men? Record your answer using a one decimal place. ______ L

3.7

A nurse is assessing the severity of a patient's urinary elimination problem. Which question is most appropriate for the nurse to ask? 1 "Does your urinary problem restrict you from doing your usual activities?" 2 "Do you dribble urine before voiding, after voiding, or at other times?" 3 "Have you been hospitalized or have you received a diagnosis of a new medical problem recently?" 4 "How often are you awakened with the urge to void while you are sleeping?"

4 "How often are you awakened with the urge to void while you are sleeping?"

A patient with epigastric and abdominal pain is scheduled for a barium swallow. Which statement by the patient indicates a correct understanding of the required preparation for the test? 1 "I will eat only soft foods the day before the test." 2 "There is no need for special preparation before the test." 3 "I will not eat or drink anything for 24 hours before the test." 4 "I will take a laxative to clear my bowels the day before the test."

4 "I will take a laxative to clear my bowels the day before the test."

Which statement by a student nurse regarding urinary incontinence requires correction? 1 "Urinary incontinence is common in older adults." 2 "Urge incontinence and stress incontinence are common forms of urinary incontinence." 3 "Urinary incontinence is characterized by any involuntary loss of urine." 4 "Mixed incontinence is a combination of stress and functional incontinence."

4 "Mixed incontinence is a combination of stress and functional incontinence."

A parent tells the nurse, "My infant who is breastfed passes stools an average of 5 times per day." How does the nurse respond? 1 "It would benefit the child to increase the maternal intake of dietary fiber." 2 "You should supplement breastfeeding with bottle-feeding." 3 "Administer a dose of antidiarrheal medication each day to your child." 4 "This is a normal finding for the infant."

4 "This is a normal finding for the infant."

A cleansing enema is prescribed for an adult patient before intestinal surgery. What is the maximum amount of fluid the nurse should give? 1 150 to 200 mL 2 200 to 400 mL 3 400 to 750 mL 4 750 to 1000 mL

4 750 to 1000 mL

While performing continuous bladder irrigation, a nurse assesses the patient's urine for color, amount, clarity, and the presence of mucus, blood clots, or sediment. What is the nurse looking for? 1 Bladder spasms 2 A need for further patient instruction 3 Accurate urine output measurements 4 A need for increased irrigation rate to prevent bleeding

4 A need for increased irrigation rate to prevent bleeding

A nurse is assisting the health care provider assess a patient with altered urinary elimination. After assessing the patient, the health care provider suspects that the patient has an obstruction of the ureters. Which diagnostic test does the nurse expect the patient to undergo? 1 Cystoscopy 2 Abdominal roentgenogram 3 Ultrasound of the urinary bladder 4 Axial computed tomographic scan

4 Axial computed tomographic scan

Which type of laxative acts by causing the stool to absorb water and swell? 1 Emollient 2 Stimulant 3 Lubricant 4 Bulk-forming

4 Bulk-forming

How would the nurse position a female patient for examining the genitalia for inflammation and infection related to urinary elimination problems? 1 Supine 2 Fowler's 3 Squatting 4 Dorsal recumbent

4 Dorsal recumbent

A patient who has undergone urological surgery is prescribed urinary catheterization. Which diameter of catheter does the nurse anticipate will be used for this patient? 1 5 to 6 French (Fr) 2 8 to 10 Fr 3 12 Fr 4 Greater than 16 Fr

4 Greater than 16 Fr

An older male patient states that he is having problems starting and stopping his stream of urine and feels the urgency to void. Which intervention to assist this patient is best? 1 Help him stand to void. 2 Place a condom catheter. 3 Have him practice the Credé method. 4 Initiate Kegel exercises.

4 Initiate Kegel exercises.

A patient is being assessed for a possible urinary tract infection (UTI). Before sending a urinalysis specimen to the laboratory, the nurse collects a small amount of urine to perform a dipstick test. If the patient has a UTI, which component should be detected in the urine? 1 Protein 2 Glucose 3 Ketones 4 Leukocytes

4 Leukocytes

Which substance may cause complications for a patient who has kidney dysfunction? 1 Castor oil 2 Mineral oil 3 Docusate sodium 4 Magnesium hydroxide

4 Magnesium hydroxide

Which tube is appropriate as an intervention for bleeding esophageal varices? 1 Ewald 2 Dobhoff 3 Miller-Abbott 4 Sengstaken-Blakemore

4 Sengstaken-Blakemore