*Elevate Module 2 Q Review Quiz
The nurse is teaching a male client how to perform intermittent self-catheterization. In what order should this procedure be taught? Hold your penis on both sides just behind the head Clean the meatus Lubricate several inches of the catheter tip Insert the catheter 6 inches (15.24 cm) into the urethra Gently, but firmly push past the sphincter muscle 2-3 inches(5-7.6 cm) Allow urine to drain completely
1. Clean the meatus 2. Lubricate several inches of the catheter tip 3. Hold your penis on both sides just behind the head 4. Insert the catheter 6 inches (15.24 cm) into the urethra 5. Gently, but firmly push past the sphincter muscle 2-3 inches(5-7.6 cm) 6. Allow urine to drain completely Correct Order: First, clean the meatus. Second, lubricate several inches of the tip of the catheter. Third, hold your penis on both sides just behind the head. Next, insert the catheter six inches into the urethra, using a steady gentle pressure. Fifth, use gentle but firm pressure on the catheter until the muscle relaxes and the catheter becomes easier to advance. It will be necessary to pass the catheter another two or three inches before it enters the bladder. Sixth, allow urine to drain completely.
A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that further treatment is necessary? 1. Fixed urine specific gravity 2. Serum K+ 4.9 mEq (4.9 mmol/L) 3. Serum Na+ 143 mEq (143 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours
1., & 4. Correct: A fixed specific gravity indicates that the kidneys are not working properly. The lungs would need to be clear to verify that treatment has been effective. 2. Incorrect: The serum potassium is within normal range. The serum potassium level would be elevated if the client was still in the oliguric phase. 3. Incorrect: This is a normal sodium level, which indicates that the client is improving. The serum sodium level would be low in the oliguric phase due to increased dilution of the blood. 5. Incorrect: This urine output is adequate to indicate proper kidney perfusion.
A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)
1., 2., 3., & 4. Correct: These signs and symptoms indicate an emergency with loss of circulation to the extremity. This is an emergency, and the primary healthcare provider is the only one that can save this foot from ischemia. Don't delay. Epigastric pain could indicate the client is having an MI. Always assume the worse! 5. Incorrect: Temperature of 101º F (38.3º C) or more indicates a problem.
A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. The nurse should assess for what additional signs and symptoms? 1. Anxiety 2. Dizziness 3. Headache 4. Shortness of breath 5. Upper back pain
1., 2., 4. & 5. Correct: The nurse should be thinking myocardial infarction (MI)! All of these are signs of an MI. 3. Incorrect: Headaches do not commonly occur with MI.
What teaching points should the nurse include when teaching a client how to prevent a venous stasis ulcer? 1. Maintain a healthy weight. 2. Do not sit for longer than 2 hours at a time. 3. Exercise helps to improve circulation. 4. Crossing of the legs should be limited to 30 minutes at a time. 5. Elevate legs above the heart for 30 minutes three times a day.
1., 3., & 5. Correct: Excess weight leads to high pressure in the veins of the legs, which can damage the skin. Venous ulcers are much more common among people who are overweight. Exercise to improve circulation and reduce body fat. Elevating legs above the heart for 30 minutes, three times a day will minimize edema and reduce intra-abdominal pressure. 2. Incorrect: Get up every 30 minutes to cut the risk of death. Research has warned time and time again that "sitting disease" is real. But if you're sitting all day at work, you should get up every 30 minutes and move to cut your risk of death. 4. Incorrect: Crossing of the legs causes venous obstruction that can lead to stasis.
A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Protecting my legs from trauma is very important." 4. "I will wear compression stockings every day." 5. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep."
1., 3., 4., & 5. Correct: Minimize stationary standing as much as possible. Protect legs from trauma as this can lead to ulcerations. Elastic compression stockings are recommended for clients with chronic venous insufficiency to prevent pooling and promote venous return. Leg elevation decreases edema, promotes venous return, and provides symptomatic relief. Legs should be elevated frequently throughout the day (for at least 15-30 minutes every 2 hours). During the night, the client should sleep with the foot elevated approximately 6 inches (15.24 cm). 2. Incorrect: The client should avoid wearing any constricting clothing, even for short periods of time. This will decrease blood flow.
During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? 1. Anorexia 2. Bradycardia 3. Chills 4. Fever 5. Hematuria
1., 3., 4., & 5. Correct: The client with acute pyelonephritis, will often exhibit these signs/symptoms due to the kidney infection. 2. Incorrect: Bradycardia is not a symptom of acute pyelonephritis. The client will more likely experience tachycardia due to fever and chills.
The nurse is planning care for a client who has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which intervention would the nurse include in this plan? 1. After voiding, instruct client to void a second time. 2. Encourage the client to void every 6 hours. 3. Teach client to perform Valsalva maneuver. 4. Have client place hand in warm water. 5. Demonstrate intermittent catheterization for retention.
1., 4., & 5. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Place bedpan, urinal, or bedside commode within reach. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. If these methods are unsuccessful, the client will need education on intermittent catheterization. 2. Incorrect: Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection. 3. Incorrect: Perform Credé method, not valsalva, over bladder to increase bladder pressure.
What dietary supplements or herbs should the nurse instruct a client to avoid when prescribed digoxin? 1. Black licorice 2. Coenzyme Q-10 3. Garlic 4. Ginseng 5. St. John's Wort
1., 4., & 5.Correct: Black licorice contains a natural ingredient called glycyrrhiza, which can deplete the body of potassium while causing an increased retention of sodium. Ginseng can elevate blood levels of digoxin by as much as 75%, while St. John's Wort decreases blood levels of this drug by 25%. 2. Incorrect: Taking coenzyme Q-10 can decrease the effectiveness of warfarin. Blood pressure may be affected if the client is also taking a calcium channel blocker, such as diltiazem. 3. Incorrect: Garlic increases a person's risk of bleeding if taking an anticoagulant, such as aspirin, clopidogrel, or warfarin.
The nurse is planning to educate a client who has a diagnosis of right sided heart failure? What information should the nurse include? 1. Blood backs up in the left upper chamber of the heart. 2. It is common to see swelling of lower extremities. 3. The heart rate decreases. 4. Side effects of this disease include fatigue and depression. 5. Nausea and anorexia occurs because of flu
2. 4. & 5. Correct: Vascular congestion is evident by swelling of the lower extremities. Clients usually experience fatigue and depression. Ascites may increase pressure on the stomach and intestines causing GI upset with nausea and anorexia. 1. Incorrect: The blood backs up into the right atrium and venous circulation. 3. Incorrect: The heart rate increases in an attempt to increase cardiac output.
A client had a coronary artery bypass surgery (CABG) x 3 performed 24 hours ago. What assessment findings would make the nurse suspect cardiac tamponade? 1. Bradycardia with wet lungs 2. Increased central venous pressure 3. Distended bilateral neck veins 4. A widening pulse pressure 5. Decreasing blood pressure
2, 3, and 5. CORRECT: Cardiac tamponade occurs when blood or fluid enters the pericardial sac, causing compression of the heart chambers. Such pressure prevents blood from either entering or leaving the heart, thus decreasing cardiac output. Central venous pressure (CVP) increases because of the compression of the right atria, but because no fluid is exiting the heart, blood pressure drops. Since the returning blood cannot enter the heart, neck veins become distended, though lungs remain clear. 1. INCORRECT: Because little blood is moving within the heart chambers, no fluid would back up into the lungs. The client's lungs remain clear, even though the cardiac output decreases and neck veins are distended. 4. INCORRECT: Widening pulse pressure is noted with increased intracranial pressure, not cardiac tamponade. Pulse pressure in tamponade would narrow since the heart is being compressed.
An elderly client with a history of coronary artery disease (CAD) has just been admitted to the telemetry unit following a syncopal episode at home. The admitting nurse places EKG leads on the client and notes the following rhythm on the monitor. When the client indicates the need to void, the nurse knows that what would be the safest action? Exhibit ECG Monitor: 1. Request order for a foley catheter. 2. Assist client with the use of a bedpan. 3. Provide a bedside commode chair. 4. Perform in and out straight catheterization.
2. CORRECT. The exhibit shows bradycardia with premature ventricular contractions (PVCs), and more specifically, bigeminy. The safest approach for a syncopal client with this rhythm is the use of a bedpan for bathroom needs. Even with assistance, this client would be at risk for falls when ambulating. 1. INCORRECT. Because the client has experienced syncope and is bradycardic, keeping the client in bed is safer than ambulating to the bathroom. However, a foley catheter is an invasive procedure that could place the client at risk of infection. There is a better option. 3. INCORRECT. The client has experienced syncope and is bradycardic. Keep the client in bed. This is a safety issue. 4. INCORRECT. This client is newly admitted with a diagnosis of syncope. The exhibit shows the heart rate is bradycardic with PVCs, which are non-perfusing beats. In and out straight catheterization is an invasive procedure that could place the client at risk for infection. There is a better option.
A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.
2., 3., 4., & 5. Correct: Caffeine, stress, and nicotine cause vasoconstriction and vasospasm, which impedes peripheral circulation. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling. Vasodilation will be increased by providing warmth in the environment. Cold causes vasoconstriction. Isometric exercise and walking promote the development of collateral circulation. 1. Incorrect: Lower the extremities below the level of the heart for arterial problems. Dependent extremities enhance arterial blood supply.
The nurse is caring for a client who is receiving enoxaparin after a diagnosis of deep vein thrombosis of the left leg. Which nursing interventions would be appropriate for this client? 1. Monitor PT and aPTT 2. Initiate bedrest 3. Elevate left leg 4. Monitor closely for bleeding 5. Monitor complete blood count
2., 3., 4. & 5. Correct: The main complication of anticoagulant therapy is bleeding. Periodic complete blood counts, including platelet count, and stool occult blood tests are recommended during the course of treatment with enoxaparin sodium Injection. Bedrest will reduce the risk of a clot dislodging. Elevate left leg to decrease swelling and promote venous return. 1. Incorrect: When administered at recommended prophylaxis doses, routine coagulation tests such as Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are relatively insensitive measures of enoxaparin.
A client arrives to the emergency department with reports of palpitations, chest discomfort, and lightheadedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? Exhibit 1. Administer Epinephrine 1 mg intravenous push (IVP). 2. Initiate oxygen at 2 liters per nasal cannula. 3. Prepare for immediate synchronized cardioversion. 4. State defibrillation at 200 joules. 5. Have client do the valsalva maneuver.
2., & 3. Correct: This client has a rapid heart rate of 188/min. The actual rhythm is atrial tachycardia but can also be identified as supraventricular tachycardia because the heart rate is greater than 150/min. This client is considered unstable so requires oxygen therapy, with O2 saturation monitoring, and synchronized cardioversion. 1. Incorrect: Epinephrine is not indicated for an atrial or supraventricular dysrhythmia. 4. Incorrect: The valsalva is not within the scope of practice of the nurse. Asystole could result. 5. Incorrect: This client has a pulse, so defibrillation is not needed.
The nurse is planning to teach a client about home peritoneal dialysis. What information should the nurse include? 1. After washing hands with soap and water, put on sterile gloves to clean catheter site. 2. Apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab. 3. Carefully remove crust from insertion site with tweezers. 4. Pat the skin around the site dry after cleaning. 5. Wash the skin around the catheter site with hydrogen peroxide.
2., & 4. Correct: Apply a prescription antibiotic cream to the skin around the catheter with a cotton-tip swab every time the dressing is changed. Pat the skin around the site dry after cleaning. A clean cloth or towel is suggested. 1. Incorrect: Before cleaning the area, wash your hands with soap and water and put on clean gloves. 3. Incorrect: Do not pick at or remove crusts or scabs at the site. 5. Incorrect: The skin around the catheter site should be washed daily or every other day with antibacterial soap or an antiseptic (either povidone iodine or chlorhexidine). The soap should be stored in the original bottle (not poured into another container). Other types of cleansers, such as hydrogen peroxide or alcohol, should NOT be used.
The nurse is assessing a client admitted with a diagnosis of chronic renal failure. Which finding would the nurse expect to see in the client? 1. Ascites 2. Anorexia 3. Dark skin pigmentation 4. Dependent edema 5. Hypokalemia
2., & 4. Correct: The client will have fatigue from anemia and anorexia from toxins. Fluid volume excess leads to edematous extremities. 1. Incorrect: Ascites is seen with liver failure or cancer. 3. Incorrect: The client may have an uremic frost not dark skin pigmentation. 5. Incorrect: Hyperkalemia can be caused by reduced renal excretion or excessive intake.
A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? 1. Daily strenuous exercise 2. DASH diet 3. Maintaining a BMI less than 25 kg/m2 4. Managing diabetes 5. Use of anti-embolic stockings
2., 3., & 4. Correct: Senior clients are at increased risk for peripheral artery disease for a variety of reasons, though many erroneously believe that this process is an unavoidable part of the aging process. Educating clients on preventative activities will help reduce incidence of atherosclerosis and improved mobility along with quality of life. Managing hypertension is essential. One way to do this is to follow the DASH diet. Reduce caloric intake to achieve a body mass index of 18.5 to 24.9 hg/m2. Poorly managed diabetes leads to vessel damage. 1. Incorrect: Clients can increase collateral circulation with a moderate exercise program of at least 30 minutes three times a week. 5. Incorrect: Anti-embolic stockings are ordered to improve venous return in clients with restricted or limited mobility.
A client has sublingual (SL) nitroglycerin prn added to the medication regimen. Which statement made by the client indicates to the nurse that further teaching is needed? 1. "I will take this medication if I have an episode of chest pain." 2. "I will wait at least 1 hour after I take my erection agent before using Nitroglycerin." 3. "I can take up to 3 tablets every 10 minutes if my angina occurs." 4. "I know that I must put this tablet under my tongue for it to work." 5. "I will keep my medication handy, in a pocket."
2., 3., & 5. Correct: These statements are not correct and indicate that further teaching is needed. Nitroglycerin should not be used with erection agents, as extreme hypotension may occur. Take one tablet every 5 minutes x 3 doses. Nitroglycerin should be keep in a cool, dark place. 1. Incorrect: This is a true statement and indicates that the client understands teaching. Nitroglycerin should be used for chest pain. 4. Incorrect: This is a true statement and indicates that the client understands teaching. For sublingual administration the medication should be placed under the tongue.
A nurse, planning an educational seminar on chronic kidney disease, would invite clients with which medical conditions? 1. Cystitis 2. Hyperlipidemia 3. Obesity 4. Polycystic kidney disease 5. Nephrotic syndrome
2., 3., 4 & 5. Correct: Polycystic kidney disease is a genetic condition that causes damage to the kidneys. Clients with diabetes and hypertension make up more than 67% of clients diagnosed with chronic kidney disease. Glomerulonephritis damages the kidneys and can lead to permanent damage. 1. Incorrect: Cystitis is an inflammation of the bladder. Inflammation is where part of your body becomes irritated, red, or swollen. In most cases, the cause of cystitis is a urinary tract infection (UTI).Acute UTIs do not generally lead to chronic kidney disease.
The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? Exhibit Cardiac Strip: 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine
3. Correct: Although the rhythm strip looks like ventricular fibrillation, you must first check the client. Assess for consciousness, airway, breathing, circulation first. 1. Incorrect: Assess the client first. Do not rely on the strip alone. It may be artifact. If there is no pulse, then you defibrillate. 2. Incorrect: Assess the client first. Defibrillate, then CPR. 4. Incorrect: While CPR is in progress after defibrillation, start IV, if one is not available, then give lidocaine.
A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.
3. Correct: With mass casualties, community response teams are needed. 1. Incorrect: This would be the second step so that further injuries are not encountered. 2. Incorrect: Triage must occur before treatment of anyone so that an accurate assessment of level of injuries can be made. With mass casualties, a color tag system is usually implemented. 4. Incorrect: This would be the third step.
When an explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention? 1. An elderly adult with a traumatic left eye enucleation. 2. A child with an open, compound fracture of the femur. 3. An adult with a head laceration bleeding profusely. 4. An adolescent with a rigid, board-like lower abdomen.
4. CORRECT: This client's symptoms indicate the presence of internal bleeding. Without emergency surgery, this client will quickly develop hypovolemic shock and may not survive. 1. INCORRECT: This client has lost the left eye due to trauma. Despite the fact that this client is elderly and may have other comorbidities, the eye injury is not considered life-threatening. 2. INCORRECT: A fractured femur can lead to other issues, such as blood loss or fat emboli; however, even an open, compound fracture is not considered the most life-threatening injury here. 3. INCORRECT: Lacerations of the face, head or hands generally do bleed profusely because the vessels are near the surface of the skin. However, this represents capillary blood and is not critical.
A home health nurse is educating a client about home care considerations for clean intermittent catheterization. Which statement made by the client would indicate to the nurse that teaching was successful? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will discard the catheter after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done when I feel the need to void."
4. Correct: Catheterization is done when the client feels the need to void, but cannot void. 1. Incorrect: First of all, with intermittent catheterization, you do not have a bag with tubing. There is no tubing to secure. 2. Incorrect: For intermittent catheterization in the home, the client should follow clean technique. Wash catheters thoroughly with soap and water after use, dry, and store in a clean place. 3. Incorrect: With intermittent catheterization there is typically no drainage bag, unless it is a temporary collection bag. Therefore, the bag would not be maintained at a certain level.
A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective?y 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.
4. Correct: This answer provides visible proof that the renal calculi has been broken up by the shock waves. 1. Incorrect: Pain can occur because of spasm of smooth muscle when the stone is moving. 2. Incorrect: There will be blood in the urine for several days after treatment. 3. Incorrect: Blocked urine flow from stone fragments may cause decreased urine output.