Exam 2 H&I pre and post test

The nurse is instructing a 28-year-old married female with a urinary tract infection how to prevent UTI's. Which statement indicates a lack of understanding of this teaching? -"I will empty my bladder regularly even if I don't have the urge to go. -"I will drink 2 liters of fluid every day." -"I will drink cranberry juice daily in attempt to decrease the number of bacteria in my bladder." - "It's okay to soak in the tub with a bubble bath to make sure I am properly cleaned."

- "It's okay to soak in the tub with a bubble bath to make sure I am properly cleaned."

A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? -"You must clean around your catheter daily with soap and water." - "You might want to get pants with elastic waistbands." -"Operations to repair your bladder are available, and you can consider these." -"You will need to be on your drug therapy for life."

- "You might want to get pants with elastic waistbands."

A nurse teaches a patient who is at risk for fecal impaction. Which statements would the nurse include in this patient's teaching? -"Drink prune juice to stimulate peristalsis." -"Take Metamucil or other bulk-forming products." -"Take a laxative every evening to improve motility." -"Eat a high-fiber diet including raw fruits and vegetables."

-"Eat a high-fiber diet including raw fruits and vegetables."

The nurse is teaching a new nursing assistant about caring for older adults and sensory perception. Which statement should the nurse include in this teaching? -"You always need to check for earwax." -"Face the client when you are talking to them." -"Stand over the client and talk down to them." -"Assess the client's hearing with the whisper test."

-"Face the client when you are talking to them."

A 60-year-old woman was admitted this morning with vomiting and pain in the midabdominal region related to a bowel obstruction. The dietary department delivers a regular lunch food tray and asks if you could take it into the room. Which response is most appropriate? -"Thank you so much. She needs her nutrition." -"I don't think this tray was ordered for her. I will double check the physician's orders." -"That's the wrong consistency, she needs soft foods only." -"I will give her only the liquids from the tray."

-"I don't think this tray was ordered for her. I will double check the physician's orders."

A nurse is teaching home safety to the family of a client with Alzheimer's disease. The client has begun wandering around the house at night. Which of the following statements made by the family indicates an understanding of the teaching? -"I will make sure he knows his address in case he wanders outside" ​ -"I will place restraints to remind him not to get out of bed." ​ -"I will keep the room dark at night to improve sleep." ​ -"I have new locks at the tops of all outside doors." ​

-"I have new locks at the tops of all outside doors." ​

A mother tells the nurse she is concerned because her 8-month-old infant sleeps all day and night and is only awake about 2-3 hours per day. What is the nurse's best response? -"Be sure you are laying the child on his back to sleep at night." - "This sleep pattern is very normal for an infant at this age." -"I recommend that you notify the child's pediatrician." -"Adding an additional feeding will keep the child awake more."

-"I recommend that you notify the child's pediatrician."

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statements made by the client indicate an understanding of the instructions? Select all that apply. -"I will limit my total intake of fluids." -"I shall try to lose about 10% of my body weight." -"I must avoid drinking alcoholic beverages." -"I must avoid drinking caffeinated beverages."

-"I shall try to lose about 10% of my body weight." -"I must avoid drinking alcoholic beverages." -"I must avoid drinking caffeinated beverages."

A nurse cares for a patient who is scheduled for the surgical creation of a Urostomy. The patient is anxious, stating "what is it like to have this?" How would the nurse respond? -"I will ask the Ostomy nurse to see you." -"I will ask the provider to prescribe you an anti-anxiety medication." -"Would you like to discuss the procedure with your doctor once more?" -"I think it would be nice to not have to worry about finding a bathroom."

-"I will ask the Ostomy nurse to see you."

A patient was recently discharged from the hospital after having sepsis. She wonders why she remains fatigued one week later. The nurse provides instructions to lessen the fatigue. Which of the following statements should the nurse identify as an indication that the client understands the instructions? -"I will increase my sleep to 12 hours per day." -"I will increase my caffeine intake." -"I will walk 30 minutes a day." -"I will eat more carbohydrates to improve the fatigue."

-"I will walk 30 minutes a day."

A patient asks why it is so important for oral care to be completed at least twice a day. What is the nurse's best response? -"Oral care is important to all of our clients." -"It keeps the bacteria in the oral cavity under control to prevent infection" -"Oral care is performed mostly for the client's comfort." -"Cleaning the surface of the teeth will prevent discoloration."

-"It keeps the bacteria in the oral cavity under control to prevent infection"

A patient who was diagnosed with dementia has become incontinent of urine. When the patient's daughter asks the nurse why this is happening. What is the nurse's best response? -"The brain doesn't send the message for the need to urinate." -"She is uncooperative because of the dementia." -"She is angry about the dementia diagnosis." -"She doesn't want to use the commode because it is unfamiliar."

-"The brain doesn't send the message for the need to urinate."

The nurse assesses a client in the emergency room who presents with lower abdominal bladder distention. Which question would the nurse ask first? -"Have you tried laxatives or enemas?" -"Are you drinking plenty of water?" -"What medications are you taking?" -"When was the last time you voided?"

-"When was the last time you voided?"

The nurse is caring for a client with urinary incontinence. The client states, "I am so embarrassed. I'm just like a baby." How would the nurse respond? -"More people experience incontinence than you might think." -"Incontinence pads will minimize leaks in public." -"I understand how you feel. I would be mortified." -"Would you like me to teach you strategies to help control your incontinence?"

-"Would you like me to teach you strategies to help control your incontinence?"

The nurse recognizes that which patients are at highest risk for physiologic fatigue? (Select all that apply.) -25-year-old pregnant female -Parents of a newborn -Businessman who consumes six cups coffee/day -Grandmother who takes half mile walks -Adolescent with anorexia

-25-year-old pregnant female -Parents of a newborn -Businessman who consumes six cups coffee/day -Adolescent with anorexia

When assessing patients for pressure injuries, which of the following patients is at greatest risk? -A 26 year old with a fractured leg from a motor vehicle accident -A 44 year old with pneumonia -A 65 year old with a stroke and incontinence -78 year old requiring assistance to ambulate with a walker

-A 65 year old with a stroke and incontinence

Which client is at greatest risk for developing delirium? -A 59-year-old man with a history of heart disease who just had surgery. -A 70-year-old woman just admitted to the hospital for pneumonia who has a history of dementia. -A 65-year-old man taking opioid analgesics for pain after a motor vehicle accident. -A 10-year-old child on the pediatric floor who has a Foley catheter in place.

-A 70-year-old woman just admitted to the hospital for pneumonia who has a history of dementia.

Which client would benefit most from anticholinergic medications? -A client who is pregnant and leaking urine. -A client with pelvic floor weakness and stress incontinence. -A client with prostate issues and a distended bladder. -A client with constipation and a history of fecal impaction.

-A client with pelvic floor weakness and stress incontinence.

Which statement best describes the assessment data associated with late hypothermia? -A late sign of hypothermia is flushed diaphoretic skin. -A late sign of hypothermia is confusion, stupor and coma. -A last sign of hypothermia is delirium and shivering. -A late sign of hypothermia is skin that is cool, slowed capillary refill.

-A late sign of hypothermia is confusion, stupor and coma.

The heat index is well over 100 degrees Fahrenheit and the emergency room has several patients with heat-related injuries. Which patient should be seen first? -A homeless person looking for a cool place to stay. -A marathon runner with altered muscle coordination, confusion and hot dry skin. -An obese adult whose air conditioner is not working. -An older adult with dizziness after watching a parade.

-A marathon runner with altered muscle coordination, confusion and hot dry skin.

Which of the following clinical manifestations are associated with small bowel obstruction? Select all that apply. -Non-distended abdomen -Abnormal electrolyte values -Vomiting -High pitched bowel sounds

-Abnormal electrolyte values -Vomiting -High pitched bowel sounds

How can nurses make it easier for a patient who wants to sleep in the hospital setting? Select all that apply. -Address pain issues -Put a sign on the door "do not disturb." -Close the drapes during the evening and nighttime hours. -Cluster nursing duties.

-Address pain issues -Put a sign on the door "do not disturb." -Close the drapes during the evening and nighttime hours. -Cluster nursing duties.

Which actions should the nurse implement when caring for a client with a Stage 4 pressure wound on the leg? -Administer analgesics before wound care. -Position the leg below the level of the heart. -Cleanse the wound with antibacterial soap daily. -Maintain a dry wound.

-Administer analgesics before wound care.

A hospitalized child with an infection has a fever. Which actions by the nurse help to promote the child's comfort? Select all that apply. -Place ice bags in the armpits and groin. -Administer antipyretics for comfort as needed. -Change the child's gown when it becomes damp. -Sponge bath the child with rubbing alcohol

-Administer antipyretics for comfort as needed. -Change the child's gown when it becomes damp.

A patient is admitted for heatstroke. Which intervention should the nurse include in the patient's plan of care? -Administer ibuprofen -Adminster intravenous solution of sodium chloride. -Cool patient rapidly -Administer aspirin

-Adminster intravenous solution of sodium chloride.

What type of dressing is needed for a wound with a stage 3 pressure injury with a large amount of exudate? -An absorbent dressing -Tegaderm (transparent dressing) -Use a large bandaid -Wet to dry saline gauze dressing changes

-An absorbent dressing

A nurse in a long-term care facility is caring for a client with Alzheimer's disease who says she saw a little child under the bed, when clearly there was no little child under her bed. How should the nurse respond? -Explain to the client she needs her eyes rechecked. ​ -Ask the client about her past to distract her from what she believes she's seeing. ​ -State clearly you do not see the child under the bed. ​ -Verify you see the child is under the bed, although you do not actually see it. ​

-Ask the client about her past to distract her from what she believes she's seeing.

A nurse assesses an older client who has a rash on both hands and complains of itching. Which action should the nurse take? -Apply moisterizing lotion -Apply gloves to minimize friction -Ask the patient what they were doing when they developed the rash. -Administer an antihistamine

-Ask the patient what they were doing when they developed the rash.

What actions by the nurse are considered best practices? Select all that apply. -Assess for pain. -Consult with the Dietician. -Consider wound vac for wounds .that have lots of drainage. -Consult with the wound nurse for therapies that are not promoting healing. -Soak wounds to remove dead tissue. -Cleanse around the wound with normal saline

-Assess for pain. -Consult with the Dietician. -Consider wound vac for wounds .that have lots of drainage. -Consult with the wound nurse for therapies that are not promoting healing. -Cleanse around the wound with normal saline

A nurse assesses a patient with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the patient reports constant abdominal pain. Which action would the nurse take next? -Administer intravenous opioid medications. -Insert a nasogastric tube for decompression. -Assess the patient's bowel sounds. -Position the patient with knees to chest.

-Assess the patient's bowel sounds.

A nurse is caring for a client whose Braden scale score indicates a high risk for skin breakdown. Which interventions are evidence-based practices (EBP) to prevent or treat skin breakdown? Select all that apply. -Assess the skin at daily -Keep the head of bed elevated -Perform perineal cleansing every 2 hours -Request a referral to a nutritionist -Use barrier cream for incontinence

-Assess the skin at daily -Perform perineal cleansing every 2 hours -Request a referral to a nutritionist -Use barrier cream for incontinence

Which nursing intervention would be most appropriate to meet safety needs when caring for an older adult with sensory change? ​ -Massage with additional pressure because perception is diminished. ​ -Use care when administering an injection because older adults experience more pain. ​ -Assist with preparing a bath because the client may be less able to feel the temperature. ​ -Use minimal touch with an older adult because touch may feel uncomfortable. ​

-Assist with preparing a bath because the client may be less able to feel the temperature. ​

The nurse is caring for a 72-year-old patient who is incontinent and has a stage 2 pressure ulcer. Which of the following interventions can the nurse delegate to the aid? -Assisting the patient to the commode every two hours. -Documenting the skin assessment. -Performing a skin assessment. -Evaluating for healing.

-Assisting the patient to the commode every two hours.

Which of the following recommendations should the nurse give to a patient who complains of difficulty sleeping at night? Select all that apply. -Avoid using the bed for anything other than sleep -Avoid smoking -Avoid drinking warm milk before bedtime -Avoid caffeine -Avoid alcohol -Avoid naps

-Avoid using the bed for anything other than sleep -Avoid smoking -Avoid caffeine -Avoid alcohol -Avoid naps

A patient has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this patient? (Select all that apply.) -Be careful not to drop the hearing aid when handling. -Soak the hearing aid in hot water for 20 minutes. -Use a toothpick to clean debris from the device. -Turn the hearing aid off when the patient goes to bed.

-Be careful not to drop the hearing aid when handling. -Use a toothpick to clean debris from the device. -Turn the hearing aid off when the patient goes to bed.

A patient presents to the clinic complaining of sore throat, muscle aches, fever, and fatigue. The patient is diagnosed with Influenza. How would you categorize the fatigue? -Has a chronic cause -Caused by physiologic processes -Caused by a secondary acute condition -Treatment related cause

-Caused by a secondary acute condition

The nurse in Urgent Care has four patients waiting to be seen. Which one should be seen first? -Client who has ringworm infection on the arm. -Client who has gastroenteritis and diarrhea. -Client who has a reaction to the TB skin test -Client who has influenza and reports increased dyspnea

-Client who has influenza and reports increased dyspnea

Which of the following diagnostic test is used to visually examine the large intestine? -Uroscopy -Stool for occult blood -Colonoscopy -Cystoscopy

-Colonoscopy

Which isolation precaution is necessary for a patient with a MRSA infection on the skin? -Droplet Precautions -Airborne Precautions -Contact Precautions -Standard Precautions

-Contact Precautions

The nurse is caring for a patient who has discomfort related to dermatitis. Which of the following is a nonpharmacologic measure that the nurse should implement? -Heating pad -Rub with baby oil -Cool moist compress -Topical corticosteroids

-Cool moist compress

The nurse is concerned he may need surgery on his prostate. Which of the following is a benefit of having laser surgery? -Decreased risk of bleeding -Minimally invasive -Decreases the frequency of urination -Improves urinary flow

-Decreased risk of bleeding -Minimally invasive -Decreases the frequency of urination -Improves urinary flow

A patient was diagnosed with dermatitis after exposure to poison ivy. What interventions should the plan of care focus on? -Preventing infection -Decreasing pruritus -Promoting drying of lesions -Decreasing pain

-Decreasing pruritus

Which of the following is an accurate statement about the differences between dementia and delirium? ​ -Delirium is permanent and dementia is temporary. ​ -Dementia can be caused by infection and delirium is caused by heredity. -Dementia has an early onset and delirium has a late-onset. ​ -Delirium is acute and dementia is chronic. ​

-Delirium is acute and dementia is chronic. ​

A patient has a progressive functional impairment and personality changes. Is this behavior associated with dementia, delirium, or both? -Delirium -No answer text provided. -Both dementia and delirium -Dementia

-Dementia

Which interventions prevent infection in the hospital setting? Select all that apply. -Disinfect all frequently touched surfaces. -Monitor patients white blood cell counts. -Screen all visitors for infection. -Promote adequate nutritional intake.

-Disinfect all frequently touched surfaces. -Monitor patients white blood cell counts. -Screen all visitors for infection. -Promote adequate nutritional intake.

A patient tells the nurse that he experiences daytime fatigue even after 7-8 hours of sleep each night. What is the best assessment question for the nurse to ask? -Do any of your close relatives have any sleep disorders? -Have you tried getting 10 hours of sleep instead of 8 hours? -Do you also have any recent lifestyle or behavior changes? -How long are you in the rapid eye movement (REM) stage?

-Do you also have any recent lifestyle or behavior changes?

The nurse is teaching community members how to prevent heat-related illnesses. Which of the following statements should the nurse include in the teaching? -Drink plenty of fluids throughout the day. -Wear dark colored clothing. -Use sunscreen with SPF of 8. -Check with the older adult daily in hot weather. -Take cool baths or showers after outdoor activities.

-Drink plenty of fluids throughout the day.-Check with the older adult daily in hot weather. -Take cool baths or showers after outdoor activities.

A six-year-old child visiting primary care complains of abdominal pain. The mother states he hasn't had a bowel movement for about a week. Which of the following patient instructions are appropriate? Select all that apply. -Drink plenty of fluids with a high fiber diet -Stimulant laxatives should be used daily -Miralax can be given if needed to children -Encourage exercise

-Drink plenty of fluids with a high fiber diet -Miralax can be given if needed to children -Encourage exercise

A patient has cellulitis on the right forearm. The nurse should anticipate which of the following orders? Select all that apply. -Elevate right forearm above the level of the heart. -Limit use of antipyretics. -Administer antibiotics as prescribed. -Notify physician for increased area of redness, swelling and warmth.

-Elevate right forearm above the level of the heart. -Administer antibiotics as prescribed. -Notify physician for increased area of redness, swelling and warmth.

A 90-year-old patient is hospitalized with a history of 10 liquid stools per day for 3 days in a row. What is the priority nursing concept to consider when planning interventions? -Tissue Integrity -Pain -Elimination -Nutrition

-Elimination

Which of the following clinical symptoms are not associated with an enlarged prostate? -Enuresis -Weak stream -Nocturia -Frequently urinating small amounts

-Enuresis

Napping for hours all day will improve long-term care residents' nighttime sleeping. -True -False

-False

Taking naps helps older adults maintain good sleep hygiene. -True -False

-False

A client on antibiotics develops diarrhea three times a day for three days. Which action by the nurse is most important? -Notify the provider and recommend Imodium. -Delegate skin care to the nursing assistant. -Place the client on NPO until the diarrhea resolves. -Notify the provider and recommend stool cultures.

-Notify the provider and recommend stool cultures.

A 76-year-old woman with Alzheimer's disease was admitted to a memory care facility after falling at home. The family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only 2-3 hours a night. Which interventions would help her to function at the highest level possible? Select all that apply. -Vary the timing of day-to-day activities. -Furnishing her room with familiar possessions. -Reducing overstimulation. -Encourage her to perform cognitive skills above her level of ability. -Having her take part in activities that distract her. -Avoid unfamiliar situations whenever possible.

-Furnishing her room with familiar possessions. -Reducing overstimulation. -Having her take part in activities that distract her. -Avoid unfamiliar situations whenever possible.

A client has been diagnosed with C-difficile. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the patient? -Gloves -Goggles -Gown -Surgical face mask -Shoe covers -N95 respirator

-Gloves -Gown

Which action by the infection control nurse would be most effective in reducing the incidence of health care associated infections? -Require full PPE before entering each patient room. -Have hand sanitizer available inside and outside every patient room. -Screen all patients for MRSA. -Develop a policy on antibiotic therapy.

-Have hand sanitizer available inside and outside every patient room.

A nurse is teaching older adults at a senior center about changes to the ears that occur with aging. What instruction would the nurse include? (Select all that apply.) -All adults may have some degree of hearing loss. -Hearing function may be reduced because cerumen is drier and impacts more easily. -Use cotton swabs to clean the ears or remove cerumen. -Hearing aids can contribute to cerumen impaction.

-Hearing function may be reduced because cerumen is drier and impacts more easily. -Hearing aids can contribute to cerumen impaction.

The nurse is caring for an adult client who is diagnosed with a urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply.) -Fever -Hematuria -Burning with urination -Frequency -Dysuria -Chills

-Hematuria -Burning with urination -Frequency -Dysuria

The nurse caring for patients understands which factors must be present to transmit infection? Select all that apply. -Host -Reservoir -Poor hygiene -Colonization -Mode of transmission -Portal of entry

-Host -Reservoir -Portal of entry

The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? -What type of incontinence pads to use? -What types of liquids to drink and when? -Need to perform intermittent catheterizations. -How to do Kegel exercises to strengthen muscles?

-How to do Kegel exercises to strengthen muscles?

A truck driver routinely refuses to stop to use the restroom on his route. Which of the following is the most serious complication associated with intentionally holding urine? -Hydronephrosis -Loss of urine when sneezing -Bladder incontinence -Delay in urine flow

-Hydronephrosis

A nurse witnesses a client with dementia eat breakfast. Afterward, the client states, "I am hungry and want breakfast." How would the nurse respond? -"Your family will be here soon. Let's get you dressed." -"It appears you are confused this morning." -I see you are still hungry. I will get you some toast." -"You ate your breakfast 30 minutes ago."

-I see you are still hungry. I will get you some toast."

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? Select all that apply. -Increase fiber intake -Refrain from smoking -Increase water consumption. -Refrain from alcohol.

-Increase fiber intake

A nurse is caring for a client who has a nonhealing pressure injury. Which assessment finding indicates the wound is a nonhealing? -Decreased in the depth of the wound. -Patient is requesting pain medication. -Increased size in the length and width of the wound -Color of the wound is red and beefy

-Increased size in the length and width of the wound

Which patient population is at greatest risk of life-threatening complications from diarrhea? -School age child -Older adult -Adult -Infant

-Infant

Which of the following clinical manifestations are associated with glaucoma? -Loss of peripheral vision -Cloudy central vision -Eye itching -Increased depth perception

-Loss of peripheral vision

A nurse plans care for an older adult patient. Which interventions should the nurse include in this client's plan of care to promote urinary health? (Select all that apply.) -Make sure the call light is within the patient's reach. -Encourage use of the toilet every 1-2 hours. -Assess for urinary retention and urinary tract infection. -Leave the bathroom light on at night. -Ensure adequate fluid intake. -Provide thorough perineal care after each voiding. -Request indwelling catheter placement for incontinence.

-Make sure the call light is within the patient's reach. -Encourage use of the toilet every 1-2 hours. -Assess for urinary retention and urinary tract infection. -Leave the bathroom light on at night. -Ensure adequate fluid intake. -Provide thorough perineal care after each voiding.

The nurse is caring for a post-surgical patient who is being discharged with antibiotics, oral opioid analgesics, and stool softeners. Which of the following is important to include in the discharge instructions? -Monitor for both constipation and diarrhea -Take a laxative if constipated -Decrease fluid intake -Maintain a low fiber diet

-Monitor for both constipation and diarrhea

A hospitalized patient is on Contact Precautions for MRSA. The physician ordered a CT scan. What action by the nurse is most appropriate? -Notify the physician the patient cannot leave the room. -Have the aid go with the patient to the CT scan. -No special precautions are needed when this patient leaves the unit. -Notify the CT scan staff of the isolation precautions

-Notify the CT scan staff of the isolation precautions

A client is admitted with possible sepsis. Which action should the nurse perform first? -Obtain specified cultures -Place the patient in isolation -Administer antibiotics -Give an antipyretic

-Obtain specified cultures

Which of the following statements is true about fever? -Those individuals who are immunocompromised are most likely to develop a fever. -Younger children are less likely to develop a fever when ill. -Adults are likely to have a fever with every infection. -Older adults are less likely to develop a fever when ill.

-Older adults are less likely to develop a fever when ill.

A student asks the nurse why older adults have a greater risk to getting Covid infection than other adults. Which explanation is accurate? Select all that apply. -Older adults have a decrease in immune function. -Older adults have decreased cough and gag reflexes. -Older adults are less likely to wear a mask. -Older adults have a higher rate of chronic illnesses, placing them at greater risk.

-Older adults have a decrease in immune function. -Older adults have decreased cough and gag reflexes. -Older adults have a higher rate of chronic illnesses, placing them at greater risk.

The nurse instructs a 55 year old male patient at a routine physical the importance of guaiac testing. Which of the following situations require guaiac testing of the stool? -Per routine to screen for colon cancer -When the patient complains of rectal bleeding -When there is a palpable mass on digital rectal examination. -When the patient says there is a history of polyps

-Per routine to screen for colon cancer

The nurse is caring for a client in long term care who has been receiving antibiotics for a urinary tract infection. The client complains of watery, odorous diarrhea. What interventions does the nurse anticipate for this client? Select all that apply. -Place the client on contact isolation. -Monitor for signs of dehydration. -Wash hands thoroughly with hand sanitizer. -Insert a catheter to obtain another urine specimen. -Push fluids.

-Place the client on contact isolation. -Monitor for signs of dehydration. -Push Fluids.

The most common causes of delirium for an older person include (select all that apply): -Pneumonia -Recent hip fracture -Air pollution -Foley catheter -Anticholinergic medications -Opioid analgesic medications -Urinary tract infection -Being placed in a new environment

-Pneumonia -Recent hip fracture -Foley catheter -Anticholinergic medications -Opioid analgesic medications -Urinary tract infection -Being placed in a new environment

Which of the following are risk factors for UTI. Select all that apply. -Postmenopausal women -Older age -Dehydration -Female -Indwelling catheter placement -Patient's who wipe from back to front after toileting -History of sexually transmitted disease at a young age

-Postmenopausal women -Older age -Dehydration -Female -Indwelling catheter placement -Patient's who wipe from back to front after toileting

Which of the following conditions or persons are at greatest risk for impaired sleep? Select all that apply. -Pregnant women -Caregivers -A nurse who works days one week and nights the next. -Older adults with chronic conditions. -Truck drivers who cross multiple time zones. -Women with hot flashes

-Pregnant women -Caregivers -A nurse who works days one week and nights the next. -Older adults with chronic conditions. -Truck drivers who cross multiple time zones. -Women with hot flashes

Which of the following have the potential to affect bowel elimination? Select all that apply. -Privacy -Anticholinergic medications -Neuromuscular disorders -Exercise -Age -Surgery -Fiber intake

-Privacy -Anticholinergic medications -Neuromuscular disorders -Exercise -Age -Surgery -Fiber intake

A patient in urgent care is diagnosed with a corneal abrasion sustained while at work. Which of the following is the most important thing for the nurse to stress when giving patient instructions? -Know where the emergency wash stations are located at work. -Have a first aid kit available in your locker. -Workplace policies for handling chemicals should be followed. -Protective eye wear should always be worn.

-Protective eye wear should always be worn.

Which are treatment related causes of fatigue? (Select all that apply.) -Radiation therapy -Side effects of medications -Surgery -Chemotherapy -Blood transfusion

-Radiation therapy -Side effects of medications -Surgery -Chemotherapy

The nurse must awaken a patient from Stage 4 non-rapid eye movement sleep in order to prepare the patient for a procedure. The patient is disoriented. What is the nurse's best action? -Notify the healthcare provider. -Re-assess the patient's orientation. -Cancel the patient's procedure. -Administer an anti-anxiety medication.

-Re-assess the patient's orientation.

The nurse is caring for a client who is prescribed habit training to manage incontinence. Which of the following interventions should the nurse implement? Select all that apply. -Recording the client's incontinence episodes -Toileting the client after breakfast -Making sure the client has an incontinence brief on when they wake up each day. -Encouraging the client to drink fluids

-Recording the client's incontinence episodes -Toileting the client after breakfast -Encouraging the client to drink fluids

Which of the following is true about sleep for toddlers and preschoolers? -Enter REM sleep immediately. -Require approximately 8 hours of sleep a night. -Their normal biologic pattern is to sleep later and wake later than previously. -Require approximately 12 hours of sleep a night.

-Require approximately 12 hours of sleep a night.

A 76-year-old woman with Alzheimer's disease was admitted to a memory care facility after falling at home. The family states she has a history of dementia with wandering and cannot be trusted alone. On the first few days, she is restless and agitated, sleeping only 2-3 hours a night. As you develop a plan for her care, which of the following has the highest priority? -Elimination -Safety -Chronic confusion -Impaired communication

-Safety

Which of the following statements about elimination across the lifespan are true? Select all that apply. -Newborns are at high risk for constipation. -School aged children who have a busy schedule will often forget to use the bathroom. -The risk for functional incontinence increases with age because of slowed peristalsis. -Older adults have a greater risk for constipation due to medications. -Constipation is common with pregnancy due to the elevated progesterone. -Older male adults are more likely to develop benign prostatic hyperplasia.

-School aged children who have a busy schedule will often forget to use the bathroom. -Older adults have a greater risk for constipation due to medications. -Constipation is common with pregnancy due to the elevated progesterone. -Older male adults are more likely to develop benign prostatic hyperplasia.

A nurse cares for a patient who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? Select all that apply. -Serum potassium of 2.8 mEq/L (low) -Loss of 15 lb (6.8 kg) without dieting. -Low-pitched bowel sounds -Abdominal pain in upper quadrants.

-Serum potassium of 2.8 mEq/L (low) -Abdominal pain in upper quadrants.

A patient has been placed on Contact Precautions. The client's family is very afraid to visit, for fear of "catching something" from the patient. What action by the nurse is best? -Show the family how to perform hand hygiene and use isolation precautions. -Tell the family they will never get the infection. -Tell the family how depressed the patient is without seeing them. -Explain how isolation precautions are mandated by law.

-Show the family how to perform hand hygiene and use isolation precautions.

Which of the following is the most important barrier to infection? -Skin and mucous membranes -Inflammatory process -Gastrointestinal secretions -Colonization by host bacteria

-Skin and mucous membranes

Which of the following are used to determine the risk for Obstructive Sleep Apnea (OSA) prior to surgery using the STOPBANG questionnaire? Select all that apply. -Snoring -Daytime tiredness -Gender- female -Neck circumference larger than 40 cm -Bed partner observes the patient stop breathing -History of hypertension

-Snoring -Daytime tiredness -Neck circumference larger than 40 cm -Bed partner observes the patient stop breathing -History of hypertension

Which of the following interventions help to improve communication with the resident with dementia? -Speak clearly and calmly to the resident. -Give long explanations with a lot of detail to the resident. -Keep the television on all day to help reorient them. -Ask questions while the resident is completing a task.

-Speak clearly and calmly to the resident.

The nurse enters a patient's room and the patient startles easily and appears to jerk his arms and legs before awakening. Which stage of non-rapid eye movement sleep did the patient most likely awaken from? -Stage 4 -Stage 1 -Stage 3 -Stage 2

-Stage 1

Which description best matches the type of pressure injury? -Stage 4: wound is obscured with eschar or slough -Stage 2: may have visible adipose tissue and slough. -Stage 1: nonblanchable tissue -Stage 3: may have a pink or red wound bed.

-Stage 1: nonblanchable tissue

The nurse is making rounds on the hospital unit and observes a patient sleeping. The patient's pulse and respiratory rates are slower than baseline. The nurse realizes the patient has most likely just entered which stage of non-rapid eye movement sleep? -Stage 3 -Stage 2 -Stage 4 -Stage 1

-Stage 2

The nurse is caring for a client with functional urinary incontinence. Which of the following are appropriate for this client's condition? Select all that apply. -Teach the patient the importance of having a commode near in the bedroom. -Timed toileting practices. -Discuss the side effects of antispasmodic medications. -Avoid drinking more than 2 liters/day.

-Teach the patient the importance of having a commode near in the bedroom. -Timed toileting practices.

A parent brings their child to urgent care with complaints of abdominal pain and hard stools. Which of the following place the child at risk for constipation? Select all that apply. -The child doesn't like to take a shower. -The child is engaged in after school sports. -The child has food preferences that don't include high fiber. -The child likes to go to bed early and wake up early.

-The child is engaged in after school sports. -The child has food preferences that don't include high fiber.

A client is disoriented to person, place, and time. Which of the following observations made by the nurse indicate the client is experiencing delirium? -The confusion began 5 months ago. -The client's pupils are 4mm in diameter and respond equally to light. ​ -The client has disorganized thinking. -The client remains awake and alert.

-The client has disorganized thinking.

The nurse recognizes which of the following patients require a "fracture bed pan" for having a bowel movement? -The confused patient -The patient who is obese -The patient recovering from hip surgery -The patient who is undernourished

-The patient who is obese

What is the best goal for a patient with obstructive sleep apnea? -The patient's duration of restorative sleep increases from 6 to 8 hours. -The patient has a blood pressure of 160/80 -The patient can teach back the purpose of surgical management. -The patient's body mass index is at 37

-The patient's duration of restorative sleep increases from 6 to 8 hours.

What happens during the sleep cycle? -Immune response is suppressed. -The restoration of brain tissue occurs. -Muscles become tense. -Regulation of electrolytes occurs.

-The restoration of brain tissue occurs.

A client has a wound that is healing by secondary intention. Which statement best describes this type of wound? -The wound was stapled together after an infection was cleared up. -The wound is contaminated with debris and can't be closed at all. -Wound edges are well approximated and stitched together. -The wound is in an open cavity that will fill with granulation tissue.

-The wound is in an open cavity that will fill with granulation tissue.

The nurse working in memory care is caring for a patient with dementia who has periodic episodes of incontinence of the bowel and bladder. Which of the following interventions should the nurse implement? -Establish a bedtime ritual for the patient. -Speak with the patient's family about food choices. -Toilet the patient upon waking, at bedtime, after meals and every two hours, even if they have incontinent episodes. -Speak with the family about past elimination habits.

-Toilet the patient upon waking, at bedtime, after meals and every two hours, even if they have incontinent episodes.

A patient with cancer presents to the clinic complaining of nausea, weakness, and fatigue only after receiving chemotherapy. How would you categorize the fatigue? -Caused by physiologic processes -Has a chronic cause -Treatment related cause -Caused by a secondary acute condition

-Treatment related cause

For older adults, it is best to have a bedtime ritual. -True -False

-True

A nurse plans care for a patient who has chronic diarrhea. Which actions would the nurse include in this patient's plan of care? Select all that apply. -Keeping broken skin areas open to air to promote healing. -Turning the patient from right to left every 2 hours -Using pre-moistened disposable wipes for perineal care -Using an antibacterial soap to clean periarea after each stool. -Applying a barrier cream to the skin after cleaning.

-Turning the patient from right to left every 2 hours -Using pre-moistened disposable wipes for perineal care -Applying a barrier cream to the skin after cleaning.

A client reports needing to find the bathroom quickly or she will dribble urine. Which condition should the nurse consider that the client is experiencing? -Enuresis -Dysuria -Polyuria -Urgency

-Urgency

A nurse plans care for several patients who are immobile. Which interventions should the nurse include to prevent pressure injuries for this group of patients? Select all that apply. -Use a lift sheet to prevent shearing -Use a "donut" in the chair -Ask the patient to "off load" their weight while sitting in the chair. -Place a pillow under the calfs to elevate the heels. -Limit fluids and protein in the diet.

-Use a lift sheet to prevent shearing -Ask the patient to "off load" their weight while sitting in the chair. -Place a pillow under the calfs to elevate the heels.

The nurse working in-home care is giving patient teaching on safety to the older diabetic client. Which of the following instructions should the nurse include? Select all that apply. -Inspect the feet once a month -Use adaptive devices as needed. -Place cold fingers in hot water to warm them. -Wearing proper foot wear will reduce the risk of trauma.

-Use adaptive devices as needed. -Wearing proper foot wear will reduce the risk of trauma.

A nurse cares for a client who has dementia from Alzheimer's disease. Which communication techniques would the nurse implement? (Select all that apply.) -Use pictures when giving instructions -Provide multiple choices -Provide gestures when speaking -Validate client feelings -Ask open-ended questions

-Use pictures when giving instructions -Provide gestures when speaking -Validate client feelings

A patient has a sacral ulcer that is 4 x 2 x 5 cm. Which dressing is most appropriate for this wound? -Alginate -Wet to dry dressing -Autolytic debrider -Colloid dressing

-Wet to dry dressing

Which of the following questions is important to ask the newly admitted patient who may have a bowel obstruction? -When was the last time you moved your bowels? -How often do you use stool softeners, laxatives or enemas? -How often do you have a bowel movement? -Describe your bowel movements.

-When was the last time you moved your bowels?

Which of the following are clinical manifestations associated with infection? Select all that apply. -chills -fever -malaise -urine culture with greater than 100,000 colonies per ml of bacteria -lowered white blood cell count

-chills -fever -malaise -urine culture with greater than 100,000 colonies per ml of bacteria

Which clinical manifestation would the patient with dementia exhibit as a sign of infection? -Confusion -Decreased glucose -Pain with urination -Headache

-confusion

Which of the following is a potential cause of constipation for older adults? Select all that apply. -slowed peristalsis -medical conditions -anticholinergics -opioids -gastroenteritis

-slowed peristalsis -medical conditions -anticholinergics -opioids

A client with BPH asks the nurse why he should avoid taking cold medications. These medications should be avoided because they are associated with: -urinary retention -impotence -incidence of bladder cancer -increase in the size of the prostate

-urinary retention