NURS 3280 Final Exam vSim Questions

Which patients have an increased risk for developing colorectal cancer?

-63 year old who is healthy -70 year old diagnosed as obese -30 year old with 13 year history of Crohn's -50 year old who eats meat daily

The nurse is completing documentation following the insertion of an intermittent urinary catheter. What should be included in the documentation?

-Date the procedure was performed -Patient's tolerance to procedure -Size of the catheter -Time procedure was performed

After completing an intermittent catheterization what information concerning the procedure will the nurse include in Ms. Johnsons medical record?

-Description of the patient's tolerance -Characteristics of the urine obtained -Size of catheter used -Time procedure was performed

The nurse is completing an admission assessment on a patient admitted for an infected, non healing wound. What are factors that could contribute to this condition?

-Diabetes mellitus -Obesity -Poor circulation -Poor hygiene

The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. What question would be appropriate for the nurse to ask the patient?

-Have you noticed any swelling on your feet, ankles or fingers -do you have some areas of your skin that seem warmer or colder than others -have you used pads of special pants because you cant control your urine -do you have any sores on your body

Which statements indicate that a patient who recently acquired a colostomy has achieved the outcomes set for regular bowel elimination?

-I've gotten accustomed to drinking at least 2 quarts of water a day -I've learned to implement the techniques I learned in stress management -my routine includes about 30 minutes of daily exercise -I know what I eat has a large impact on my bowel function

When performing an assessment on a wound what should be included in documentation?

-Odor -Location -Drainage -Tunneling

What information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure?

-The scan typically does not cause any pain -The scanner is moved over the patient's lower abdomen -The patient's body is draped to protect privacy

The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history?

-When did the edema start? -Can you describe the edema? -What were you doing just before you noticed the edema? -Do you have a recent history of surgery or illness? -What are your usual daily activities? -Do you stand a lot? -What medications do you take? -Do you have heart disease or blood vessel disease

Which interventions will the nurse implement to help minimize a postoperative patient's risk for surgical site complications?

-advancing diet as appropriate to provide adequate nutrition -monitoring for elevation in body temperature -providing sufficient fluids to maintain hydration -following strict aseptic technique when changing surgical dressing

The nurse is preparing discharge education for a patient with a permanent colostomy. What information concerning diet and nutrition will the nurse include?

-avoid high fiber foods for 8 weeks after surgery -avoid foods tat previously caused diarrhea -gradually add new foods into diet -drink at least 2 quarts of water a day

The nurse has received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patients specimen?

-clarity -odor -sediment -color

The nurse is preparing to catheterize a female patient and is positioning the patient. Which position(s) would be appropriate for this procedure?

-dorsal recumbent -side lying

Which statements will guide the nurse when preparing to educate a patient whose condition requires a permanent colostomy?

-encouraging the patient to take part in the care process -if the patient is accepting, including family members in the teaching -assess the patients for signs of depression -help the patient get accustomed to looking at the ostomy

The nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. What questions would the nurse include when assessing the patient?

-have you noticed any change in your usual voiding pattern? -do you ever leak urine? -how often do you urinate?

Which statements best support the nurse's evaluation that a patient who recently experienced a sigmoid colostomy has begun to accept the body change?

-having a colostomy is a small price to pay for being healthy -my stoma continues to be red and moist -my ostomy nurse always has helpful suggestions about daily routine care -I'm anxious to find a swimsuit that accommodates my colostomy

Which assessment data would the nurse expect to find to support the assumption that Mr. Hayes's surgical incision is in the inflammatory phase of healing?

-incision is slightly edematous -increased white blood cell count -redness surrounding incision -incisional site pain

What information should the nurse include in the documentation associated with the changing of a patient's colostomy pouch?

-patient's response to process -description of stoma -characteristics of fecal matter -condition of the skin around the stoma

Which nursing interventions are implemented primarily to prevent respiratory complications in a patient after abdominal surgery?

-prompting to cough -education on incentive spirometer use -encouraging deep breathing -assisting in early ambulation

Nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the care of plan for this patient?

-provide skin care -monitor for signs of skin breakdown -assist with rang of motion exercises -perform neurovascular checks. -encourage ambulation as tolerated

What information will the nurse include when providing education for a patient who is scheduled for a sigmoid colostomy?

-the term ostomy refers to an opening from the inside of an organ to the outside of the body -when an ostomy is needed, intestinal mucosa is brought through the abdominal wall -a stoma is the portion of intestinal mucosa that is secured to the skin of the abdomen -a healthy stoma is bright red, moist, and rounded

The nurse is recording fluid intake for Ms. Johnson. Which items on the dinner tray should the nurse include when completing this documentation?

-tomato soup -iced tea -ice cream

The nurse is providing discharge education on complications associated with intermittent self catheterization. Which possible complications should the nurse include in the teaching session?

-urinary tract infections -urethral strictures -bladder spasms -bladder perforation

A patient is placed on omeprazole 20 mg daily. When will the nurse administer the medicine?

1 hour before breakfast

The nurse is performing a sterile dressing change. After donning sterile gloves the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time?

Ask the patient to press the call bell to summon a co-worker to obtain another dressing

Which intervention takes priority when a nurse determines that a postoperative patient has hypoactive bowel sounds?

Assess the abdomen for signs of distension

The nurse is providing education to Mr. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing?

Baked Chicken

The nurse is caring for a patient who is unable to urinate voluntarily since a gunshot incident. Patient data associated with which intervention will provide information regarding the client's kidney function?

Daily serum creatinine levels

The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg?

Dark discoloration of the skin surrounding the wound site.

The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed?

Full thickness tissue loss with possible visible subcutaneous fat

The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12?

High risk

The nurse is providing patient education on self cath. What statement indicates need for further teaching?

I can use either an indwelling or intermittent catheter

The nurse is providing Ms Johnson discharge education about intermittent self catheterization. What statement if made by the patient would indicate the need for further instruction?

I should maintain sterile technique throughout the procedure

Nurse is preparing to irrigate a wound. Which statement if made by the nurse indicates an understanding of the procedure?

I will gently direct a stream of fluid into the wound, keeping the syringe tip at least one inch from the upper tip of the wound

Which statement made by the patient indicates an understanding of diet progression after surgery?

I'll start drinking water as soon as the nausea subsides

The nurse has an order to check a patient's post-void residual urine. How would the nurse carry out this order?

Measure the amount of urine in the bladder using a bladder scanner

The need for a sigmoid colostomy is generally a result of cancer at what point in the intestinal tract?

Near the rectum

Nurse is preparing to irrigate a patients wound, upon assessment the wound appears to be healing and the wound bed is beefy red. What solution should the nurse select for this procedure?

Normal saline

Which diagnostic test is used as a screening tool for the possible diagnosis of colon cancer?

Occult blood

A postoperative patient is receiving enoxaparin sodium therapy. Which assessment data would the nurse report immediately to the HCP?

Patient has reported self-medicating with aspirin 3 times since surgery

The nurse is reviewing the patients laboratory results. Which lab test most accurately represent current nutritional status?

Prealbumin- has a shorter half life and is more sensitive measurement of current nutritional status

The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding?

Purulent

Nurse providing education to a patient and daughter on management of venous stasis in the lower extremities. What would be appropriate for the nurse to include in the teaching session?

Put on antiembolism stockings as soon as you get up in the morning and wear them all day

Nurse is irrigating a patients wound when the patient complains of pain what is the appropriate action by the nurse?

Stop the procedure and administer ordered analgesic

Which statement by the nurse indicates a thorough understanding of the purpose of postoperative nursing care?

The goal is to ensure uneventful recovery from surgery

What information will the nurse include when providing education for a patient scheduled for a colostomy as treatment for rectal cancer?

The ostomy will be permanent because of the nature of the illness

Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse?

The procedure helps remove drainage and debris from the wound

The nurse has received an order to apply a hydrocolloid dressing to Mr. Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education?

This dressing will need to be held in place by surgical tape

Ms Johnson asks: why do I need to self-cath at regular interval? What would be the appropriate response by the nurse?

This helps your bladder from becoming overdistended

Ms Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session?

This medication helps reduce bladder spasms

When should the nurse caring for a patient with a new colostomy plan to change the pouching system?

before breakfast

The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse?

call for a coworker to help hold the patients legs in position

While inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. What is the appropriate action by the nurse?

leave the catheter in the vagina as a landmark and begin the procedure again with new supplies

The nurse is caring for a patient experiencing the effects of paraplegia. What urinary condition is associated with this diagnosis?

neurogenic bladder

The nurse has created a sterile field and is preparing to catheterize a patient. While using sterile balls to clean the patient prior to the procedure, the nurse corps a contaminated cotton ball in the middle of the sterile field. What is the correct action of the nurse at this time?

obtain a new catheter kit and restart the process

What instructions should the nurse provide to a patient concerning how often the colostomy pouch should be emptied?

whenever the pouch is 1/3 full of fecal matter