Week 8 HESI quiz

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?

"Wear cotton underpants." Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments.

An infant is admitted to the neonatal intensive care unit with exstrophy of the bladder. What covering should the nurse use to protect the exposed area?

A moist sterile dressing The bladder membrane is exposed; it must remain moist and, as much as possible, sterile.

A 4-year-old child with nephrotic syndrome is admitted to the pediatric unit. What clinical finding does the nurse expect when assessing this child?

Dark, frothy urine This is characteristic of a child with nephrotic syndrome; large amounts of protein in the urine cause it to take this appearance

Which instruction should the nurse provide the client who is concerned about contracting amebic dysentery during foreign travel?

Drink only bottled water. Entamoeba histolytica, the organism that causes amebic dysentery, is transmitted through excreta; bottled water prevents consumption of water that may be contaminated by the causative microorganism.

The nurse observes a client with kidney failure has increased rate and depth of breathing. Which laboratory parameter does the nurse suspect is associated with this client's condition?

Bicarbonate 15 mEq/L An increased rate and depth of breathing is called Kussmaul respiration and occurs due to metabolic acidosis in clients with kidney disease. Serum bicarbonate level decreases in metabolic acidosis. The normal range of serum bicarbonate is 23-30 mEq/L. Therefore the bicarbonate value of 15 mEq/L is associated with Kussmaul respirations in the client.

A client had a colon resection and formation of a colostomy two days ago. Which color indicates to the nurse the stoma is viable?

Brick-red A brick red stoma indicates adequate vascular perfusion. A blue, gray, or dark purple color indicates inadequate perfusion of the stoma.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client

Control of Pain After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs.

An infant has exstrophy of the bladder. What does the nurse anticipate that the primary healthcare provider will prescribe to protect the exposed bladder area?

Sterile nonadherent dressings These help to prevent infection and ulceration of the surrounding skin.

A nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. What is the volume of solution the nurse should prepare?

The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. The nurse should prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.

Which client's urine specific gravity level is abnormal?

1.041 The normal specific gravity of urine lies between 1.005 and 1.030.

The healthcare provider prescribes 1 liter of intravenous (IV) fluid to infuse over 4 hours for a client admitted for a urinary tract infection and hyponatremia. The tubing drop factor is 10 drops/mL. At what rate will the nurse infuse the medications?

42 drops/minute

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare?

500 to 750 mL In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes?

Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool.

A client is admitted to the hospital from the emergency department with a diagnosis of urolithiasis. The nurse reviews the client's clinical record and performs an admission assessment. Which is the priority nursing action?

Administer the prescribed morphine. Pain relief is the priority. Clients report that ureteral colic is excruciatingly painful. Once pain is under control and the client is comfortable, other medical and nursing interventions can be implemented. Although straining all urine is required, pain relief is the priority. Once the client is medicated for pain, the urine that was set aside can be strained.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?

High osmolarity of the feedings The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula.

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings?

Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.

After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention?

Evaluating the client's ability to care for the ileostomy. The client's feelings, knowledge, and skills concerning the ileostomy must be assessed before discharge.

A nurse is caring for an infant with hypertrophic pyloric stenosis. A pyloromyotomy is scheduled. Which pathophysiologic modification must be addressed before this surgery can be performed safely?

Fluid and electrolyte imbalances must be corrected. The risks of surgery are greatly increased unless dehydration and metabolic alkalosis from prolonged vomiting are corrected.

Which organ-specific autoimmune disorder is associated with a client's kidney?

Goodpasture Syndrome (GPS)

A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?

Hemorhage After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the area.

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period?

Keeping the client's skin around the stoma clean. If the area is not kept both clean and dry, drainage from the colostomy can quickly cause a breakdown of the skin around the stoma. This, in combination with a warm, moist surface, predisposes the individual to infection.

A nurse is performing a health history and physical assessment of a client with cholelithiasis and obstructive jaundice. Which clinical finding should the nurse expect this client to exhibit?

Pain in the upper right quadrant. The gallbladder is located in the right upper quadrant. Pain occurs after fatty meals and may radiate to the right back or shoulder. The stool will be clay-colored due to the lack of bile.

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss?

Weighing the child at the same time each day Comparison of daily weights is the most accurate way to assess fluid retention or loss.

Monitoring vital signs, particularly the blood pressure and the rate and quality of the pulse, is essential in detecting physiologic adaptations in a preschool child with nephrotic syndrome. Which clinical manifestation should the nurse be able to detect from these vital signs?

Hypovolemia The shift of fluid from the intravascular to the interstitial compartment predisposes the child to hypovolemia; a weak, thready pulse and hypotension are signs of impending shock.

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis, what should the nurse do?

Instruct the client to empty the bladder Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered.

The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, which strategy should be included in the client's plan of care?

Instructing the client to drink 8 to 10 glasses of water daily. Increasing fluid intake dilutes the urine, and crystals are less likely to coalesce and form calculi.

A client who has been diagnosed with a myocardial infarction is receiving morphine for pain. The client takes digoxin and fluoxetine at home. Docusate sodium is prescribed. What drug does the nurse identify as a risk factor for straining due to constipation?

Morphine Morphine is an opioid. Opioids decrease peristalsis, which may precipitate constipation; straining at stool should be avoided to prevent the Valsalva maneuver, which increases demands on the heart.

A client is transferred to the postanesthesia care unit after undergoing a pyelolithotomy. The client's urinary output is 50 mL/hr. What should the nurse do?

Record the output as an expected finding. An output of 50 mL/hr is adequate; when urine output drops below 20 to 30 mL/hr, it may indicate renal failure, and the primary healthcare provider should be notified.

The urinalysis report of a client reveals cloudy urine. What does a nurse infer from the client's report?

The client has a urinary infection. The urine becomes cloudy when an infection is present due to the presence of leukocytes. Therefore the nurse concludes that the client has a urinary infection.

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents?

Paralytic ileus After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation