AH1 (EXAM 4) questions

Pt had a left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the MD? A) Decrease urine output B) Hematuria C) Flank pain D) Flank bruising

A) Decrease urine output

Which statement is best for treatment of atopic dermatitis? A) 1-2 showers a day B) Use lotions to keep skin moist C) Take antibiotics till resolved D) Move to Florida for the weather.

B) Use lotions to keep skin moist

What should the nurse do to prevent catheter-associated urinary tract infection (CAUTI)? Select all that apply. A. change the catheter daily. B. provide perineal care several times a day. C. monitor the temperature as an indicator of the infection. D. encourage the client to drink 3,000 ml fluids daily. E. recommend the healthcare provider (HCP) prescribe antibiotics.

B. provide perineal care several times a day. C. monitor the temperature as an indicator of the infection. D. encourage the client to drink 3,000 ml fluids daily. //////////////////////////////////////// Catheter-associated urinary tract infection is the most common healthcare acquired infection and represents as much as 80% of hospital-acquired infections in hospitals. Meticulous perineal care , adequate fluid intake, and assessment of infection such as elevated temperature can reduce the risk for CAUTI.

The nurse is teaching a student how to obtain a wound culture from a red wound bed. The nurse knows the student knows what's up with which statement? A) "Thoroughly irrigate the wound before collecting the culture." B) "Used a sterile swab to wipe the crusty area around the outside of the wound." C) "Gently roll the sterile swab from the center of the wound outward to collect drainage." D) "Use one swab to collect drainage from several possible infected sites along the incision."

C) "Gently roll the sterile swab from the center of the wound outward to collect drainage."

A patient is diagnosed with atopic dermatitis. He is upset and asks how to avoid another outbreak, the nurse determines the patient does not need further education by making which statement? A) "Avoid bacterial infections." B) "Avoid fungal infections." C) "It is hereditary." D) "Avoid viral infections."

C) "It is hereditary."

Which assessment finding on a pt admitted with pyelonephritis must be relayed to the MD? A) Foul-smelling urine B) C/o of flank pain 10/10 C) Blood pressure of 88/45 D) Temp of 101.8

C) Blood pressure of 88/45

The nurse is preforming a sterile dressing change. What is the most important intervention by the nurse? A) Put on sterile gloves right after hand washing. B) Place a sterile gauze ½" from the edge. C) Clean the incision first then the skin around the incision D) Use the same gauze to clean the wound.

C) Clean the incision first then the skin around the incision

Pt arrives to the ER with severe colicky left flank pain that radiates to the groin and hematuria. What is the priority nursing intervention A) Give IVF bolus of isotonic solution B) Encourage oral fluids C) Give analgesics D) Give antiemetic's

C) Give analgesics

The nurse uses auscultation during assessment of the urinary system to A) Check for ureteral peristalsis B) Assess for bladder distension C) Identify renal artery or aortic bruits D) Determine the position of the kidneys

C) Identify renal artery or aortic bruits

A patient arrives to the MD office complaining of a rash. The nurses assesses the patient and notes several palpable, elevated masses, each about 0.5 cm. The nurse documents these assessment finds using which term? A) Erosion B) Macules C) Papules D) Vesicles

C) Papules

How will the nurse assess the flank area of a patient with pyelonephritis for tenderness? A) Push gently into the 2 lowest intercostal space B) Palpate along both sides of the lumbar vertebral column C) Position one hand flat at the CVA & strike it w/ the other fist D) Use 2 fingers to percuss the area between the iliac crest and ribs

C) Position one hand flat at the CVA & strike it w/ the other fist

A friend c/o leaking urine when she jumps on a trampoline. What advice can you give her? A) Demonstrate the Crede maneuver B) Encourage diaper usage C) Teach Kegal exercises D) Tell her to avoid jumping

C) Teach Kegal exercises

When changing a dressing on a pressure ulcer, a nurse notes a necrotic wound bed. Which intention will the nurse anticipate this wound will heal by? A) Primary B) Secondary C) Tertiary D) IDK

C) Tertiary

Which information will the nurse include when teaching a patient about phenazopryidine (pyridium)? A) Take med for at least 7 days B) Use sunscreen while on this med C) Urine may turn reddish-orange D) Use this med before sexual intercourse

C) Urine may turn reddish-orange

A patient has been admitted with dehydration is confused and incontinent. Which action will be the best to include in his plan of care? A) Apply incontinent pads B) Restrict fluid after evening meal C) Insert foley catheter D) Assist pt to bathroom every 1 hour.

D) Assist pt to bathroom every 1 hour.

Best way to prevent hospital acquired UTI? A) Encourage oral fluid B) Test urine daily for glucose C) Increase caffeine and soda D) Avoid unnecessary catheterizations

D) Avoid unnecessary catheterizations

Pt admitted with fever, chills, vomiting, and a history of BPH. Which findings will be most helpful in determining whether the patient has an upper UTI? A) Suprapubic pain B) Bladder distension C) Foul-smelling urine D) Costovertebral tenderness

D) Costovertebral tenderness

Pt presents c/o of "UTI". Which assessment question will the nurse initially ask about? A) Last sexual encounter B) Nausea C) Urine output D) Dysuria

D) Dysuria

The nurse determines that instructions regarding prevention of future UTI has been effective when the patient states A)" I will use vaginal sprays to reduce bacteria" B) " I will drink a quart of water a day" C) " I will wash with soap and water before I have sex" D) I will empty my bladder every 3-4 hours."

D) I will empty my bladder every 3-4 hours."

Which patient assessment is most concerning for a patient with a UTI? A) Dysuria B) Hematuria C) Temp of 100.6* D) Left-sided flank pain

D) Left-sided flank pain

person has avulsion, what is the primary concern? A) Enhancing self-esteem B) Promoting hygiene C) Reducing anxiety D) Preventing infection

D) Preventing infection

The nurse is assessing a 30 yo patient admitted with partial-thickness burns to his arms after a freak propane tank exploding incident. The nurse should document which assessment? A) Pain and redness. B) Damage to the epidermis. C) Tissue damage through all layers of the skin. D) Tissue damage through most of the dermis

D) Tissue damage through most of the dermis

A confused older male patient is agitated, confused with a distended bladder. Which of the following interventions should the nurse implement first? A) Apply a diaper B) Straight cath C) Place the patient on the toilet D) Use a bladder scanner

D) bladder scanner

Nurse assumes care of a post-op patient with a dehiscence. Which person is best to delegate to obtain the best pt outcome? A) Wound care RN B) Dietician C) General Surgeon D) Physical Therapist

A) Wound care RN

After reviewing a UA result for your patient, which information needs to be called to the doctor? A) pH: 6.2 B) Trace protein C) WBC: 20-26 D) Specific gravity: 1.021

C) WBC: 20-26

A patient is diagnosed with cystitis. The RN provides teaching aimed at preventing a recurrence. Which instruction does the RN provide? A) Wear cotton underwear B) Bathe in a tub C) Use a feminine hygiene spray D) Limit your intake of cranberry juice

A) Wear cotton underwear

The nurse is performing a skin assessment on a recently admitted patient. The nurse finds the coccyx red and nonblancing. What is the priority nursing intervention? A) Apply a cream like Proshield B) Ambulate the patient to the chair C) Reposition the patient into supine D) Call the MD

A) Apply a cream like Proshield

Which of the following actions will the nurse plan to take first when admitting a patient who has a cervical spinal cord injury & history of a urinary retnetion? A) Ask about the usual urinary pattern & any measures used for bladder control B) Assist pt to toilet on schedule C) Check for urinary incontinence every 2 hours D) Use intermittent cath on a regular schedule

A) Ask about the usual urinary pattern & any measures used for bladder control

Which meds are most commonly used to treat UTI? A) Cipro and Bactrim B) Flagyl and Bactrim C) Cipro and Flagyl D) Avelox and Cipro

A) Cipro and Bactrim

Dimitri has a maculopapular puritic rash on his hands, arms, and lower legs. He states that the itching is severe and he cannot keep from scratching. Along with Benadryl what is the next best thing? A) Cool compresses B) Moist heat C) Cutting finger nails D) Wearing a sweat suit

A) Cool compresses

Patient is diagnosed with statis dermatitis. What is the priority goal of this patient? A) Prevention of infection B) Increase circulation C) Reduce swelling D) Reduce pain

A) Prevention of infection

What should the nurse teach the client to do to prevent stress incontinence? Select all that apply. A. Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises. B. Avoid natural diuretics such as caffeine or alcoholic beverages. C. Carry an extra incontinence pad when away from home. D. Maintain a fluid intake of 500mL/day. E. Refrain from coughing or laughing.

A. Use techniques that strengthen the sphincter and structural supports of the bladder, such as Kegel exercises. B. Avoid natural diuretics such as caffeine or alcoholic beverages. ////////////////////////////////////////// Answer: A, B Kegel exercises strengthen the sphincter and structural supports of the bladder and the nurse should ensure the client knows how to do these. Teach the client to establish a voiding schedule and drink as least 2 to 3 L/day of fluid. Caffeinated beverages such as tea, coffee and cola may irritate the sphincter and increase incontinence.

The nurse finds a fluid container with the client's urine specimen siting on a counter in the bathroom. The client states that the specimen has been sitting in the bathroom for at least 2 hours. The nurse should: A. discard the urine and obtain a new specimen. B. send the urine to the lab as quickly as possible. C. add fresh urine to the collected specimen and send the specimen to the laboratory. D. refrigerate the specimen until it can be transported to the laboratory.

A. discard the urine and obtain a new specimen /////////////////////////////////////// Urine that is allowed to stand at room temperature will become alkaline with multiplying bacteria. Examine the urine specimen within 1 hour.

A client has nephropathy. The healthcare provider (HCP) prescribes a 24-hour urine collection for creatinine clearance (estimates how well the kidneys are perfusion). Which action is necessary to ensure proper collection of the specimen? A. collect the urine in a preservative-free container and keep it on ice B. inform the client to discard the last voided specimen at the conclusion of urine collection C. obtain a self-report of the client's weight before beginning the collection of urine D. Request a prescription for insertion of an indwelling urinary catheter

Answer: A ///////////////////////////// The first urine voided at the beginning of the collection is discarded in order to reduce risk for contaminants. All urine for creatinine clearance must be saved in a preservative-free container and refrigerated or kept on ice.

Patient has contact dermatitis from a necklace. How long ago was she wearing the necklace? A) IDK B) 48 hours ago C) 5 minutes ago D) 7 days

B) 48 HRS AGO

Patient arrives with cellulites of the eye. Place the nursing interventions in the proper order... A) ID the patient, insert IV, administer abx, obtain culture B) ID patient, obtain culture, insert IV, administer abx C) ID patient, insert IV, obtain culture D) Obtain culture, obtain temp, give abxs

B) ID patient, obtain culture, insert IV, administer abx

A creatinine clearance test is ordered for a patient with possible renal insufficiency. Which equipment will the RN need to obtain? A) Sterile specimen cup B) Large container for urine C) Foley catheter & drainage bag D) Towelettes for perineal cleaning

B) Large container for urine

A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6 degrees F. which outcome is the priority for this client? A. prevention of urinary tract complications B. alleviation of nausea C. alleviation of pain D. maintenance of fluid and electrolyte balance

C. alleviation of pain //////////////////// Alleviation of pain is the priority for this client at this time because it can be excruciating. Prevention of urinary tract complications and alleviation of nausea should be ongoing throughout the hospital stay.

patient urinates and you bladder scan him. What volume do you call the MD and report urinary retention ? A) 25ml B) 35ml C) 45ml D) 55ml

D) 55 ml

Which factor would put the client at risk for pyelonephritis? A. history of hypertension B. intake of large quantities of cranberry juice C. fluid intake of 2,000mL/day D. history of diabetes mellitus

D. A client with a history of diabetes mellitus (high urine glucose), urinary tract infections or renal calculi is at risk for pyelonephritis (Billings & Hensel, 2017). /////////////////////////////////////////// ~Diabetes mellitus can lead to poor circulation making it more difficult for white blood cells to travel

The client asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in most instances, cystitis is caused by: A. congenital strictures in the urethra. B. an infection elsewhere in the body. C. urinary stasis in the urinary bladder. D. an ascending infection from the urethra.

D. an ascending infection from the urethra. /////////////////////////////////////////// An ascending infection from the urethra caused by strictures and urinary retention can lead to cystitis (an infection in the kidneys, bladder or urethra)

The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that: A. fluid and food will be withheld the morning of the examination. B. a tranquilizer will be given before the examination. C. an enema will be given before the examination. D. no special prep is required for the examination.

D. no special prep //////////////////////////// KUB is done while the client is supine, requires no contrast and no preparation for the examination.

BUY ME A CHICKEN QUESADILLA

seriously

The nurse informs the pt undergoing cystoscopy that following the procedure, the patient A) Will be on bedrest for 5 hours after B) Will need a narcotic to control pain C) Will have pink tinged urine D) Will be NPO for 8 hours

C) Will have pink tinged urine

Tenting on an elderly person's hand indicates? A) Over hydration B) Normal skin turgor C) Normal part of aging D) Dehydration

C). Normal part of aging

A patient who is scheduled for an intravenous pyelogram (IVP) gives the nurse the following information. Which information has the most immediate implication for the patient's care? A) Pt has an allergy to shellfish B) Pt has been npo for 12 hours C) Pt has + CVA tenderness D) Pt has taken Ducolax the night prior

A) Pt has an allergy to shellfish

Patient arrives to ER c/o of intense pruritus all over the body after rolling in the grass. Which action is the nurse's priority? A) Remove the clothing. B) Administer Benadryl. C) Apply cool compresses. D) Start patent IV.

A) Remove the clothing.

The nurse is assessing the LLE of a patient with type 2 DM and cellulitis. The nurse should do which of the following? A) Instruct the pt to elevate the left leg when sitting in the chair. B) Encourage the pt to ambulate down the halls. C) Massage the LLE to stimulate circulation. D) Cleanse the LLE with Bath and Body Works soap.

A) Instruct the pt to elevate the left leg when sitting in the chair.

At Publix a person tells you he has a sore on the inside of his ankle that will not heal. After noting the varicosities and coarse discoloration around the sore, you suspect which condition? A) Acute venous insufficiency B) Chronic venous insufficiency C) Acute arterial occlusive disease D) Chronic arterial occlusive disease

B) Chronic venous insufficiency

What would you rather have? A) Atopic dermatitis B) Contact dermatitis C) Statis dermatitis D) Cellulitis

B) Contact dermatitis

The MD orders wet to dry dressing for a patient who has pressure ulcer with purulent drainage-why? A) Prevent infection B) Debride the wound C) Keep wound moist D) Reduce pain

B) Debride the wound

A patient with a distended bladder has no urine output for 6 hours and c/o suprapubic pain. Do you give a loop diuretic Lasix at this time? A) Yes B) No

B) No

The client is scheduled for an intravenous pyelogram (IVP) to determine the location of the renal calculi. Which action would be most important for the nurse to include in pretest preparation? A. ensure adequate fluid intake on the day of the test B. prepare the client for the possibility of bladder spasms during the test. C. check the client's history for allergy to iodine. D. determine when the client last had a bowel movement.

C. check the client's history for allergy to iodine. /////////////////////////////// A client scheduled for an IVP should be assessed for allergies to iodine and shellfish because they may also be allergic to the IVP dye and could be at risk for an anaphylactic reaction.

A client is admitted to the recovery room after cystoscopy with biopsy. Before the nurse can discharge the client, the nurse should be sure the client: A. has a bowel movement B. has received the first dose of pain medication C. has voided D. has no blood in the urine

C. has voided ////////////////////////////////// The nurse should verify the client has voided prior to discharge in order to evaluate bladder function. Hematuria post procedure is an expected outcome post renal biopsy.

A home health RN is assessing 4 patients. The nurse determines which patient is a highest risk for impaired wound healing? A) 65 yo with HTN B) 60 yo who is overweight C) 78 yo drinks 1-2 wine daily D) 75 yo with DM

D) 75 yo with DM

A patient with diabetic neuropathy is admitted for a right renal biopsy. Immediately after the biopsy, which of these nursing actions are essential? A) Monitor BUN & creatinine B) Check blood glucose C) Insert straight cath to check for hematuria D) Apply pressure dressing & keep pt on affected side

D) Apply pressure dressing & keep pt on affected side