EQA's Intro Units 17 & 19
What finding supports the nurse's conclusions that the client is at risk for kidney damage and the health care provider needs to increase the IV fluid rate? ◘ Pulse pressure 40mm Hg ◘ Urine output is 25mL per hr ◘ Systolic BP is 120 mm HG ◘ Blood osmolality is 280 milliosmoles/kg
Urine output is 25mL per hr 😼Rationale: ➥Urine output should be at least 30 mL/hr
Sodium biphosphate/sodium phosphate
☙Sodium biphosphate is a saline (hypertonic) cathartic that increases osmotic pressure within the intestine so that body fluids are drawn into the bowel, stimulating bowel stretching, peristalsis, and defecation. ☙Fleet Enema
Which genitourinary factor contributes to urinary incontinence in older adult clients & needs to be considered by the nurse when planning the care for these clients? ◘ Sensory deprivation ◘ Urinary tract infections ◘ Frequent use of diuretics ◘ Inaccessibility of a bathroom
Urinary tract infections 😼Rationale: ➥Urinary tract infections affect the genitourinary tract and interfere with voluntary control of micturition. ☙Sensory deprivation is a neurological, not a genitourinary, factor. ☙Frequent use of diuretics is an iatrogenic, not genitourinary, factor. ☙Inaccessibility of a bathroom is an environmental, not genitourinary, factor. Tip: Micturition➟the action of urinating➟"the condition is characterized by frequent micturition and urinary incontinence"
Loperamide (Imodium)
*class*: antidiarrheal *Indication* acute diarrhea, decrease drainage post ileostomy *Action*: inhibits peristalsis, reduces the volume of feces while increasing the bulk and viscosity *Nursing Considerations*: -may lead to constipation - insure proper use - assess bowel function - assess fluid and electrolyte levels
When, during the first 24 hours postopertively, will analgesics be administered to a client who undergoes an abdominal cholecystectomy for gangrene of the gallbladder?
As prescribed by the health care provider
What circumstance explains the finding of no drainage from the colostomy observed by the nurse during the first 24 hours after a client has had a permanent colostomy created.
Absence of intestinal peristalsis
Which is the rational for the RN emptying the collection device frequently for a client with an ileal conduit? ◘ Force urine to back up into the kidneys. ◘ Suppress production of urine. ◘ Cause the device to pull away from the skin. ◘ Tear the ileal conduit.
Cause the device to pull away from the skin. 😼Rationale: ➥If the device becomes full and is not emptied, it may pull away from the skin and leak urine. ➟Urine in contact with unprotected skin will irritate and cause skin breakdown.
While caring for a client who sustained a severe head injury in a motor vehicle accident, the nurse observes that the client is constantly passing urine and is dehydrated. What does the nurse suspect as the cause for the client's condition?
Decreased secretion of antidiuretic hormone 😼Rationale: ➥In the absence of antidiuretic hormone, water is not reabsorbed from the tubules in the nephron & therefore gets eliminated as urine.
Which action would the RN take when observing that a postsurgical human has urine output of 800 mL total in the first 24 hours after surgery? ◘ Notify the provider ◘ Increase oral fluid intake ◘ Document the normal finding ◘ Begin an intravenous infusion of N.S.
Document the normal finding 😼Rationale: ➥Urine output of 800 mL is normal postoperative output since it is more than 30mL/hr.
A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next?
Give naloxone intravenous push med (IVP) per protocol. 😼Rationale: ➥A respiratory rate of 10 breaths per min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for postoperative opioid-induced respiratory depression. Pain level also is a part of the PCA documentation protocol. According to protocol, PCA status needs to be documented every 2 hours for the first day and then every 4 hours. The rapid response team might still need to be called, but naloxone must be given first.
What factor would the nurse identify as the cause of the pain experienced by a client who is experiencing acute coronary syndrome?
Heart muscle ischemia
Which manifestations are exhibited with syndrome of inappropriate secretion of antidiuretic homrome (SIADH)
Hyponatremia and decreased urine output
Hemicolectomy
surgical removal of half (a portion) of the colon
Which intervention would prevent urinary stasis & Formation of renal calculi in an immobile human? ◘ Increase oral fluid intake to 2 to 3 L per day. ◘ Maintain bed rest after discharge. ◘ Limit fluid intake to 1 L/day. ◘ Void at least every hour
Increase oral fluid intake to 2 to 3 L per day. 😼Rationale: ➥Increasing oral fluid intake (if not contraindicated to meds/other treatments) will dilute urine & promote urine flow, preventing stasis & complications such as renal calculi ✤ Calculi (Stones)
The nurse would expect to find an increase of which substance in the urine of a client following a low-carbohydrate diet?
Ketones 😼Rationale: ➥As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. 😨 Increased ketone in the blood can cause metabolic acidosis.
Which substance is released in response to low serum levels of calcium?
Parathyroid hormone 😼Rationale: ➥If serum calcium levels decline, the parathyriod gland releases pararthyriod hormone to maintain calcium homeostasis.
idiosyncratic
Peculiar to one person; highly individualized
Which method would the nurse use to assess a client suspected of having a distended bladder? ◘ Inspect and palpate in the epigastric region ◘ Auscultate and percuss in the inguinal areas ◘ Percuss and palpate the hypogastic region ◘ Percuss and palpate in the lumbar areas
Percuss and palpate the hypogastic region 😼Rationale: ➥The hypogastric region (below the stomach) contains the organs around the pubic bone. These include bladder, part of the sigmoid colon, the anus, and many organs of the reproductive system, such as the uterus and ovaries in females and the prostate in males.
The nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which safeguard would the nurse take during this procedure? ◘ Droplet precautions ◘ Reverse isolation ◘ Surgical asepsis ◘ Medical asepsis
Surgical asepsis 😼Rationale: ➥Catheter insertion requires the procedure to be performed under sterile technique. ☙Droplet precautions are used with certain respiratory illnesses. ☙Reverse isolation is used with clients who may be immunocompromised. ☙Medical asepsis involves clean technique/gloving.
Family members received discharge instructions for an older adult male recovering from a urinary tract infection. Which statement indicates family understanding of age-related changes and required care? ◘ Small glass of water at his side to ensure sipping before bedtime. ◘ Respond immediately with the urinal whenever he indicates a need to void ◘ Provide privacy and stand by assistance to help him void. ◘ I encourage him to use the urinal at least every 2 hours during the day."
Provide privacy and stand by assistance to help him void.
What prescription by the health care provider would the nurse question when caring for a client who is hospitalized for an acute myocardial infarction?
Rectal suppository as needed for constipation
Which intervention would the nurse implement when providing care for an older adult male client who is immobile & incontinent of urine? ◘ Restrict the client's fluid intake. ◘ Regularly offer the client a urinal. ◘ Apply incontinence pants. ◘ Insert an indwelling urinary catheter.
Regularly offer the client a urinal.
Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin? 1 Relief of anginal pain 2 Improved cardiac output 3 Decreased blood pressure 4 Dilation of superficial blood vessels
Relief of anginal pain 😼Rationale: ➥
Which rationale would the nurse give to explain the purpose of administering an opioid analgesic via epidural catheter when providing postoperative teaching?
Relieves abdominal pain 😼Rationale: ➥Analgesics alleviate pain by binding with opioid receptors in the brain, thus altering the perception of and response to pain; patient-controlled analgesia (PCA) via an epidural catheter gives the client control over medication administration and usually results in the client using less medication. Opioids do not facilitate oxygen use; they decrease the respiratory rate, and less oxygen is used; the client should be monitored. Although decreasing anxiety and restlessness may be responses to an opioid, they are not the primary reason why opioids are used after abdominal surgery. Opioids are not given to dilate blood vessels; antianginal medications and vasodilators are used for this purpose
polyuria
excessive production of urine
The RN is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? ◘ "I will avoid the pooling of urine in the tubing." ◘ "I will avoid prolonged clamping of the tubing." ◘ "I will avoid draining urine from the tubing before ambulation." ◘ "I will avoid raising the drainage tube above the level of the bladder."
"I will avoid draining urine from the tubing before ambulation." 😼Rationale: ➥Urine should be drained from the tubing into the drainage container before ambulation or exercise.
When assessing a client during the postoperative period of receiving a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mmol/L). Which action would he nurse take first in response to this lab report? ◘ Notify the primary healthcare provider. ◘ Obtain current blood test results. ◘ Assess for decreased urine output. ◘ Check the intravenous (IV) infusion.
Assess for decreased urine output. 😼Rationale: ➥The expected serum creatinine range is 0.7 to 1.4 mg /dL (62 to 124 mcmol/L). The nurse should obtain additional information that may indicate acute rejection; therefore, the nurse must first assess for decreased urine output and changes in vital signs. Once additional data are collected (e.g., urine output, current blood work reports) and the intravenous (IV) infusions are checked, the nurse should contact the primary healthcare provider, explain the situation, and implement further prescriptions. Eventually the nurse should ensure that proper infusion rates, along with IV medications, are being maintained after the client is first assessed for decreased urine output and for changes in vital signs. Current blood work reports should be obtained after the client is assessed for decreased urine output and changes in vital signs.
Which client condition is an adult client with a weakened urinary sphincter at risk? ◘ Bladder distention ◘ Skin irritation ◘ Tendency to fall or trip over objects ◘ Urinary retention
Skin irritation 😼Rationale: ➥The weakening of the urinary sphincter results in involuntary dribbling of urine, which increases the risk of skin irritation and infections. Therefore maintaining thorough hygiene in the perineum area reduces the chance of occurrence of infection or skin rash. The nurse should observe for signs of bladder distention in clients who have a tendency to retain urine. Keeping a bedside light at night is an intervention to prevent night falls in clients who have nocturia. A weakened urinary sphincter will cause loss of urine.
Which preventative would the nurse anticipate will be prescribed daily to avoid straining due to constipation for a client who has had a recent brain attack (cerebrovascular accident/stroke)
Stool softener
Older client with Alzheimer disease who has intermittent episodes of urinary incontinence, what action would the nurse take? ◘ Pointing out the behavior to the client ◘ Obtaining incontinence pads for the client ◘ Taking the client to the bathroom at regular intervals ◘ Encouraging the client to call for help when there is an urge to urinate
Taking the client to the bathroom at regular intervals
Which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? ◘ Tubing injection port ◘ Distal end of the tubing ◘ Urinary drainage bag ◘ Catheter insertion site
Tubing injection port
While collecting a human's urine sample, which condition would the RN suspect if the sample has a strong odor of ammonia? ◘ Malabsorption ◘ Bladder cancer ◘ Diabetic ketoacidosis ◘ Urinary tract infection
Urinary tract infection 😼Rationale: ➥Strong ammomia odor in the urine can indicate a UTI or possible renal failure.
Docusate sodium (Colace)
stool softener/laxative
Which complication would the nurse monitor for a human on strict bed rest for 3 days? (Select all that apply) ◘ Atelectasis ◘ Hypotension ◘ Constipation ◘ Pressure injuries ◘ Urinary tract infections
◘ Atelectasis ◘ Hypotension ◘ Constipation ◘ Pressure injuries ◘ Urinary tract infections 😏 Atelectasis➟is a condition where alveoli in your lung or a part of your lung deflates, causing a partial or complete collapsed lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid.
☙ ❥ ✤ ൠ ت ↬ ⇢ ➟ ➟ ➥ ➦ 🙀 😼😈😷 😏 😏 😨 ☹ 🔹 ◘ • ⛔ 😼Rationale: ➥
☙ ❥ ✤ ൠ ت ↬ ⇢ ➟ ➟ ➥ ➦ 🙀 😼😈😷 😏 😏 😨 ☹ 🔹 ◘ • ⛔ 😼Rationale: ➥
