EXAM 2

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline." Feedback:The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following?

"I need to void after sexual intercourse." Feedback:The client's statement about voiding after sexual intercourse to prevent urinary tract infection is accurate. Taking frequent bubble baths, wiping the perineum from back to front, and wearing snug fitting pants increases the risk of urinary tract infection. The client should avoid taking frequent bubble baths, using harsh soaps, and wearing tight-fitting pants because they can irritate the urethra. The client also should always wipe from front to back after urinary or fecal elimination.

A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more education?

"I will keep the toilet paper in the specimen." Feedback:Instruct clients not to put toilet paper into the urine because this makes analysis more difficult. Urine for a routine urinalysis does not have to be sterile. Ask the client to void into a clean receptacle and avoid contamination with stool. Note on the request form if a woman is having her menstrual period.

A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which scenario would she document?

"Ileostomy bag half filled with liquid feces." Feedback:The client with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid.

A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client's anxiety?

"Let me explain to you what they do during this procedure." Feedback:Various diagnostic procedures, typically performed in a hospital operating room or outpatient facility, are used to study the urinary system. Nurses are responsible for preparing the client and giving aftercare. Explaining the procedure helps reduce the client's anxiety. Telling the client that the procedures are done every day so not to worry about it or using empathy expressing that the nurse has had the procedure completed are not caring statement expected by nurses. Suggesting that the client has a tumor can cause more anxiety about the procedure and results.

Which are examples of breaches of client confidentiality? Select 3 that apply.

A nurse discusses information about a client with a coworker in the elevator. Correct! A nurse shares her computer password with another nurse who was unable to log in to the system. A nurse updates the employer of a client regarding the client's date of return to work.

The client's heart rate is 160 beats per minute. The client is experiencing complications of an excessive heart rate. The primary care provider issues a verbal prescription for intravenous medication to the nurse. Place the steps of taking the verbal prescription in chronological order.A. Record the prescription in the client's medical record, including date and timeB. Read back the prescription to the primary care provider who initiated itC. Obtain verification from the primary care provider that the prescription is correctD. Initiate the prescription and administer the medicationE. Obtain the signature of the primary care provider who gave the verbal prescription

A, B, C, D, E

A student is collecting a sterile urine specimen from an indwelling catheter that was inserted 4 days ago. How will the student correctly obtain the specimen?

Aspirate urine from the collection port on the tubing. Feedback:When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should always be obtained from the catheter itself using the special collection port.

A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding?

Assist him to a standing position. Feedback:Helping clients assume their usual voiding positions may be all that is necessary to resolve an inability to void. If male clients cannot void lying down, encourage them to void while standing at the bedside unless this is contraindicated. Pouring cold water on the genitalia will not promote urination. Telling him that he needs to void prior to discharge is putting stress on performing the activity and is counterproductive. Asking his wife to assist with hold the urinal may also make him uncomfortable.

A nurse is assessing a client the first day after colon surgery. Based on knowledge of the effects of anesthesia and manipulation of the bowel during surgery, which focused assessment will be included?

Bowel sounds Feedback:Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, which may cause a condition termed paralytic ileus. This temporary stoppage normally lasts 24 to 48 hours. Nurses will listen for bowel sounds as part of regular assessments.

Which method of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse?

Charting by exception Feedback:Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against a nurse.

The nurse has been assigned to five clients. To ensure accurate charting, what actions does the nurse perform? Select 3 that apply.

Checks to make sure she has the correct chart prior to making an entry Documents interventions as close as possible to the time of execution Places a label with the client's name and identification number on each page of the client's chart Feedback:To ensure accurate charting, the nurse checks that charting is done on the correct chart, documents interventions as close as possible to the time of execution, and places a label with the client's name and identification number on each page of the chart. The nurse documents observations of client behavior, not interpretations. The nurse charts percentage of meals and actual volume in mL of fluids ingested, not "sufficient quantity."

What is the nurse's best defense if a client alleges nursing negligence?

Client's record Feedback:The client record is the only permanent legal document that details the nurse's interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence. Testimony of other nurses and client's family can attest to the interactions of the client and nurse that was observed. Testimony of expert witnesses can provide evidence of the nurse's standard of care that is document in the client's medical record.

What is the primary purpose of the client record?

Communication Feedback:The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another.

A nurse caring for older adult clients in an assisted-living facility encourages clients to eat a diet high in fiber to avoid which developmental risk factor for this group?

Constipation Feedback:Constipation is often a chronic problem for older adults and a diet high in fiber is recommended.

The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client?

Constipation Feedback:Peristalsis is defined as the contractions of the circular and longitudinal muscles of the intestine. Decreased peristalsis will result in constipation because the movement of the fecal mass will occur at a slower rate and more fluid will be absorbed in the colon.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. What is the best technique for recording the error made in documentation?

Cross out the incorrect statement with a single line and place nurse's initials above it. Feedback:When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one. The nurse should not cross out the wrong statement in a way that makes the statement unreadable. The nurse should not use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?

Dark red and moist Feedback:The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purple-blue color (possible ischemia), or bleeding.

A client is admitted to the health care facility reporting pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as:

Dysuria Feedback:Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a burning sensation during urination. Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent increase in fluid intake. Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood in the urine.

Which part of the client's record is commonly used to document specific client variables, such as vital signs?

Flow Sheets Feedback:Flow sheets are tables that have vertical and horizontal columns that allow nurses to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

A nurse is caring for a client with a colostomy. What type of stools would she expect to find in the colostomy bag?

Formed Feedback:A colostomy is an opening of the large intestine that allows formed feces from the colon to exit through the stoma.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider?

ISBAR Feedback:The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last in the sequence when conducting an abdominal assessment?

It disturbs normal peristalsis and bowel motility Feedback:The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility.

A nurse is providing care to a client who has undergone a colonoscopy. What would be most appropriate for the nurse to do after the procedure?

Monitor for rectal bleeding. Feedback:The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse should provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are avoided and liquids are encouraged. Laxatives are also given before the procedure.

The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper (pad) daily. Which of the following nursing diagnoses is the most appropriate for this client?

Risk for impaired skin integrity Feedback:A client who is incontinent, utilizes adult diapers (pads), and only changes them daily is at Risk for Impaired Skin Integrity in the genital and perineal area.

A nurse in a long-term care facility is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent?

SOAP note Feedback:A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

A client is on bed rest, and an enema has been ordered. In what position should the nurse position the client?

Sims' Feedback:A reclining position on the left side (Sims' position) is recommended. The head may be slightly elevated, but Fowler's position should be avoided because the solution will remain in the rectum and expulsion will occur rapidly, resulting in minimal cleansing.

An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which nursing diagnosis?

Social Isolation Feedback:Urinary incontinence is a special problem for older adults who may have decreasing control over micturition, or find it more difficult to reach the toilet in time. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person's self-concept, causing him to feel like a social outcast.

A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which position would the nurse place the client?

Supine Feedback:Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Results are most accurate when the client is in the supine position during the scanning.

A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?

The position does not facilitate downward pressure. Feedback:Most people assume the squatting or slightly forward-sitting position with the thighs flexed to defecate. These positions result in increased pressure on the abdomen and downward pressure on the rectum to facilitate defecation. Obtaining the same results when seated on a bedpan is difficult.

A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called?

Uncontrolled voiding Feedback:The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence.

A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill?

Wash hands and put on gloves. Feedback:The first step of any skill involving body fluids is to wash hands and don gloves. All the steps listed are correct to remove a urinary catheter.

During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the episode is resolved, the nurse assesses the client's vital signs and expects to observe which of the following?

an increase in the client's blood pressure Feedback:When an individual bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart; this act elevates the client's blood pressure.

After surgery, a postoperative client has not voided for 8 hours. Where would the nurse assess the bladder for distention?

between the symphysis pubis and the umbilicus Feedback:When the bladder is distended with urine, it rises above the symphysis pubis and may reach to just below the umbilicus. The other choices are anatomically incorrect for assessing a distended bladder.

What is occult blood?

blood that cannot be seen Feedback:Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on gross examination. It can be detected with simple screening tests, such as a Hematest.

A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?

increased bowel sounds Feedback:The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.

A client has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate?

increased output of dilute urine Feedback:Diuretics result in moderate to severe increases in the production of dilute urine. Concentration will decrease, not increase, and there is no accompanying risk of urinary tract infections. For some clients, this sudden increase in urine output may precipitate transient incontinence, but this remains an abnormal finding.

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?

suprapubic catheter Feedback:A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra.

A student has reviewed a client's chart before beginning assigned care. Which action violates client confidentiality?

writing the client's name on the student care plan Feedback:Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?

Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. Feedback:Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. The diminished ability of the kidneys to concentrate urine may result in nocturia (urination during the night). Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control and the ability to reach a toilet in time. Individuals who view themselves as old, powerless, and neglected may cease to value voluntary control over urination, and simply find toileting too much bother no matter what the setting. Incontinence may be the result.

The nurse works on a busy unit at the hospital and maintains client confidentiality. What actions would the nurse take to ensure client information remains confidential? Select 3 that apply.

Dispose of client SBAR forms in a secured container for shredding of documents at the end of the shift. Exit the client's room when called on the hospital-issued cell phone about another client on the team. Verify the number in the fax machine as correct prior to transmission. Feedback:To maintain client information as confidential, the nurse disposes of client SBAR forms in a secured container prior to leaving the agency, exits the client's room to talk on the hospital-issued cell phone, and verifies the number in the fax machine prior to transmitting documents. The nurse assesses client information on the portable computer where visitors cannot see and prints client information to a printer on the nursing unit. Shared printers with another nursing unit is not recommended.

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

Habitual laxative use is the most common cause of chronic constipation. Feedback:Occasional use of laxatives is not harmful for most people, but clients should not become dependent on them. Although many people do take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is the most common cause of chronic constipation.

Which is an expected outcome for a client undergoing a bowel training program?

Have a soft, formed stool at regular intervals without a laxative Feedback:Clients who have chronic constipation and impaction, and those who are incontinent of stool, may benefit from a bowel training program. The purpose of this program is to manipulate factors within the client's control (such as exercise or fluid intake) to produce the elimination of a soft, formed stool at regular intervals without a laxative.

The client who has diabetes is scheduled for an abdominal CT scan. The nurse is preparing the client for the test. What assessments and instructions would the nurse perform? Select 3 that apply.

Instruct the client to withhold metformin prior to the CT scan. Correct! Ask the client about allergies, particularly iodine, shellfish, and/or IV contrast. Correct! Obtain and review BUN and creatinine levels prior to the CT scan. Feedback:In preparing the client for a CT scan of the abdomen, the nurse would ask about allergies. Clients may have experienced an allergic reaction to iodine, shellfish, and/or IV contrast. The nurse would assess for renal impairment, which would be demonstrated in the BUN and creatinine levels. If the client is taking metformin, a common oral hypoglycemic medication, the client would be instructed to withhold it until the BUN and creatinine are assessed again after the test. The client is NPO for 4 hours prior to the CT scan, and informed consent is required for the CT scan.

A nurse is delegating the collection of urinary output to an unlicensed assistive personnel (UAP). What should the nurse tell the UAP to do while measuring the urine?

Wear gloves when handling a client's urine. Feedback:Gloves are required when handling urine to prevent exposure to pathogenic microorganisms or blood that may be present in the urine. In addition, goggles are also worn if there is a concern of urine splashing.

A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of statement describes this condition?

The stoma is protruding into the bag and may become twisted. Feedback:During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if the stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom?

Urinary retention Feedback:Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Incontinence is involuntary loss of urine from the bladder. Frequency is voiding more often than usual.

A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure

a sterile catheterization kit or tray Feedback:The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The equipment used for catheterization is usually prepackaged in a sterile disposable kit or tray. Within the sterile disposable kit or tray, there is sterile solution to clean the vagina for placement of the catheter into the urethra. A clean catheter and rubber gloves are not used to catheterize a client.

A nurse is preparing to catheterize a female client. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra?

shorter in length Feedback:The anatomy of the urethra differs in males and females. The male urethra is about 5 1/2 to 6 1/4 inches (14 to 16 cm) long. The female urethra is about 1 1/2 to 2 1/2 inches (4 to 6 cm) long. This difference is important in terms of catheterization and risk for infection. The female anatomy does not have different innervation but it connects with the bladder similar to the male anatomy.

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?

straight catheter Feedback:The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time.