Exam 5

The pediatric nurse explains to the parents of an infant diagnosed with a bowel obstruction that one of the most common causes of intestinal obstruction in infancy is from? 1. Intussusception 2. Hypertrophic pyloric stenosis 3. Appendicitis 4. Celiac disease

1. Intussusception Intussusception is a condition that occurs when a proximal section of the intestine and the mesentery "telescopes" into a distal section of the intestine. Bloody, mucous-like bowel movements can occur.

A patient recovering from a partial nephrectomy is in the postanesthesia care unit. Which interventions would be a priority for this patient? Select all that apply. 1. Irrigate all catheters with sterile normal saline. 2. Label and secure all catheters, tubes, and drains. 3. Administer cough suppressant medication as needed. 4. Report the onset of bright red bleeding to the surgeon. 5. Connect all catheters and drains to a single collection device.

2. Label and secure all catheters, tubes, and drains. 4. Report the onset of bright red bleeding to the surgeon.

A patient admitted with possible kidney stones suddenly experiences acute crampy pain on the left side that radiates into the groin. The patient is nauseated, vomits clear fluid, and voids pink urine. What should the nurse do first? 1. Strain all urine. 2. Notify the physician. 3. Administer the prescribed narcotic analgesic. 4. Obtain a bladder scan to assess for residual urine.

2. Notify the physician.

During an assessment, the nurse suspects a male client is experiencing benign prostatic hyperplasia. On which body system is the patient experiencing symptoms that supports the nurse's suspicions? 1. skin integrity 2. bowel elimination 3. urinary elimination 4. peripheral vascular function

3. urinary elimination BPH has manifestations from urinary obstruction and a decrease in bladder contractibility and compliance.

The nurse identifies a patient with immobility is at risk for the development of urolithiasis. What should the nurse include when planning this patient's care? 1. Monitor urine pH. 2. Administer calcium supplements. 3. Maintain an indwelling urinary catheter. 4. Increase fluid intake to 3000 mL/day.

4. Increase fluid intake to 3000 mL/day.

A nurse is providing care for four clients on a medical surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers?

A client who has protein calorie malnutrition A client who has right sided heart failure and 4+ edema to the lower extremities A client who has postoperative delirium

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching? A. "Eating yogurt can help decrease the amount of gas that I have." B. "I should eliminate pasta from my diet so that I don't have as many loose stools." C. "My largest meal of the day should be in the evening." D. "Carbonated beverages can help control odor."

A. "Eating yogurt can help decrease the amount of gas that I have."

A nurse is instructing a client who is scheduled for a transurethral resection of the prostate (TURP) about his postoperative care. Which of the following information should the nurse include in the teaching? A. "You may have a continuous sensation of needing to void even though you have a catheter." B. "You will be on bed rest for the first 2 days after the procedure." C. "You will be instructed to limit your fluid intake after the procedure." D. "Your urine should be clear yellow the evening after the surgery."

A. "You may have a continuous sensation of needing to void even though you have a catheter."

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Encourage the use of the incentive spirometer every 2 hr B. Instruct to splint incision when coughing and deep breathing C. Reposition the client every 2 hr D. Administer antibiotic therapy E. Assist with early ambulation

A. Encourage the use of the incentive spirometer every 2 hr B. Instruct to splint incision when coughing and deep breathing C. Reposition the client every 2 hr E. Assist with early ambulation

A nurse is reinforcing teaching to a client who is experiencing constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply) A. Excessive laxative use B. Ignoring the urge to defecate. C. Inadequate fluid intake. D. Increased fiber in the diet. E. Increased activity

A. Excessive laxative use B. Ignoring the urge to defecate. C. Inadequate fluid intake.

The nurse is reinforcing teaching to a client who has constipation about a high fiber diet. Which of the following foods should be included as sources of fiber? (Select all that apply) A. Kidney beans B. Blackberries C. Refined cereals D. Whole wheat bread E. Lean turkey

A. Kidney beans B. Blackberries D. Whole wheat bread

A nurse is reviewing discharge instructions with a client who had spontaneous passage of a calcium phosphate kidney stone. Which of the following should be included in the teaching? (Select all that apply.) A. Limit intake of food high in animal protein. B. Reduce sodium intake. C. Strain urine for 48 hr. D. Report burning with urination to the provider. E. Increase fluid intake to 3 L/day.

A. Limit intake of food high in animal protein. B. Reduce sodium intake. D. Report burning with urination to the provider. E. Increase fluid intake to 3 L/day.

A nurse is caring for an older adult client on bed rest. Which of the following should be included in the client's diet? A. Stewed prunes B. Hash browns potatoes C. Eggs D. Citrus fruits

A. Stewed prunes

A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective the client should be taken to the bathroom at which of the following times? A. When the client has the urge to defecate. B. Q2h while the patient is awake. C. Immediately before meals. D. After client feels abdominal cramping.

A. When the client has the urge to defecate.

A nurse is completing discharge instructions with a client who has spontaneously passed a calcium oxalate stone. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) A. Red meat B. Black tea C. Cheese D. Whole grains E. Spinach

B. Black tea E. Spinach

A nurse is completing the admission assessment of a client who has a kidney stone. Which of the following is an expected finding? A. Bradycardia B. Diaphoresis C. Nocturia D. Bradypnea

B. Diaphoresis

A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? A. Decreased sensation in the lower extremities B. Diminished peripheral pulses in the lower extremities C. Pale, cool extremities D. Reddened areas over bony prominences

B. Diminished peripheral pulses in the lower extremities

A nurse in a provider's office is obtaining a history from a client who is being evaluated for benign prostatic hyperplasia (BPH). Which of the following findings are indicative of this condition? (Select all that apply.) A. Backache B. Frequent urinary tract infections C. Weight loss D. Hematuria E. Urinary incontinence

B. Frequent urinary tract infections D. Hematuria E. Urinary incontinence

A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following assessment findings requires immediate intervention by the nurse? A. Flank pain that radiates to the lower abdomen B. Client report of nausea C. Absent urine output for 2 hr D. Client report of feeling sweaty

C. Absent urine output for 2 hr

A nurse is caring for a child who is in the postoperative period following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding? A. Hgb of 11.6 and Hct of 37% B. Inflamed and reddened throat C. Frequent swallowing and clearing of the throat D. Blood-tinged mucus

C. Frequent swallowing and clearing of the throat

A pregnant client tells the nurse she has constipation. What is the appropriate nursing recommendation for this client? A. Regular use of a laxative B. Maintenance of good posture C. Increase cellulose and fluid in the diet D. Regular use of glycerine suppositories

C. Increase cellulose and fluid in the diet

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following should the nurse include in the planning? A. Keep the ulcer bed dry. B. Clean the wound from the outer edge towards the center. C. Provide the client a high vitamin C diet. D. Reposition the client at least q4h.

C. Provide the client a high vitamin C diet.

How does the nurse position a client with postoperative nausea and vomiting? A. Flat in bed, with the head in alignment with the body B. Prone, with the head of the bed flat C. Side-lying, with the head in a neutral position D. Supine in bed, with the neck flexed

C. Side-lying, with the head in a neutral position

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? A. Pain at the surgical site B. Requirement for verbal stimuli to awaken C. Snoring sounds when inhaling D. Sore throat on swallowing

C. Snoring sounds when inhaling

The nurse is caring for a client who has returned from gastric resection surgery with an indwelling nasogastric tube. What is the appropriate nursing intervention for this client? A. Eliminate mouth care to reduce the possibility of dislodgment B. Untape the tube periodically C. Administer warm saline throat irrigations D. Keep the nostrils clean and lubricated

D. Keep the nostrils clean and lubricated

A nurse is caring for a client who practices Orthodox Judaism. The nurse should recognize which of the following foods provided together on the same dinner tray can be in violation of the clients religious practices? A. Kosher roast beef and ice cream B. Carrot sticks and cottage cheese C. Macaroni and cheese and peas D. Kosher chicken breast and boiled potatoes.

D. Kosher chicken breast and boiled potatoes.

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? A. Decrease expected blood loss during surgery B. Eliminate any risk of infection C. Ensure that the bowel is sterile D. Reduce the number of intestinal bacteria

D. Reduce the number of intestinal bacteria

A nurse is caring for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). The nurse should anticipate a prescription for which of the following medications? A. Oxybutynin (Ditropan) B. Diphenhydramine (Benadryl) C. Ipratropium (Atrovent) D. Tamsulosin (Flomax)

D. Tamsulosin (Flomax)

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as cause of constipation?

Excessive laxative use. Ignoring the urge to defecate. Inadequate fluid intake.

A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain?

Renal stones

Which of the following is a true statement about the effects of medication on bowel elimination? a. Diarrhea commonly occurs with amoxicillin clavulanate use b. anticoagulants cause a white decoloration of the stool c. narcotic analgestics increase gastrointestinal motility d. iron salts impair digestion and cause a green stool

a. Diarrhea commonly occurs with amoxicillin clavulanate use

Which of the following would be common nursing diagnosis for the patient with an ileostomy? a. Disturbed body image b. constipation c. delayed growth and development d. excess fluid volume

a. Disturbed body image

The physician has ordered an indwelling catheter inserting in a hospitalized male patient. The nurse is aware of which of the following consideration? a. The male urethra is more vulnerable to injury during inspection b. In the hospital, a clean technique is used for catheter insertion c. The catheter is inserted 2" to 3" into to meatus d. Since it uses a closed system, risk for urinary tract infection is absent

a. The male urethra is more vulnerable to injury during inspection

Which of laxative acts by causing the stool to absorb water and swell? a. bulk-forming b. emollient c. lubricant d. stimulant

a. bulk-forming

After surgery, Ms. Young is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? a. pouring warm water over Ms. Young's fingers b. Having Ms. young ignore the urge to void until her bladder is full c. using a warm bedpan when Ms. Young feels the urge to void d. Stroking Ms. youngs leg or thigh

b. Having Ms. young ignore the urge to void until her bladder is full

When collecting a urine specimen for routine urinalysis from a patient, the nurse keeps in mind which of the following? a. A sterile specimen is required for collection. b. Results may be altered if a sample is left standing at room temperature for a long time. c. The external meatus requirements cleaning with antiseptic soap and water before voiding d. A cleaning- catch midstream specimen is necessary

b. Results may be altered if a sample is left standing at room temperature for a long time.

If a patient was instructed to avoid foods that may have a laxative effect, the nurse would advise the patient to avoid which of the following foods? a. Cheese b. alcohol c. eggs d. pasta

b. alcohol

Which of the following terms denotes a patient's inability to void even though the kidneys are producing urine that enters the bladder? a. urgency b. retention c. oliguria d. dysuria

b. retention

Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this? a. they will cause a fecal impaction b. they will cause a chronic constipation c. they change the pH of the gastrointestinal tract d. they inhibit the intestinal enzymes

b. they will cause a chronic constipation

Mr. T is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test by explaining that it allows which of the following? a. visual examination of the esophagus and stomach b. visual examination of the large intestines c. radiographic examination of the large intestines d. fluoroscopic examination of the small intestines

b. visual examination of the large intestines

Nursing care for a patient with an indwelling catheter includes which of the following? a. Irrigation of the catheter with 30 mL of normal saline solution every 4 hours b. Disconnecting and reconnecting the drainage system quickly to obtain a urine specimen. c. Encouraging a generous fluid intake if not contraindicated by the patient's condition. d. Telling the patient that burning and irritation are normal, subsiding within a few days.

c. Encouraging a generous fluid intake if not contraindicated by the patient's condition.

Mr. Bales is 60 year old and alert. He is timid and reluctant to talk about his urinary retention problem. Which part of this plan could create stress for Mr. Bales and possible increase his inability to urinate? a. Assisting him in assuming his normal voiding position b. pulling curtains around him to provide privacy during voiding c. staying with him while voiding d. offering the urinal on a regular schedule

c. staying with him while voiding

Which of the following would the nurse incorporate into the teaching plan for a patient to promote healthy urinary functioning? a. Drinking more than 2,000 mL of fluid per day will cause fluid retention b. The healthy adult should drink four to six 8-ounce glasses of water per day. c. Children need fewer reminders to drink because of greater thirst sensitivity d. Caffeine- containing beverages should be monitored to prevent excess intake.

d. Caffeine- containing beverages should be monitored to prevent excess intake.

As a nurse prepares to assist Mrs. P with her newly created ileostomy, she is aware of which of the following? a. An appliance will not be required on a continual basis b. The size of the stoma stabilizes within 2 weeks c. Irrigation is necessary for regulation d. Fecal drainage will be liquid

d. Fecal drainage will be liquid

Mrs. Lonte is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which of the following assessments would indicate her diet should not be advanced? a. Mrs. Lonte consumed 75% of the liquids on her breakfast b. Mrs. Lonte tells you she is hungary c. Mrs. Lonte's abdomen is soft, nondistened, with bowel sounds d. Mrs. Lonte reports fullness and diarrhea after breakfast.

d. Mrs. Lonte reports fullness and diarrhea after breakfast.

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Of the information below, which is least important for the evaluation process? a. The incontinence pattern b. state of physical mobility c. medications being taken d. age of the patient

d. age of the patient

A bowel training program includes which of the following? a. Using a diet that is low in bulk b. decreasing fluid intake to 1,000 mL c. administering an enema once a day to stimulate peristalsis d. allowing ample time for evacuation

d. allowing ample time for evacuation

Which of the following is an appropriate nursing to promote regular bowel habits? a. encouraging the patients to avoid moving his bowel until a certain time of the day b. encourage the patient to avoid excess fluid intake and too much fiber c. avoiding strenuous exercise to limit stress on abdominal muscle and impair peristalsis d. assisting the patient to as normal position as possible to deficate

d. assisting the patient to as normal position as possible to deficate

Mr. Cheng, a hospitalized patient with diabetes mellitus, has developed a UTI. He is 80 years old and has an indwelling catheter in place. Which factor is most likely the cause of his UTI? a. The close proximity of the male genitalia to the rectum b. Decreased immunity c. A high urine glucose level d. the indwelling urinary catheter

d. the indwelling urinary catheter