Final Exam
When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection?
Performing hand hygiene before and after providing perineal care
The nurse is caring for a client with a fractured femur that has not been repaired. Fat emboli and pulmonary emboli are both potential complications of this condition. Which symptoms would be suggestive of fat emboli versus a pulmonary emboli?
Petechiae over the trunk and in axillary folds
An older client is admitted for treatment of a fractured left hip. The fracture is repaired by internal fixation. What would be a priority nursing intervention regarding positioning this client in the immediate postoperative period?
Placing a pillow or foam frame between the legs to maintain abduction of the left leg
The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection?
Placing the drainage bag on the side rail of the patient's bed
o The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is
Pressure
The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete?
Provide analgesic medication as ordered.
Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective?
Recording an output that is larger than the amount instilled
foods of iron
Red meat, pork, poultry, beans, dark leafy veg, iron fortified cereals
Pt has limited movement and needs helps with meals, what do you do
Request OT
o In providing oral care to an unconscious patient, it is important for the nurse to
Rinse the mouth and immediately suction the oral cavity.
Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority?
Risk of infection
A patient has developed a decubitus ulcer. What laboratory data would be important to gather?
Serum albumin
Immobility complications
Skin breakdown, demineralized bones, increased cardiac workload, thrombus formation
The nurse has been falsely accused of providing inadequate care to a patient by another nurse. The nurse has received praise in the past for providing quality care to the patients. Which tort does this indicate?
Slander
Which physiological change can cause a paralytic ileus
Surgery for Crohn's disease and anesthesia
Subjective data
Symptoms described by the patient or "What the patient says, not necessarily what the nurse sees"
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
Take a stool softener such as docusate sodium daily.
A patient who is hospitalized with chronic illness is depressed and demands to go home. The nurse applies a physical restraint and administers medication to the patient. What does this nursing intervention indicate?
The nurse may be charged with false imprisonment.
Which nursing observation would indicate that the patient was at risk for pressure ulcer formation
The patient has fecal incontinence
The surgical nurse is collecting the necessary documents to obtain a patient's informed consent before a surgery. In which instance should the nurse refrain from obtaining informed consent?
The patient was administered morphine.
Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation?
Urinary output of 20 mL/hr over 2 hours
The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient?
Utilize a transfer sliding board and assistance to slide the patient into the new position
o An 11-year-old girl comes into the health care provider's office stating dysuria. The nurse suspects a urinary tract infection. Which findings on the laboratory report is consistent with a urinary tract infection?
WBCs: 20 per high-power field.
What are some complications with tap water enema
Water intoxication, hyponatremia
Which of the following statements by the client who has recently had a total hip replacement indicates that the client does not understand the mobility limitations?
"It is okay to cross my legs if I am sitting in a chair."
What protein would you substitute for a toddler who is vegetarian
(At risk for B12 deficiency) Cheese, fortified cereal, eggs, yogurt, soy
What is a grain? Which answer choice is 1oz of grains?
1 slice of bread, ½ cup rice, 1 mini bagel
When caring for a patient with urinary retention, the nurse would anticipate an order for
A urinary catheter.
Using NG tube, when do you use it for feeding for pt to get nutrition
After placement has been verified by X-ray and gastric contents are tested
Where do you assess the heart rate on an infant
Brachial
You have wound dressings, how do you dispose of the soiled dressings
biohazard
Which nursing intervention for catheter care should have the highest priority?
cleaning the area around the urethral meatus
About to collect stool specimen, and put on wrong size sterile gloves
does not have to be sterile gloves, can use regular gloves
Pressure Ulcer Stage 3
full thickness tissue loss with visible fat
Pressure Ulcer Stage 1
nonblanchable erythema of intact skin
A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding?
"My medication may discolor my urine; this should resolve once the medication is stopped."
What IV site would you use for TPN
(large veins) Superior vena cava, subclavian, jugular
The nurse is collecting data on a client with a urinary tract infection (UTI). Which statements should the nurse expect the client to make? Select all that apply.
- "I need to urinate frequently." -"It burns when I urinate." - "I need to urinate urgently."
The nurse properly obtains a 24-hour urine specimen collection by
-Asking the patient to void and to discard the first sample. -Keeping the urine collection container on ice.
What are contraindications to give oral medications
-Aspiration risk -Unconscious patients -If gastric suction is present - Surgical resection of GI tract, irritation of GI tract
The nurse has failed to obtain informed consent before performing a procedure on a patient. Which type of torts result from this nursing action?
-Battery -Negligence
When witnessing a patient giving informed consent prior to undergoing surgery, which actions should the nurse perform?
-Confirm that the patient has understood the information about the surgery. -Inform the healthcare provider if the patient refuses to undergo the surgery. -Sign the consent form as a witness, once the patient voluntarily gives consent.
The nurse is caring for a surgical patient in the preoperative area. The nurse witnesses the patient's informed consent for the surgical procedure. Which statements are true regarding informed consent? Select all that apply.
-It must be signed while the patient is free from mind-altering medications. -It may be withdrawn at any time. -It is usually obtained by the healthcare provider and not the nurse.
Which nursing actions are acceptable when collecting a urine specimen?
-Labeling all specimens with date, time, and initials -Allowing the patient adequate time and privacy to void -Transporting specimens to the laboratory in a timely fashion -Placing a plastic bag over the child's urethra to catch urine
What should the nurse do to prevent catheter associated urinary tract infection (CAUTI)? Select all that apply. a) Provide perineal care several times a day. b) Encourage the client to drink 3,000 mL of fluids a day. c) Monitor the temperature as an indicator of the infection. d) Recommend the health care provider (HCP) prescribe antibiotics. e) Change the catheter daily.
-Provide perineal care several times a day. -Encourage the client to drink 3,000 mL of fluids a day. -Monitor the temperature as an indicator of the infection.
The nurse hears a physician say to the charge nurse that he doesn't want that same nurse caring for his patients because she is stupid and won't follow his orders. The physician also writes on his patient's medical records that the same nurse, by name, is not to care for any of his patients because of her incompetence. What component(s) of defamation has the physician committed?
-Slander -Libel
Risk factors for constipation
-dehydration -insufficient fiber intake -cognitive impairement/mobility -mechanical- twisted bowels -side effects of medication: 1.anticholinergic side effects (antidepressants, neuroleptics, antihistamines, antiparkinsonian agents) 2. some antihypertensive agents (ACE inhibtors, diuretics, calcium channel blockers)
The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s)
4
The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline the nurse will follow?
A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.
Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take?
Administer the ordered oral opioid pain medication.
Type of isolation for TB
Airborne
Your disposing of narcotics, who do you use as a witness
Another nurse
You want to give newborn an IM injection, where do you give it
Anterolateral thigh
Fat embolism is a major complication of a client with a fractured femur. What assessment finding would alert the nurse to the possibility of this complication occurring?
Blood-tinged sputum
Organs of immunity
Bone marrow, thymus, tonsils, skin, mucous membranes
The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include?
Bowel sounds
Have a sustained release tablet, and another nurse did something to it (crushed it). What do you do?
Cannot administer, need to get a new pill or receive a new order for a less dose if entire enteric pill is too much
Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?
Complaint by patient that something has given way
The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse?
Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.
A client has a fractured femur and is scheduled for surgery and stabilization with internal fixation. The nurse is assessing the client for the development of a fat embolism. What early assessment findings would suggest the development of this complication?
Confusion and restlessness
A client with Crohn's disease is scheduled for a barium enema. What should the plan of care include today to prepare for the test tomorrow?
Encourage plenty of fluids.
High calcium foods include
Dairy products, soy/almond milk, dark leafy greens, fish with edible bones (sardines)
Giving pt pain meds, which route to give it
Depends on the status of the patient
When establishing a diagnosis of altered urinary elimination, the nurse should first
Discuss causes and solutions to problems related to micturition.
1. Someone with a fever, does it matter how fast you cool them down?
Do not want them to shiver, as this is counterproductive and uses energy
Have a pt who states something on a living will, but then something is opposing or a contrast to the living will; what do you do
Ensure that the advance directives reflect the client's current decisions.
When do you use different feeding methods
Enteral, IV feeding, purée
The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because
Escherichia coli pathogens are transmitted during surgical or catheterization procedures.
A client's x-ray film shows a fractured right femur. The nurse will assess the client for what potential complication?
Fat embolus
What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine?
Fever and chills
The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom?
Frequency
Pressure Ulcer Stage 4
Full thickness tissue loss with exposed bone, tendon, or muscle; extensive destruction; tissue necrosis; slough and eschar may be present; often includes undermining and tunneling
Checking pre-op V/S. Why do you do this before someone goes to surgery? What's the most appropriate reason
Gain a baseline and assess for the presence of any surgical risks
The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk?
Gentle cleaners and thorough drying of the skin
Doffing PPE what is removed first
Gloves
Given a topical corticosteroid for pt who has psoriasis, what can you do to enhance the effects of the corticosteroids?
H 2 drugs Pepcid and Zantac
Giving TPN and about to run out of TPN. Means they're running out of nutrition.
Hang dextrose or something with glucose or they can become hypoglycemic
A nurse notifies the provider immediately if a patient with an indwelling catheter
Has not collected any urine in the drainage bag for 2 hours.
To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to
Hold the labia apart while voiding into the specimen cup.
The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage
II
A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take?
Increase fluids.
The unconscious patient is resisting attempts by the nurse to provide oral hygiene. To provide the needed care, the nurse may
Insert an oral airway upside down.
Heart rate of an infant
Is 80 to 160 b/m
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?
Less than 2 hours
A patient is abusive and rude with the student nurse. The student nurse documents that the patient is uncooperative and shows symptoms of alcohol withdrawal. As a result the patient will be transferred to a different floor. Which is the best classification of this nurse's error?
Libel
A patient suffering from cardiac arrest is brought to the hospital. The patient previously underwent a coronary artery bypass graft (CABG) and angioplasty, and the patient has been chronically ill since then. The patient has requested in writing that not to be resuscitated in case of emergency. What is the term for this request?
Living will
A client returned from surgery eight hours ago and has not voided. Which action should the nurse take first?
Palpate over the synthesis pubis for fullness.
What is a proper needle length for IM
a. 1-1.5 inches
Medication reconciliation. Why do you do it?
a. Identifies medication discrepancies and prevents errors b. Obtain all patient medications, review what has been taken, compare with what is ordered, communicate
What do you do when you drop a tablet
a. Throw it away, document
What lab do you take that indicates malnutrition
albumin
As a nurse why do you delegate?
allows a qualified healthcare worker, like an RN, to transfer routine and low-risk duties to nursing assistive personnel.
The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?
an orange, raisin bran and milk, and wheat toast with butter
When do you hold digoxin
apical rate of less than 60 BPM
o The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.)o a. Mobility b. Hyperemia c. Induration d. Blanching e. Temperature of skin f. Nutritional status
b. Hyperemia c. Induration d. Blanching e. Temperature of skin
Have a pt in bucks traction, how do you promote mobility when they're out of traction
o Skin traction
Pressure Ulcer Stage 2
partial thickness skin loss involving epidermis, dermis, or both
How do you obtain BP?
proper cuff size don't cross legs
Assessing pulses
rate, rhythm, elasticity, force
The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 22 kg, has a normal saline lock in his right hand, and has had 30 mL of urine output in the last four hours. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for:
starting a fluid bolus of normal saline.
