Foundations Weeks 9-14

The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) A. Asking the patient to void and to discard the first sample. B. Keeping the urine collection container on ice. C. Withholding all patient medications for the day. D. Asking the patient to notify the staff before and after every void.

A, B Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine in cool condition. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution.

A recently hired nurse is preparing to ambulate a client with limited mobility, for the first time. What must the nurse consider about safety? (Select all that apply) A. How much can the client assist? B. Does the nurse require assistance from other nurses? C. Does the hospital have a no-lift policy? D. Is the client at risk for orthostatic hypotension? E. The height of the bed should be at waist level.

A, B, C, D Rationale: Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients. The use of patient-handling equipment in combination with proper body mechanics is more effective than either one. Body mechanics cannot be ignored even when patient handling equipment is being used. Manual lifting is the last resort, and it is only used when there is sufficient help.

The nurse should assess for which potential complications of physical immobility? (Select all that apply.) A. Pneumonia B. Decreased urine output C. Hypertension D. Activity intolerance E. Urinary stasis

A, B, D, E Rationale: Immobility leads to complications such as pulmonary emboli or pneumonia. Other possible diagnoses include impaired skin integrity. Insomnia and social isolation are more common complications than somnolence or increased socialization.

Which interventions, for the family, should the nurse implement at the time of a client's death? (Select all that apply.) A. Listen to the family as family members express their needs. B. Avoid giving the family advice. C. Postpone the discussion of organ donation. D. Remind the family the patient is no longer suffering. E. Ask the family how the nurse can best assist them.

A, B, E Rationale: After the death of a patient, the nurse turns his/her focus on the family. In other words, the family becomes "the patient." The nurse uses assessment to determine the immediate needs of the family. By law, health care providers are expected to talk to family members about organ donation.

A nurse is doing discharge teaching for a patient who is going home with an illeostomy. What should the nurse teach the patient about application of a pouch. Select All That Apply. A. Apply protective skin barrier. B. Select a pouch that is able to hold sufficient output to reduce the frequency of pouch emptying. C. Thoroughly scrub the skin around the stoma to remove excess stool and adhesive. D. Only purchase pouches that are pre-cut by the manufacture. E. How to open and close the pouch.

A, B, E Rationale: Selecting a pouch that holds a large volume of output will decrease the frequency of emptying the pouch and may ease patient anxiety about pouch overflow. The barrier device should be changed every few days unless it is leaking or is no longer effective. Periostomal skin should be gently cleansed, vigorous rubbing can cause further irritation or skin breakdown. A pre-cut pouch may not accommodate the size of every stoma. Therefoer a pouch that allows the patient to cut the opening may be needed. Learning how to correctly open and close a pouch may prevent accidental leakage.

A client, taking an antibiotic, suddenly exhibits symptoms associated with a mild allergic response. Select All That Apply. A. Hives (urticaria) B. Wheezing C. Itching (pruritus) D. Difficulty breathing (dyspnea) E. Watery discharge from the nose (Rhinitis)

A, C, E Rationale: Hives, itching, and watery discharge from the nose are all symptoms of a mild reaction. Wheezing and difficulty breathing are symptoms of a severe allergic reaction (anaphylactic reaction).

What are the physiological responses to pain? (Select All That Apply) A. Increased oxygen intake. B. Stimulation of the Parasympathetic Nervous System C. Pupillary constriction D. Increased blood supply to peripheral circulation. E. Decreased gastrointestinal motility.

A, E Rationale: Irritability and Social isolation are PSYCHOLOGICAL responses to pain.

Which statement by the patient indicates an understanding of atelectasis? A. "It is important to do breathing exercises every hour to prevent atelectasis." B. "If I develop atelectasis, I will need a chest tube to drain excess fluid." C. "Atelectasis affects only those with chronic conditions such as emphysema." D. "Hyperventilation will open up my alveoli, preventing atelectasis."

A. "It is important to do breathing exercises every hour to prevent atelectasis." Rationale: Atelectasis develops when alveoli do not expand. Breathing exercises increase lung volume and open the airways. Deep breathing opens the pores of Kohn between the alveoli to allow sharing of oxygen between alveoli. This prevents atelectasis from developing.

The nurse wants to support the autonomy of an elderly patient. Which intervention would be best to support the patient's independence? A. Allow the patient to decide which activities of daily living he wishes to do on his own. B. Ask the patient what type of help he receives at home. C. Tell the patient that a male tech can assist him with his personal hygiene. D. Tell the patient not to feel embarrassed if he needs help with personal hygiene.

A. Allow the patient to decide which activities of daily living he wishes to do on his own. Rationale: The best response is to give the client an opportunity to select which activities of daily living he is capable of performing by himself. All of the other options are either treating the patient disrespectfully or encouraging the patient's dependence.

A client smokes two packs of cigarettes per day. Postoperatively, what are the client's greatest risks? A. Atelectasis, pneumonia, and fever B. Hypotension, aspiration, and fever C. Malignant hyperthermia, atelectasis, and fever D. Clostridium difficile, hypotension, and fever

A. Atelectasis, pneumonia, and fever Rationale: Smokers who have surgery have a greater difficulty than nonsmokers clearing the airways of mucous secretions and are more likely to experience atelectasis, pneumonia, and fever. Hypotension, aspiration, and fever are not necessarily indicators of poor ventilation status for smokers. Malignant hyperthermia is a hereditary condition due to anesthetic complications. Clostridium difficile is a bacteria usually caused by antibiotic therapy that has disrupted the normal digestive flora.

The nurse is assessing a patient 2 hours after colon surgery. Based on the procedure done, what focused assessment will the nurse include? A. Bowel sounds B. Presence of flatulence C. Bowel movements D. Nausea

A. Bowel sounds Rationale: Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. The patient is NPO until the bowel sounds return.

Day four, postoperatively, a client has a sudden coughing episode and tells the nurse "something popped" in the abdominal incision. Upon inspection, the nurse finds evisceration has occurred. What nursing action should be taken first? A. Cover the area with a large sterile, saline-soaked dressing. B. Position the client in bed with knees bent. C. Attempt to re-insert the intestines back into the abdomen. D. Pack the wound with nonadherent gauze.

A. Cover the area with a large sterile, saline-soaked dressing. Rationale: Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurse's first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist. While notifying the surgeon and positioning the client are important, covering the wound is the priority. Nothing should be packed into this wound. Implementation Physiologic integrity Application

A student nurse reported to the instructor that a patient, who had not had a bowel movement in 4 days, was experiencing diarrhea. The instructor explained that watery stools may be a symptom of A. an adverse effect of a medication. B. a possible impaction. C. an intestinal parasite. D. increased peristalsis related to stress.

B. a possible impaction. Rationale: The nurse should suspect an impaction when a continuous oozing of liquid stool occurs in a patient that has not had a bowel movement for several days. The liquid part of feces located higher in the colon seeps around the impacted mass.

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? A. Grape and walnut chicken salad sandwich on whole wheat bread B. Broccoli and cheese soup with potato bread C. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing D. Turkey and mashed potatoes with brown gravy

A. Grape and walnut chicken salad sandwich on whole wheat bread Rationale: A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.

The nurse completes the Braden scale for the client being cared for(see figure). Based on the nurse's assessment, select the nursing intervention the nurse will include in the client's plan of care to prevent a pressure injury. A. Inspect skin when repositioning, toileting &assisting with ADLs. B. Use foam wedges or pillows to support lateral 15 - 30° tilt. C. Collaborate with occupational therapy, physical therapy or wound care. D. The nurse does not need to intervene at this time.

A. Inspect skin when repositioning, toileting &assisting with ADLs. Rationale: Prevention minimizes the impact that risk factors or contributing factors have on pressure ulcer development. Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence, (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces, and (3) education.

During drug therapy for pneumonia, a client develops a superinfection. The nurse explains that this infection is caused by: A. Large doses of antibiotics that kill normal flora. B. The infection spreading from her lungs to the new site of infection. C. Resistance of the pneumonia-causing bacteria to the drugs. D. An allergic reaction to the antibiotics

A. Large doses of antibiotics that kill normal flora. Rationale: A secondary microbial infection that occurs in addition to an earlier primary infection, often due to weakening of the patient's immune system by the first infection. It can also occur as a result of an organism not susceptible to the antibiotic used.

A client is admitted to the Medical-Surgical unit due to complications related to gallstones. The client is complaining of shoulder pain. Which is the likely explanation for this pain? A. Organ pain often results in referred pain, this explains why gallstones may cause shoulder pain. B. The client is experiencing confusion related to the anxiety caused by prolonged, severe pain. C. The clientt is experiencing prescription drug addiction lie about pain in order to receive medication. D. Bradykinin, released due to tissue destruction, enters the blood stream causing pain to travel systemically.

A. Organ pain often results in referred pain, this explains why gallstones may cause shoulder pain. Rationale: Referred pain: Common in visceral pain because many organs themselves have no pain receptors. Pain is felt in a separate part of the body from the source of the pain.

A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to A. Perform pelvic floor exercises. B. Drink cranberry juice. C. Avoid voiding frequently. D. Wear an adult diaper.

A. Perform pelvic floor exercises. Rationale: Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises, this solution best addresses the patient's problem. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding, residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail.

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient spironolcatone. What electrolyte imbalance is the nurse primarily concerned about? A. Potassium imbalance B. Sodium imbalance C. Calcium imbalance D. Phosphate imbalance

A. Potassium imbalance Rationale: Spironolactone is a potassium-sparing diuretic. An adverse effect of a potassium-sparing diuretic is hyperkalemia.

What assessment finding is the earliest sign of hypoxia? A. Restlessness B. Decreased blood pressure C. Cardiac dysrhythmias D. Cyanosis

A. Restlessness Rationale: Hypoxia is due to inadequate tissue oxygen at the cellular level. The earliest sign of hypoxia is restlessness. As it progresses, mental status changes, cardiac changes, and cyanosis can occur. Early hypoxia results in an elevated blood pressure. In later hypoxia, vital sign changes such as increased heart and respiratory rate occur. Cyanosis is a late sign of hypoxia.

A couple with two children are also caring for an aging parent who has become physically disabled. The couple may experience A. Role Strain B. Substance abuse C. Illness D. Economic stability

A. Role Strain Rationale: role strain is a manifestation of family function when events force changes in roles - when a parent becomes physically dependent on their adult children with roles of mother, father, wife, employee, etc. Role strain develops when family members cannot adapt and meet their needs

A patient has abdominal surgery and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? A. Surgical asepsis B. Increased T cells C. Decreased antibiotics D. Increased vitamin C

A. Surgical asepsis Rationale: Patients are at risk for nosocomial infections when the healthcare staff does not follow safety guidelines. Medical and surgical asepsis is the primary safety intervention for preventing disease in the healthcare environment.

Na+, K+, and Ca++ are positively charged ions called A. anions B. cations C. millimoles D. osmols

B. cations

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome would the nurse evaluate as being successful? A. The patient reports eliminating a soft, formed stool. B. The patient has quit taking opioid pain medication. C. The patient's lower left quadrant is tender to the touch. D. The nurse hears bowel sounds present in all four quadrants.

A. The patient reports eliminating a soft, formed stool. Rationale: The nurse's goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not further address bowel elimination. Present bowel sounds indicate that the bowels are moving, however, they are not an indication of defecation.

The middle-aged client reports having diabetes mellitus since childhood. Today's blood glucose reading is 180. Because of this history, the nurse would monitor this client for which sensory disturbance? A. Vision loss B. Hearng loss C. Loss of ablity to taste D. Loss of ability to smell

A. Vision loss Rationale: Uncontrolled diabetes mellitus is a leading cause of blindness in the United States.OBJ 26 A,D

The physician asks the nurse to monitor the fluid volume status of a patient at risk for clinical dehydration. What is the most effective nursing intervention for assessing dehydration? A. Weigh the patients every morning before breakfast. B. Ask the patients to record their intake and output. C. Measure the patients' blood pressure every 4 hours. D. Assess the patients for edema in extremities.

A. Weigh the patients every morning before breakfast. Rationale: An effective measure of fluid retention or loss is daily weights, each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with ECV deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.

The nurse knows anemia can cause A. hypoxemia. B. hyperglycemia. C. hypovolemia. D. hypercalcemia.

A. hypoxemia. Rationale: Patients who are anemic do not have the same level of oxygen-carrying capacity. As a result, oxygen is unable to properly perfuse the tissues, resulting in hypoxemia. Impaired ventilation occurs when oxygen/carbon dioxide exchange occurs at the alveolar level. Hypovolemia is related to decreased circulating blood volume. Lung compliance is related to the elasticity of the lung tissue.

A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that A. long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. B. laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. C. natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation. D. laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

A. long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. Rationale: Long-term laxative use can lead to constipation. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Natural laxatives like mineral oil come with their own set of risks, such as inability to absorb fat-soluble vitamins. Even if malnourished, the body will produce waste if substance is consumed.

The mother of a recently deceased child keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. This behavior is defined as ______________ grief. A. normal B. prolonged C. exaggerated D. complicated

A. normal Rationale: Family members will grieve differently. One sign of normal grief is keeping the deceased individual's room intact as a way to keep that person alive in the minds of survivors. This is happening after the family member is deceased, so it is not prolonged grief. It is not abnormal or complicated grief, the child died recently.

The nurse is concerned about pulmonary aspiration when providing the patient with tube feedings. The nurse should A. verify tube placement before feeding. B. lower the head of the bed to a supine position. C. add blue food coloring to the enteral formula. D. run the formula over 12 hours to decrease volume.

A. verify tube placement before feeding. Rationale: A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs to verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward. The addition of blue food coloring to enteral formula to assist with detection of aspirate is no longer used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium for bacterial growth after that length of time.

Which factors increase a patient's risk for impaired skin integrity? (SELECT ALL THAT APPLY) A. Sufficient circulating volume B. Altered sensory perception C. Skin moisture D. Deficient nutritional status E. Position change every 2 hours

B, C, D Rationale: Sufficient circulating volume indicates adequate blood flow to the skin, thereby decreasing the risk for impaired skin integrity.

The nurse concludes that docusate sodium is appropriate for which clients? SELECT ALL THAT APPLY. A. A client preparing for a colonoscopy who needs a bowel prep. B. A postoperative client taking opioid analgesics for pain . C. To soften a fecal impaction. D. A patient with excessive flatus. E. A client with painful hemorrhoids.

B, C, E Rationale: Docusate sodium is a stool softener and would not be appropriate for excessive flatus,or as a cleansing prep for a colonoscopy.

The nurse is teaching a patient, scheduled for surgery, instructions on how to use an incentive spirometer. The patient tells the nurse, "I don't understand how using this device will help me after surgery." Select the appropriate response by the nurse. A. "It will decrease the pain you will experience." B. "It will decrease the risk of developing problems in your lungs." C. "It will prevent the formation of clots in your legs." D. "It will help keep your blood pressure within a normal range."

B. "It will decrease the risk of developing problems in your lungs." Rationale: There is solid evidence to support the use of lung expansion with incentive spirometry in preventing post-operative complications following surgery.

The nurse is caring for the clients listed below. Which client does the nurse note as at risk for a pressure injury? A. A 55-year old female who has controlled diabetes and is ambulating three times a day. B. A 35-year old male who weighs 102 pounds, is incontinent of stool, and has a right leg splint. C. A 45-year old with a Braden Scale score of 23. D. A 22-year old female who is recovering from an appendectomy.

B. A 35-year old male who weighs 102 pounds, is incontinent of stool, and has a right leg splint. Rationale: A client's exposure to urine, bile, stool, ascitic fluid, and purulent wound exudate carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition.

A student nurse visiting a nutrition center for the elderly tells the nursing instructor 'It is so depressing to see all these old people. They seem so weak and frail. They are probably all senile.' What term best describes the nursing student's comment? A. Reality B. Ageism C. Vulnerability D. Empathy

B. Ageism Rationale: Ageism is defined as a bias against older people because of their age. It differs in other forms of discrimination as it cuts across gender, race, religion and socioeconomic status.

A post-operative patient, who has been on prolonged, complete bedrest, as a result of complications resulting from hip surgery, complains of pain in the right calf. The nurse notes swelling, warmth, and redness. The nurse is concerned about which post-operative complication? A. Wound infection B. Deep vein thrombosis C. Atelectasis D. Hemorrhage

B. Deep vein thrombosis Rationale: Deep vein thrombosis symptoms commonly originates in the large veins of the legs because of the legs' relatively low velocity of blood flow. The most common cause is venous stasis as a result of immobility.

The nurse finds a client severely dyspneic, with a respiratory rate of 32 and lying in a supine position. What is the priority nursing intervention? A. Assess the client's oxygen saturation B. Elevate the head of the bed C. Take the vital signs D. Call the physician

B. Elevate the head of the bed Rationale: Severe dyspnea is associated with hypoxia. The priority nursing intervention is to elevate the head of the bed to improve respiratory effort, obtain pulse oximetry reading and administer oxygen if needed. The supine position would worsen the dyspnea/hypoxia.

The nurse is ambulating a client in the hall and the client begins to fall. What should the nurse do first to prevent injury to the client? A. Widen the client's base of support. B. Gently lower the client to the floor. C. Assess the client for orthostatic hypotension. D. Request assistance from nursing team.

B. Gently lower the client to the floor. Rationale: If the patient has a fainting episode or begins to fall, the nurse, not the patient, should assume a wide base of support with one foot in front of the other, thus supporting the patient's body weight. Then extend one leg and let the patient slide against the leg, and gently lower the patient to the floor, protecting the patient's head. Assessing the patient for orthostatic hypotension would not be the priority action to prevent immediate fall injury. Calling for assistance is beneficial, but there is no way to ensure that assistance will arrive soon enough to prevent injury to the patient.

The client was admitted with complications of bleeding. The client complains of feeling tired, listless and unable to tolerate normal activities. Which diagnostic test would the nurse review first? A. Blood urea nitrogen B. Hemoglobin and hematocrit C. Serum potassium D. Blood glucose

B. Hemoglobin and hematocrit Rationale: While disturbances in all of these laboratory values could be implicated in this client's complaints, the most likely would be a decrease in hemoglobin and hematocrit. Hemoglobin is the oxygen-carrying portion of the blood, and anemia (decrease in hemoglobin and hematocrit) is often associated with a client's complaint of feeling tired, listless, and unable to tolerate normal activities.

When a patient is experiencing excess fluid volume, what assessment data would the nurse find? A. Weak, thready pulse B. Hypertension C. Dry mucous membranes D. Flushed skin

B. Hypertension Rationale: Hypertension and a bounding pulse are symptoms of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.

Fluid located inside the cell wall is called ______________ fluid. A. Extracellular B. Intracellular C. Intravascular D. Interstitial

B. Intracellular

The nurse assesses a client's wound and notes the presence of a large amount of cloudy, yellow, foul-smelling drainage. Which documentation best describes the drainage? A. Infectious drainage noted from wound. B. Large amount of purulent, yellow, foul-smelling drainage noted from wound. C. Copious amount of serous drainage noted from patient's wound. D. Large amount of foul smelling, serosanguineous drainage noted from wound.

B. Large amount of purulent, yellow, foul-smelling drainage noted from wound. Rationale: It is incorrect to use the term "infectious" because it does not adequately describe the drainage. There is no lab to verify that the wound is infected. The term "serosanguineous" implies the presence of blood within the drainage, which would be pinkish, clear drainage.

The client is admitted with a stroke. The outcome of this disorder is uncertain, but the client is unable to move his right arm and leg. Select the best intervention associated with evidence-based practice. A. Active range of motion is the only nursing action that will prevent contractures. B. Passive range of motion must be instituted to help prevent contracture formation. C. Muscular deconditioning occurs within days during physical immobility. D. Applying a Sequential Compression Device (SCD) helps reduce loss of muscle strength.

B. Passive range of motion must be instituted to help prevent contracture formation. Rationale: When patients cannot participate in active range of motion, the nurse must institute passive range of motion to maintain joint mobility and prevent contractures. Passive range of motion can be substituted for active when needed. For the patient who does not have voluntary motor control, passive range-of-motion exercises are the exercises of choice. Unless contraindicated, the nursing care plan includes exercising each joint (not just major joints) through as nearly a full range of motion as possible. Initiate passive range-of-motion exercises as soon as the patient loses the ability to move the extremity or joint.

When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? A. Replace the urinary catheter every 48 hours using strict asepsis. B. Performing hand hygiene before and after providing perineal care. C. Ensuring the foreskin maintains retraction and sterility. D. Disconnecting and replacing the catheter drainage bag once per shift.

B. Performing hand hygiene before and after providing perineal care. Rationale: Hand hygiene helps prevent infection in patients with a urinary catheter. A catheter should be inserted in the hospital setting using sterile technique and not repeatedly. Inflating the balloon fully prevents dislodgement and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection.

The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies. In which perioperative nursing phase would this work be completed? A. Perioperative B. Preoperative C. Intraoperative D. Postoperative

B. Preoperative Rationale: Reviewing the patient's laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite, postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.

A patient has had abdominal surgery. The nurse is teaching the patient about diet and wound healing. At this time, which nutrient is most important? A. Carbohydrates B. Protein C. Fats D. Vitamins

B. Protein Rationale: Complete proteins contain sufficient amounts of the essential amino acids to maintain body tissues and to promote growth. Carbohydrates, fats, and vitamins are also needed but to promote wound healing protein is most important

A patient, who is on complete bed rest, is having difficulty defecating on a bed pan. Which action by the nurse would assist the patient to have a bowel movement? A. Administering laxatives to the patient B. Raising the head of the bed C. Preparing to administer a barium enema D. Withholding narcotic pain medication

B. Raising the head of the bed Rationale: Lying in bed is an unnatural position, raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given, however, preventative action should be taken to prevent constipation.

The nurse is caring for a patient at risk for sensory overload. What intervention should the nurse implement? A. Remove the patient's hearing aid B. Reduce the patient's pain C. Assist with all ADL D. Provide unlimited stimulation

B. Reduce the patient's pain Rationale: If the patient is experiencing sensory overload, interventions should focus on reducing stimulation involving external and internal factors. Limiting extraneous noise, bright lights, room clutter, interruptions, pain, and stress reduces stimulation. While it is true that clients with sensory overload may neglect their ADLs to the point that they need assistance, the nurse assists the patient only with the immediately essential ADLs (moving, eating, toileting, and resting). Removing hearing aid and unlimited stimulation increase anxiety.

The physician orders a serum Blood Urea Nitrogen (BUN) and Creatinine for the patient. What system/function is being assessed? A. Blood Coagulation/Clotting B. Renal (kidney) C. Hepatic (liver) D. Pancreas

B. Renal (kidney) Rationale: The BUN and Creatinine test evaluate renal/kidney function and may include a creatinine clearance. PT/INR, PTT and platelets evaluate clotting/coagulation and the effectiveness of anticoagulant medications. ALT/AST measure liver function, Amylase/Lipase evaluate pancreatic function

While performing a head-to-toe assessment on the client, the nurse notes the following wound (see figure) on the client's heel. The nurse documents this as a: A. Stage 1 pressure ulcer B. Stage 2 pressure ulcer C. Stage 3 pressure ulcer D. Unstageable

B. Stage 2 pressure ulcer

The student nurse has developed a teaching plan for a client regarding opioid pain medication. Which statement by the student nurse would require the nursing instructor to intervene during client teaching? A. Increasing fiber, fluids, and movement may assist in preventing opioid associated constipation. B. Taking this medication with naloxone can cause respiratory depression. C. Opioid pain medications may cause dizziness, please call for assistance when getting out of bed. D. We will monitor your vital signs because this drug may cause a decrease in blood pressure and respirations.

B. Taking this medication with naloxone can cause respiratory depression. Rationale: Naloxone hydrochloride is the antagonist for an opioid narcotic, and reverses respiratory depression.

In providing diet education for a patient on a low-fat diet, it is important for the patient to understand that A. saturated fats are found mostly in vegetable sources. B. saturated fats are found mostly in animal sources. C. unsaturated fats are found mostly in animal sources. D. Linoleic acid is a saturated fatty acid.

B. saturated fats are found mostly in animal sources. Rationale: Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans.

A widow repeatedly tells the details of finding her elderly husband not breathing, performing cardiopulmonary resuscitation, and seeing him pronounced dead. Family members are concerned and ask, "What can we do?" What is the nurse's best response? A. "You should tell her she has told you the same story several times." B. "Tell her she will never get over her husband's death if she keeps reliving the day her husband died." C. "Repeating the story and sharing her feelings is a helpful and necessary part of grieving." D. "She appears to have the early stages of Alzheimer's, encourage her to see her health care provider."

C. "Repeating the story and sharing her feelings is a helpful and necessary part of grieving." Rationale: Telling the personal story of loss as many times as needed is acceptable and healthy because repetition is a helpful and necessary part of grieving.

The nurse is caring for a patient with hyperkalemia. Which body system will the nurse PRIMARILY monitor? A. Musculoskeletal B. Neurological C. Cardiac D. Respiratory

C. Cardiac Rationale: Potassium balance is necessary for cardiac function. Hyperkalemia places the patient at risk for potentially serious dysrhythmias. Monitoring of neurological, and respiratory systems would be indicated for other electrolyte imbalances. Although hyperkalemia does effect the musculoskeletal system, it would not be the primary system to be assessed.

When reviewing the allergy history of a patient, the nurse notes that the patient is allergic to penicillin. Patients who are allergic to penicillin may also be hypersensitive to which class of antibiotics? A. Tetracyclines B. Sulfonamides C. Cephalosporins D. Imipenem-cilastatin

C. Cephalosporins Rationale: Allergy to penicillin may also result in hypersensitivity to cephalosporins.

What statement supports the need for a comprehensive focused assessment for elderly patients? A. The majority of elderly are demented. B. The elderly are often socially isolated and lonely. C. The senses of vision, hearing, touch, taste, and smell decline with age. D. As people age, they become more rigid in their thinking and more set in their ways.

C. The senses of vision, hearing, touch, taste, and smell decline with age. Rationale: Decline of the senses: vision, hearing, touch, taste and smell are normal signs of aging.

A pH of 7.25 is indicative of A. dehydraion B. hypertonicity C. acidosis D. alkalosis

C. acidosis

The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." The nurse needs to explain that A. Fats have no significance in health and the incidence of disease. B. All fats come from external sources so can be easily controlled. C. Deficiencies occur when fat intake falls below 10% of daily nutrition. D. Vegetable fats are the major source of saturated fats and should be avoided.

C. Deficiencies occur when fat intake falls below 10% of daily nutrition. Rationale: Deficiency occurs when fat intake falls below 10% of daily nutrition. Various types of fatty acids have significance for health and for the incidence of disease and are referred to in dietary guidelines. Linoleic acid and arachidonic acid are important for metabolic processes but are manufactured by the body when linoleic acid is available. Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids.

The nurse is caring for a client with a pressure wound on the left hip. The ulcer is black. What does the nurse anticipate as the next step in the cient's plan of care? A. Monitoring of the wound. B. Irrigation of the wound. C. Débridement of the wound. D. Management of wound drainage.

C. Débridement of the wound. Rationale: Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.

The nurse instructs the family of an elderly patient,with a visual impairment and decreased mobility, that the most common safety concern for elderly patients is related to A. Electrical cords B. Medication errors C. Falls D. Aspiration

C. Falls Rationale: The risk of falls increases when a person of advanced age, impaired mobility, or both encounters these hazards.

The older adult will have an increased risk for developing which of the following? A. Fire hazards B. Gun shot wounds C. Heatstroke D. Poisoning

C. Heatstroke Rationale: The ability to thermoregulate may become impaired, older adults are at higher risk than younger adults for hypothermia and heatstroke

A client is receiving 0.9% normal saline at 250 mL per hour. The nurse notes the client has an increased blood pressure, bounding pulse, jugular venous distention, and bilateral crackles. The nurse determines the patient may be experiencing what condition? A. Sepsis B. Hypoglycemia C. Hypervolemia D. Air embolism

C. Hypervolemia Rationale: Sepsis is a blood borne infection. Symptoms of hypoglycemia include: diaphoresis, shakiness, confusion and loss of consciousness. Symptoms associated with an air embolism include: dyspnea, chest pain, altered level of consciousness, and hypotension.

Which statement related to complications of immobility is true? A. The effects of immobility are the same for everyone. B. Immobility helps maintain sleep-wake patterns. C. Immobility can cause social isolation and loneliness. D. Immobile clients are often eager to help in their own care.

C. Immobility can cause social isolation and loneliness. Rationale: The immobilized patient often becomes depressed because of changes in role and self-concept. Every patient responds to immobility differently. Immobility or bed rest frequently affects coping and creates sleep-wake alterations because of changes in routine or in the environment. Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient's depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.

Which is the priority assessment for wound healing? A. Psychosocial assessment B. Sleep assessment C. Nutritional Assessment D. Sensation assessment

C. Nutritional Assessment Rationale: Normal wound healing requires proper nutrition. Deficiencies in any of the nutrients results in impaired wound healing.

Which of the following is a normal physiologic change associated with the aging process? A. Hormonal changes causing vasodilation and a resulting drop in blood pressure. B. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. D. Narrowing of the inferior vena cava, causing low blood flow and increased venous pressure resulting in varicosities.

C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. Rationale: Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure.

The nurse is called to a patient's room and observes the patient having a severe panic attack and hyperventilating. When ABG's (arterial blood gases) are drawn, the nurse would expect to see which finding? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C. Respiratory alkalosis Rationale: Hyperventilation causes an excess of CO2 to be eliminated during rapid ventilation. CO2 is an acid and would cause the pH to rise into alkalosis. You would expect the CO2 to be less than 35 and then pH to be greater than 7.45

After the death of several long-term clients, which action indicates the nurse is experiencing ineffective coping? A. The nurse talks at length to a colleague about the patients' deaths. B. The nurse keeps busy and doesn't think about the death for several days. C. The nurse offers to work extra shifts and to be on call for several months. D. The nurse looks in the newspaper for information about their funerals.

C. The nurse offers to work extra shifts and to be on call for several months. Rationale: The nurse is exhibiting behaviors of complicated grief because she is unable to move forward, in her grief, after a prolonged period of time.

An 80-year-old patient sees his health care provider for a routine physical examination. The patient's skin turgor is noted to be fair. When asked about the ability to perform activities of daily living, the patient verbalized feeling fatigue and weak. The skin is warm and dry, pulse rate is 126 beats per minute, and urinary sodium level is slightly elevated. After assessment, the nurse should instruct the patient to A. decrease the intake of dairy products to prevent constipation. B. drink more citrus juices to strengthen the immune system. C. drink more water to prevent further dehydration. D. eat more meat to prevent dietary anemia.

C. drink more water to prevent further dehydration. Rationale: Thirst sensation diminishes, leading to inadequate fluid intake or dehydration. Symptoms of dehydration in older adults include confusion, weakness, hot dry skin, furrowed tongue, and high urinary sodium. Milk continues to be an important food for older woman and men, who need adequate calcium to protect against osteoporosis. After age 70, osteoporosis equally affects men and women. Caution older adults to avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs. Some older adults avoid meats because of cost, or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein.

Diminshed urinary output in relation to fluid intake is called A. polyuria. B. dysuria. C. oliguria. D. anuria.

C. oliguria. Rationale: Oliguria is diminished urinary output in relation to fluid intake.

The nurse is preparing to perform a fecal occult blood test on a patient. The purpose of the procedure is A. to test for anemia. B. check for parasites in the intestine. C. to check for blood in the feces. D. to check for hyperacidity in the stool.

C. to check for blood in the feces. Rationale: A fecal occult blood test measures microscopic amounts of blood in the feces. It is a useful screening for colon cancer.

A nurse is consoling the wife of a client who just died. The wife states, "I hate him for leaving me." Which statement by the nurse will faciliate therapeutic communication? A. "Would you like me to contact the chaplain for you?" B. "Do you blame your husband for his death?" C. "Are you concerned about financial matters?" D. "Share with me what makes you angry."

D. "Share with me what makes you angry." Rationale: Asking the patient to share feelings is an open-ended question that encourages a therapeutic conversation. All other options are close-ended questions that can be answered by one or few words.

The client died at 10:07 PM. A family member tells the nurse that their culture does not permit the body to be left alone before burial. Hospital policy states that after 6PM, bodies are to be stored in the morgue refrigerator until the next day. How would the nurse best manage this situation? A. Explain the policy to the family and then implement it. B. Call the funeral home to pick up the body. C. Call the primary care provider for advice on how to resolve the situation. D. Advocate for the family to be able to stay with the body.

D. Advocate for the family to be able to stay with the body. Rationale: the role of the nurse as advocate is to understand and appreciate each patient's cultural values related to loss, death, and grieving.

Which patient is most at risk for constipation? A. An 18-year-old who ignores the urge to defecate when out with friends. B. A 35-year-old college student who is worried about his financial aid. C. A 42-year-old woman who has bowel movements every other day. D. An 80-year-old male who uses a cane to walk.

D. An 80-year-old male who uses a cane to walk. Rationale: Older individuals are at the highest risk for constipation.

A patient is admitted with a fever of 102.8 F, origin unknown. Assessment reveals bilateral crackles and a productive cough. Orders have just been written to obtain sputum and blood cultures and to administer ampicillin 500 mg IV stat and then every 6 hours. The nurse will complete these orders in which sequence? A. Blood culture, ampicillin dose, sputum culture B. Sputum culture, ampicillin dose, blood culture C. Ampicillin dose, blood and sputum cultures D. Blood and sputum cultures, ampicillin dose

D. Blood and sputum cultures, ampicillin dose Rationale: Culture specimens should be obtained before initiating drug therapy, otherwise, the presence of antibiotics in the tissues may result in misleading culture results.

When monitoring the results of antibiotic therapy for a client with an infection, which following laboratory values would indicate a therapeutic response? A. Increased RBC count B. Decreased RBC count C. Increased WBC count D. Decreased WBC count

D. Decreased WBC count Rationale: Decreased WBC counts are an indication of reduction of infection and a therapeutic effect of antibiotic therapy.

The nurse should wear a PPE gown when: A. The nurse comes in contact with the patient/client. B. The client has an elevated temperature. C. The nurse is assisting with medication administration. D. Exposure to blood or body fluids may soil clothing when performing a task.

D. Exposure to blood or body fluids may soil clothing when performing a task. Rationale: Gowns should be worn when there is a possibility that blood or body fluids could get on the nurse's clothes or when the client is on contact isolation status. The other options are not appropriate uses of gowns

During a home visit, an elderly male tells the nurse his wife died 3 years ago. Which behavior indicates the client is experiencing complicated grief? A. He pays to get his laundry done because he never learned how to use the washing machine. B. He tells the nurse his wife was am awful cook and is now eating better meals. C. He shows the nurse photographs of his wife that he keeps in an album. D. He shows the nurse his wife's sewing room and tells her, "Dont touch anything!"

D. He shows the nurse his wife's sewing room and tells her, "Dont touch anything!" Rationale: He shows the nurse his wife's sewing room that remains just as she left it before she died. Leaving the deceased wife's sewing room and belongings intact for over 3 years is considered outside the normal limits of the grief process. Showing photographs of the deceased and talking about her good and bad points are normal responses to grief. Sending out the laundry to be done is a healthy response to a problem that this client identified.

A nurse is caring for a patient who as admitted with recent right-sided weakness following a stroke. Which nursing action would be least effective in promoting positive adaptation of the patient's sensory deficit? A. Placing the patient's belongings on the affected (right) side B. Approaching the patient from the affected side C. Teaching the patient how to create a safe environment after discharge D. Helping the patient with all ADLs (Activities of Daily Living)

D. Helping the patient with all ADLs (Activities of Daily Living) Rationale: Helping the patient with all ADLs will not provide the nurse an opportunity to assess the extent of the patient's impairment or the necessary resources that will need to be provided when the patient is discharged.

The nurse has provided education regarding management of breakthrough pain after discharge. Which statement made by the client indicates that teaching has been effective? A. "I will notify my physician when I have taken an extra dose of pain medication to control my breakthrough pain, so that they may adjust my dose." B. "I will take one half dose of an over-the-counter pain medication, such as acetaminophen, to manage breakthrough pain." C. "I will wait until my pain has reached at least a 4, on a 0-10 scale, before taking my next dose of pain medication." D. I will turn on my favorite television show and use my transcutaneous electrical stimulation (TENS) unit."

D. I will turn on my favorite television show and use my transcutaneous electrical stimulation (TENS) unit." Rationale: Breakthrough pain can be managed with non pharmacological methods. Taking additional doses of pain medication may cause an overdose. Taking OTC pain medication with prescribed pain medication may cause toxicity.

An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? A. Urinary tract infections are unavoidable in the elderly because of a weakened immune system. B. Decreasing fluid intake will decrease the risk for urinary tract infection. C. Making sure to cleanse the perineal area from back to front to prevent infection. D. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

D. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection. Rationale: Cranberry juice and other acidic foods decrease adherence of bacteria to the bladder wall. Urinary tract infections are avoidable in the elderly population with proper knowledge and hygiene. Perineal skin should be cleansed from front to back to avoid spreading fecal matter to the urethra. Increasing fluids will help to flush bacteria, thus preventing them from residing in the bladder for prolonged periods of time.

A patient is to receive a topical corticosteroid for the treatment of psoriasis. When administering this medication, the nurse is aware that which of the following forms is generally the most penetrating when applied to the skin? A. Gels B. Lotions C. Creams D. Ointments

D. Ointments Rationale: Ointments are generally the most penetrating vehicles for topical forms of corticosteroids.

The client underwent a bowel surgery one day ago. Upon auscultation, the nurse notes an absence of bowel sounds. What does the nurse suspect? A. Bowel obstruction B. Dehydration C. Bowel evisceration D. Paralytic ileus

D. Paralytic ileus Rationale: A common occurrence after bowel surgery is paralytic ileus, a condition in which there is decreased bowel functioning.

Beta-lactamase inhibitors are often used with which class of antibiotics to extend the effectiveness of the drug? A. Cephalosporins B. Tetracyclines C. Sulfonamides D. Penicillin

D. Penicillin Rationale: Beta-lactamase inhibitors block the effect of the enzyme beta-lactamase, and thus allow the penicillin antibiotics to have an extended usefulness against the bacteria.

What information should the nurse include in the teaching plan for a client being discharged on opioid pain relievers? A. Management of diarrhea B. Drug addiction programs C. Dehydration due to polyuria D. Prevention of constipation

D. Prevention of constipation Rationale: Gastrointestinal adverse effects, such as nausea, vomiting and constipation are the most common adverse effects associated with opioid analgesics. Physical dependence usually occurs in patients undergoing long-term treatment. Diarrhea and polyuria are not side effects of opioid analgesics. Application Implementation Physiological Intregrity: Reduction of Risk

Select the appropriate transmission-based precaution for a patient whose immune defenses are compromised. A. Airborne Precaution B. Contact Precaution C. Droplet Precaution D. Protective isolation

D. Protective isolation Rationale: Protective isolation is used in high-risk situations to prevent infection for people whose body immune defenses are known to be compromised.

The nurse is caring for a family in a shelter after the loss of their home from a fire. The fire caused no life-threatening physical injuries to the family members. Which is the most appropriate assessment technique for the nurse to use? A. Ask the family if they have home and health insurance. B. Suggest that family members document their thoughts in a journal. C. Provide the head of the household a questionnaire about employment and financial status. D. Provide the family members an opportunity to discuss their feelings

D. Provide the family members an opportunity to discuss their feelings Rationale: Often the patient has difficulty expressing exactly what is most bothersome about the situation until their is an opportunity to discuss it with someone who has the time to listen.

Fecal impactions occur in which portion of the colon? A. Ascending B. Descending C. Transverse D. Rectum

D. Rectum Rationale: A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.

The nurse evaluates which laboratory values to assess a client's potential for wound healing? A. Fluid status B. Potassium C. Total cholesterol D. Total protein

D. Total protein Rationale: Proteins provide a source of energy and are essential for growth, maintenance, and repair of body tissue.

An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? A. Urinary retention B. Hesitancy C. Urgency D. Urinary incontinence

D. Urinary incontinence Rationale: Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine known as Urinary incontinence. Urinary retention is the inability to empty the bladder. Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of the need to void immediately.

While assessing an 82-year-old depressed female patient, who is hypertensive, the nurse determines that she is experiencing symptoms related to polypharmacy, which means: A. she has a lower risk of drug interactions. B. she takes one medication for an illness several times a day. C. she risks problems only if she also takes over-the-counter medications. D. she takes multiple medications for several different illnesses.

D. she takes multiple medications for several different illnesses. Rationale: Polypharmacy usually occurs when a patient has several illnesses and takes medications for each of them, possibly prescribed by different specialists who may be unaware of other treatments the patient is undergoing.