Fundamental Concepts and Skills for Nursing chapters 24, 29, 30 & 31

A patient fractured her ankle during a skiing accident yesterday. The type of pain she has considered: 1. acute 2. chronic 3. phantom 4. minor

1

The nurse is catheterizing a male patient, who is confused. He move several times during the procedure despite repeated verbal instructions to remain calm, quiet, and still. Which nursing diagnosis is the priority related to the presence of the catheter for this patient? 1. Risk for injury 2. Risk for infection 3. Noncompliance 4. Deficient knowledge

1

The patient had a resection or the prostate gland yesterday and had a three-way catheter for continuous irrigation. The draining urine is increasingly red. This means that the nurse needs to: 1. Notify the physician immediately 2. Increase the rate of flow of the irrigation solution 3. Increase the fluid intake to 4000 mL/24 hr 4. Empty the drainage bag to prevent clotting

1

Which abnormal stool characteristic is the cause for the greatest immediate concern? 1. Dark black, sticky stool 2. Pale white or light grey stool 3. Mucus coated; slimy appearance 4. Foul smelling and floating

1

Which statement by the patient indicates an understanding of the information that was taught for self-care related to diarrhea? 1. "I should consume clear liquids for 2 days and then try applesauce" 2. "I should increase my consumption of fruits and veggies" 3. I should eat small, frequent meals that include high-quality proteins" 4. "I should try over-the-counter antidiarrheals for at least 3 days"

1

correct technique for obtaining a stool specimen for ova and parasites is to use a wooden stick and: 1. obtain the specimen from the middle of the stool 2. place the whole stool specimen from the middle of the stool 3. obtain the specimen from two parts of the stool 4. include any liquid stool

1

when caring for the patient who has just undergone a liver biopsy, you must: 1. keep the patient positioned on the right side for two hours 2. apply pressure to the aspiration site by hand for 30 min 3. keep the patient on bed rest for 24 hours 4. turn the patient to the left side afterward

1

The patient underwent a cardiac catheterization this morning. 1. What assessments would you need to make regularly afterward? 2. If you have difficulty finding the dorsalis pedis pulse in the leg where the catheter was inserted, what would you do? 3. what might it mean if the leg in which the catheter was introduced begins to swell?

1) Check the pressure dressing over the insertion point, taking vitals every 10-15 min and measuring distal pulse the first hour and temp every 6 hours 2)

When instructing the patient about a colonoscopy, you would include that (select all that apply) 1. the prep for the procedure begins 24 to 48 hours beforehand 2. sedation will be given before the procedure 3. it's okay to drive home afterward 4. there is often some rectal bleedimg afterward

1, 2

Factors that can adversely affect sleep include: (select all that apply) 1. Alcohol consumption near bedtime 2. A rotating shift schedule 3. A very quiet environment 4. Watching television in bed 5. Reading a book in bed 6. A cool bedroom

1, 2, 4

When instructing a patient about a magnetic resonance imaging test, you would explain that: (select all that apply) 1. it is necessary to hold very still during the test 2. heavy sedation is usually provided before the test 3. loud noise will be heard during the test 4. communication with the technician is possible

1, 3, 4

When taking a culture sample from an infected throat, the nurse should: (select all that apply) 1. don sterile gloves to obtain the sample 2. depress the tongue with a tongue blade 3. swab around the back of the throat 4. swab around the tonsil area 5. spray the swab with saline 6. place the swab in a sterile culture tube and seal it

1, 3, 4

A young female patient complains of urinary frequency, urgency, and burning, particularly after sexual inter course. Which assessment question is the most relevant? 1. Has your physician ever done a urinalysis? 2. Have you been having chills or high fever? 3. Have you recently been drinking more fluids than usual? 4. Do you use any birth control?

2

In caring for a patient receiving an opioid, it is most important to monitor for: 1. nausea and vomiting 2. respiratory depression 3. hypotension 4. Constipation

2

The nurse is doing preprocedural teaching with a patient who is scheduled to have a barium enema. Which statement by the patient indicates a need for additional teaching? 1. "I will have to increase my fluid intake after the procedure" 2. "The barium increases my risk for diarrhea" 3. "I may receive a laxative after the procedure" 4. "My stool may be chalk-colored for several days"

2

The nurse must assist sever patient to use a bed pan. Which patient is most likely to need a fracture pan? 1. Patient who is passing a large amount of liquid stool 2. Patient who is post-surgical for hip repair 3. Patient who is obese and immobile 4. Patient who is unsteady and has mile cardiac failure

2

When a sleep medication is prescribed, the nurse teaches the patient to: 1. Take the medication 2 hours before bedtime 2. Use he medication for short periods 3. Use the medication every night 4. Take the medication upon retiring for the night

2

The nurse is changing the stoma appliance for a patient who has an existing colostomy. Below are the steps for the procedure. Place the steps in the correct order. 1. Center and carefully apply the pouch appliance 2. Remove old pouch by stabilizing the skin with one hand 3. Instruct the patient to lie quietly or sit still for 5 minutes 4. Apply skin barrier paste to periostomal area 5. Clean the stoma and the skin gently with warm water and soft cloth 6. Gently press down the skin barrier ring around the stoma

2, 5, 4, 1, 6, 3

A bed rest patient is complaining of constipation. Which PRN (as needed) medication is the nurse most likely to give for this complaint? 1. Loperamide hydrochloride (Imodium) 2. Morphine 3. Bisacodyl (Dulcolax) 4. Calcium channel blocker

3

A nurse is caring for a patient who is incontinent. What is the priority of action? 1. Help the patient void every 2 hours 2. Decrease the fluid intake, especially in the evening 3. Father data to find the cause of incontinence 4. Encourage expression of embarrassment

3

A patient in a long-term facility has a retention catheter in place. The nurse identifies risk for infection as a nursing diagnosis. Which urine abnormality supports the choice of this diagnosis? 1. Glycosuria 2. Ketonuria 3. Presence of casts 4. Presence of bilirubin

3

A patient returned from same-day surgery for hours ago. He is awake and alert, but has not been able to void. He cannot be discharged until he voids. He has had 1000 mL of IV fluid. Which intervention would be the most likely to help this patient urinate? 1. Give more liquids by mouth 2. Wait at least three more hours 3. Help him stand by the side of the bed to void 4. Call the physician and obtain an order for a Foley catheter

3

A patient with cystitis is prescribed phenazopyridine HCI (Pyridium). Which statement by the patient indicates that she has understood the teaching points for this medication? 1. "This medication helps to flush the bladder." 2. "This medication prevents resistance to organisms." 3. This medications turns the urine orange or red." "This medication relieves my symptoms because it cures infection."

3

A post surgical patient reports that the last bowel movement was 3 days ago. Which question is the most relevant? 1. How often do you use a laxative? 2. Are fruits and vegetables part of your normal diet? 3. What is your normal bowel pattern? 4. Do you feel like you have adequate privacy for toileting?

3

The nurse is catheterizing a male patient. Resistance is met. The nurse should: 1. Apply more pressure with a twisting motion to insert the catheter 2. Obtain a new sterile kit and try again with a sterile Coudé catheter 3. Ask him to take a deep breath and slowly exhale as the catheter is inserted 4. Discontinue the procedure and try again after the patient relaxes

3

The nurse must perform a bladder irrigation to install medication. During the procedure the tube will have to be clamped. What is the best rationale for clamping the tubing? 1. Follows he standard procedure 2. Ensures that sterility of the system is maintained 3. Prevents the solution from growing directly into the bag 4. Prevents urine from being drawn back into the catheter.

3

The sensitivity part of a culture and sensitivity test is for the purpose of: 1. identifying the causative organism of the infection 2. determining which medications are inefective aginst ​the causative organism 3. testing anti-infective medications to see to see which ones are most effective against the causative organism. 4. growing colonies of the causative organism on a culture

3

When applying the principles of pain treatment, the nurses first consideration should be: 1. All team members contribute to the plan of care 2. The patients goals must be considered 3. The patient's perception of level of pain must be accepted 4. medication side effects must be prevented or managed

3

The nurse is obtaining a urine specimen for a patient who has an existing Foley catheter. Below are the steps for the procedure. Place these steps in the correct order. 1. Scrub the aspiration port of the drainage tubing with an alcohol of 2. Aspirate 3 mL of urine by gently pulling back on the plunger 3. Clamp the tube below the aspiration port 4. Empty the syringe into the sterile container; do not touch the inside of the container 5. Close and label the container. I clamp the catheter 6. Attach a needleless connector (or needle) with attached syringe into the aspiration port

3, 1, 6, 2, 4, 5

A 24-your urine specimen is ordered for a patient. The nursing assistant discards some of the urine that should have been saved. Which is the most appropriate nursing action? 1. Verbally reprimand the nursing assistant 2. Make a note to stems the urine collection period 3. Continue the urine collection and label the specimen 4. Notify he barge nurse and restart the test

4

A culture is obtained when a patient has a bladder infection for the purpose of: 1. selecting the correct dose of medication 2. determining the prognosis of the disease 3. ruling out an infection process 4. growing and identifying causative organisms

4

A patient 1 day postoperative is receiving an analgesic via PCA pump. He reports that the pain is not being controlled adequately. The first action the nurse should take is: 1. Contact the surgeon to increase the dose 2. Try nonpharmacologic comfort measures 3. Deliver the bonus dose per standing orders 4. Assess the pain for location, quality, and intensity

4

A patient is admitted with urinary retention. There is an order to insert a Foley catheter into his bladder. He attempts to void and passes 100 mL of urine. Before catheterization the nurse should: 1. Use a condom catheter with a leg bag 2. Wait 2 hours and have him try to void again 3. Have him drink two to three glasses of water 4. Perform a bladder scan to determine amount of urine retained

4

And elderly patient living in an extended care facility has a nursing diagnosis of bowel incontinence related to confusion. Which intervention would be best for this patient? 1. Use positive reinforcement for incontinence episodes 2. Obtain a physicians order for a low-fiber diet 3. Hav the patient drink 1000 ml of fluid unless contradicted 4. Assist the patient to the toilet, especially after meals

4

Endorphins modulate pain by: 1. Acting on small-diameter nerve fibers 2. Acting on large-diameter nerve fibers 3. Inhibiting impulses originating in the thalamus 4. Attaching to nerve endings in opioid receptors

4

Intramuscular injections of pain medication may be contraindicated for patients who: 1. Have multiple drug allergies 2. Need short-term pain management 3. Have poor cognitive abilities 4. Have small, poorly developed muscles

4

Neuropathic lain is most likely to occur in the patient who had: 1. Ribs fractured in an accident 2. A severe ankle sprain 3. Bacterial pneumonia 4. Diabetes Mellitus

4

The nurse has just collected a midstream urine specimen from a patient. Which urine characteristic would be of the greatest concern? 1. Urine smells slightly of ammonia 2. Urine is dilute 3. Urine is slightly cloudy 4. Urine is dark brown

4

The nurse is a ministering in an enema to the patient. Immediately after the nurse starts the flow of enema solution, patient complains of cramping and discomfort. Which action should the nurse take first? 1. Increase the flow rate so that the procedure can be finished sooner. 2. Call the physician and report that the patient cannot tolerate the procedure. 3. Discontinue the flow of enema solution and offer the patient a bedpan. 4. Slow the flow rate and check the temperature of the solution.

4

The nurse is attempting to manually remove a decal impaction. The nurse notes that the patient is having a vagal response. What is the most appropriate action? 1. Discontinue the procedure because he patient is having severe pain in the rectal area 2. Place the bedpan because the patient is about to expel semiliquid and flatus 3. Obtain an order for an oil-retention enema because the stool is too hardened 4. Check the patients pulse and blood pressure and attack a cardiac monitor

4

The nurse is planning care for an elderly patient with a well-established ostomy. The patient has been performing her own ostomy care, but appears I have trouble manipulating equipment because of arthritis. What is the priority nursing diagnosis? 1. Risk for infection 2. Risk for disturbed body image 3. Risk for constipation 4. Risk for impaired skin integrity

4

When collecting a blood sample with a vacutainer system, it is important to: 1. replace the tube stopper firmly for each sample 2. release the tourniquet after successful venipuncture 3. withdraw the holder and tube at the same time 4. stabalize the holder when changing tubes

4

Which statement by the patient indicates that she understands how to perform the clean-catch method for a urine specimen? 1. "I should clean my genitalia area first, pee into the cup, and then clean myself" 2. "I should fill the cup completely and save it in the refrigerator" 3. "I should keep he contents of the kit sterile at all times" 4. "I should clean myself first, pee a little into the toilet, and then pee into the cup"

4

Which urine characteristic suggests that the patient might have liver disease? 1. Urine specific gravity of 1.035 2. Urine pH of 6.0 (slightly acidic) 3. Urine showing presence of ketones 4. Urine that is positive for bilirubin

4

Miss Rosshad is complaining of post operative pain after her colectomy surgery yesterday. What type of pain with this be considered? What questions would you ask to assess her pain?

Acute pain. What is your pain on a scale of 0 to 10?

Your patient is voiding only 100 mL of urine at a time. What futher assessments should you make? what questins ​should you ask this patient?

Asses the patient for anuria or any infection in the urinary system. Obtain a history of the patient usual pattern of urinary elimination. How much fluid has been taken in a 24/hr period? Is the bladder usually completely emptied or does the patient have to void again in leas than 2 hours?

Several non-pharmacologic intervention are used for the management of pain. The one that uses a machine to measure learned responses is ______________________. (Fill in the blank)

Biofeedback

Miss Thompson, who lives in a long-term care facility, frequently awakens in the middle of the night and finds it difficult to go back to sleep. What interventions could you use to assist her in returning to sleep? What interventions during the day and evening might help prevent the nighttime awakenings?

Eliminate environmental disturbances as best as possible. Using earplugs and a white noise machine may help block out noise. Avoid caffeine six hours before bed. Do not go to bed hungry or full. Do not watch TV in bed.

Mr. Rosario, age 48, is an executive with a major company. He works long hours and has little free time. He has had difficulty sleeping for the past three months. What factors may be interfering with his sleep? What techniques could you teach him to help him obtain adequate rest?

Sleep deprived, anxiety, stress. Avoid caffeine six hours prior to sleeping. Exercise regularly but not right before bed. The bedroom should be a refuge and not used to discuss the days problems.

Mr. Chen has been receiving an opioid for his cancer pain. What assessments would you make to identify side effects of the medication? What would you do if Mr. Chen is not able to remain comfortable despite receiving analgesic medication as ordered by the physician?

Track bowel movements. Try and implantable pump.

Your patient returned from surgery at 1030 and is awake and alert. She had spinal anesthesia, but has recovered the feeling in her lower extremities. It is now 1900, and she still has not voided since her return to the unit. What would you do to help her void? If she has nit voided by 2000, what would you do?

Use methods of helping the patient initiate he voiding reflex (ex: blowing bibles in water while in toilet, credé maneuver, warm water). If all other attempts fail use a straight catheter to help relieve retention when the patient is temporarily unable to void.

What would you do to make it as easy as possible to place and remove a bedpan for a patient who has an external fixation devise on his lower leg?

Use powder to keep the bedpan from sticking to the patients skin and it aids in removal of the pan

Your elderly patient is upset and concerned because his urine is a different color. What questions could you ask him to obtain more information about the color change?

What medications do you take? what food have you eaten recenty? b/c color variations may occur from medications or from water soluble dyes consumed in food

How would you make certain the patient who cannot turn to the side is properly cleansed after a bowel movement?

When the patient cannot raise the hips or turn to the side, a fracture pan is used. It can be slid into place from between the patients legs. The flattened portion of the pan is slipped under the buttocks.

A lumbar puncture is a(n) ___________________ procedure. (what type of procedure?)

aspiration

tests for typhoid are considered _________________ tests. (what type of test?)

serology