120 Exam 3

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

"Discard your first urine and begin the collection after that. rationale: The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.

A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client?

"How frequently do you urinate each day?" rationale: The client with frequent urinary tract infections may have infrequent urination, which can lead to stagnation of urine in the bladder; this potentially leads to growth of bacteria and a UTI. Taking blood pressure medication, being on a special diet, or having bowel movements do not increase the risk for urinary tract infections.

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem?

"Let's explore structuring activities and toileting breaks. rationale: The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"Let's review your medication history and whether you consume bladder irritants." rationale: "Let's review your medication history and whether you consume bladder irritants."

a nurse is caring for a client who is at high risk for aspiration. which of the following actions should the nurse take?

-instruct the client to tuck their chin when swallowing. tucking the chin when swallowing allows food to pass down the esophagus more easily

while conducting a physical assessment of a client, the nurse notes an increase in glucose level. Upon inquiry, the client discloses that lately he has been under a lot of stress at work. Which stage of stress is the client experiencing?

ALARM STAGE of stress if the glucose is increasing rapidly. this occurs when the body is responding to a stressor by raising the blood glucose as a reserve for meeting increased energy requirements.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. rationale: The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.

The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next?

Blood sugar rationale: Glycosuria is a condition that describes the finding of glucose in the urine. The natural next step would be to obtain a fingerstick for blood glucose level. Vital signs are a baseline indicator of any illness or injury. Intake and output may be important going forward, but the diagnosis directs the next action.

a nurse is planning a high-energy diet for a client. Which statement by the nurse describes the types of foods the client should include in the diet?

Include plenty of grains, fruits, and vegetables in your diet. carbs provide high energy.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds. rationale:Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron rationale: The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman's capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman's capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings. rationale: The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter. The health care provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Sitting the client up may aggravate the pain. The nurse should attempt to keep the client in the most comfortable position possible until a prescription is received from the health care provider.

During a general survey, the nurse documents the waist circumference of an overweight female client as 43 in. Which teaching should the nurse include about the risks associated with this waist circumference?

The client is at risk for diabetes. a waist measure higher than 42 inches in women and 47 inches in men has been associated with higher risk for health problems such as heart disease, diabetes, hypertension, and dyslipidemia. recent evidence also suggests that very large waist sizes may also increase the risk of certain cancers.

A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise?

The client is dehydrated rationale: The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client

The client will have to wear an external appliance to collect urine Rationale: An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. rationale: Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. rationale: The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?

Wearing gloves when handling the urine rationale: All of these interventions would be important to ensure safety in handling the client's urine and obtaining an accurate output. However, safety with handling body fluids would be a priority for the nurse to decrease risk of exposure to pathogens or blood that may be in the client's urine

what vmi indicates obesity?

a bmi greater than 30

a nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?

a. cooked barley b. pureed broccoli c. vanilla custard d. lentil soup low-residue diets are low in fiber and easy to digest. Dairy products and eggs, such as custard and yogurt, are appropriate for a low-residue diet.

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?

anuria rationale: Absence of urine for a 24-hour period reflects anuria.

a nurse conducts a health history on a client who has experienced a 15 pound (7 kilogram) weight loss in the past 3 weeks. which information would the nurse gather to determine the client's nutrition pattern?

ask the client for a 24-hour diet recall. interview questions that will focus on nutrition might include asking the client to disclose what the individual has eaten in the last 24 hours. a 24-hour diet recall would provide better information about the total nutritional pattern.

a 55 year old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use. she's on bedrest with bathroom privileges and has just been up to use the toilet. While helping the client stand to she can wipe herself, the nurse notices a few drops of blood on top of the semi-liquid, clay-colored stool in the toilet. What action should the nurse take next? a. Nothing, the nurse shouldn't alarm her unnecessarily b. ask the client if she has noted any blood in her stools lately c ask the client if her gums bled this morning when she brushed her teeth. d. ask the client if she feels dizzy

b. ask the client if she has noted any bloody stools lately. any blood in the stool indicates an abnormal condition that needs to be assessed further. Clients with liver failure can develop coagulation problems that can lead to bleeding tendencies, such as bleeding gums. However, at this time it is more important to investigate the cause of the blood on the client's stool.

a nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching? a. glucose levels will decrease with illness and stress b. blood from the fingertips shows changes in glucose more quickly than other testing sites c. calibrate the glucose meter every six months d. use a forearm sample with signs and symptoms of hypoglycemia

b. blood from the fingertips shows changes in glucose more quickly than other testing sites.

A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention? a. "I'll monitor my intake of fruit juice b. "my favorite drink is coffee with sugar." c. "at every meal, I eat a small portion of lean meat." d. "I like to eat eggs for breakfast"

b. my favorite drink is coffee with sugar foods containing added sugar as a major ingredient tend to supply calories but few, if any other nutrients. A client monitoring carbohydrate intake should be mindful foo the intake of extra sugar.

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood Rationale: A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake rationale: Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.

a nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy?

carbohydrates

a home care ensue is educating a patient with diabetes on how to self-administer insulin. Which teaching point should the nurse include in the education plan? a. for each injection use the same site on the body b. insulin syringes and needles may be reused up to three times c. store insulin needles and syringes in a glass container between use d. each time you give the injection rotate the injection site

d. each time you give the injection rotate the injection site. the client should rotate the site for each injection systematically about 1 in from the previous injection site. Rotation within one area is preferred to rotation to a new body area with each injection in order to minimize daily variability in absorption associated with different sites.

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy Rationale: The client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine. Other answers are incorrect.

a woman consumes pasta, grains, and other carbohydrates for which purpose?

energy

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?

loss of urine without any identifiable pattern or warning ' Rationale: The nurse could describe the client's condition as the loss of urine without any identifiable pattern or warning. Stress incontinence can be described as loss of a small amount of urine when intra-abdominal pressure rises. Urge incontinence can be described as the need to void being perceived frequently with a short-lived ability to sustain control of flow. Functional urinary incontinence can be described as the loss of control over urination because a toilet is not accessible.

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

protein

the nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to indicate?

risk factors for and prevention of diabetes mellitus.

Use of an indwelling urinary catheter leads to the loss of bladder tone: true or false?

true Rationale: People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.