317 Exam 4

4. What should the nurse teach the client to do to prevent stress incontinence? Select all that apply. a. Use techniques that strengthen the sphincter & structural supports of the bladder, such as Kegel exercises. b. Avoid dietary irritants such as caffeine, alcoholic beverages, etc....) c. Not to laugh when in social gatherings d. Carry an extra incontinent pad when away from home e. Obtain a fluid intake of 500ml/daily

A B

5. The nurse finds a container with the client's urine specimen sietting on a counter in the bathroom. The client states that the specimen has been sitting in the bathroom for at least 2 hours. The nurse should: a. Discard the urine and obtain a new specimen b. Send the urine to the lab as quickly as possible c. Add fresh urine to the collected specimen & sned the specimen to the lab d. Refrigerate the specimen until it can be transported to the lab

A. Urine that stands in the room becomes alkaline, with multiplying bacteria. The specimen should be examined within one hour after urination.

Which of the following actions by the nurse shows the most effective planning regarding the care of a patient whose pulse oximetry reading decreases to 88% while his tracheostomy was previous suctioned a. assessing the patient's breath sounds before suctioning b. planning to apply suctioning no longer than 15 seconds at a time c. having a manual resuscitation bag at the patient's bedside d. hyper oxygenating the patient before suctioning

C

To specifically minimize the female patients risk for infection during an intermittent catheterization the nurse should a. cleanse perineal area from clitoris toward the anus 3 times with 3 different antiseptic-soaked swabs b. advance the catheter only 2-3 inches into the urethral meatus c. properly dispose of all contaminate items, remove gloves, and then wash hands d. provide a sterile drape under patients buttock

a

An elderly client admitted with new-onset confusion, headache poor skin turgor, bounding pulse & urinary incontinency. Has been drinking copious amount of water. Upon reviewing the lab results the nurse discovers a sodium level of 122mEq/L. A report to the physician should include what recommendations? Select all that apply. a. Fluid restriction b. Encourage fluids c. Vital signs every 4 hours instead of every shift d. Bed Alarm e. Foley catheter f. Strict Intake & output g. Repeat electrolytes, urine sodium, & specific gravity in the morning. h. 2 GM. Sodium Diet

a,c,d,e,f,g,. The client if hyponatremic; the nurse will closely monitor vital signs, restrict fluids, accurately record intake & output with the aid of a foley catheter, prescribe labs for morning & ensure safety with use of bed alarm. The nurse will monitor for neurological changes & report to MD if unable to take anything by mouth.

Appropriate indication for indwelling urinary catheter utilization includes all but a. assistance with healing open sacral or perineal wounds or skin grafts in certain incontinent patients b. large incontinent patient requiring frequent linen changes c. need for accurate urine output measurement in critically ill patients d. accuse urinary retention or bladder outlet obstruction

b

Which of the following actions by the nurse shows the most effective planning regarding minimizing of the patients risk for infection during tracheostomy care a. instructing ancillary staff to report any changes in color or odor o tracheal drainage b. adhering to steril technique when appropriate c. frequently assessing for signs of local or systemic infection d. monitoring the patient for indications that trash care is needed

b

Which of the following actions is best suited to evaluate the effectiveness of the oropharyngeal suctioning on the patient's respiratory status a. confirming that the patient's pulse ox is greater than 90% b. comparing respiratory assessment data pre- and post suctioning c. assessing the patient's kin for signs of cyanosis d. asking the patient to report and symptoms of dyspnea

b

Pretesting the balloon on an indwelling catheter is no longer recommended because a. nurses were polled and it was determined that they had never experience a balloon that didn't inflate properly b. recent manufacturing methods have eliminated the potential for failure of the balloon to inflate c. all balloon are the same size and it is unnecessary to determine how much fluid each balloon will hold prior to insertion d. testing the balloon may distort and stretch the balloon causing increased trauma to the patient on insertion

d

what is a critical step when inserting an indwelling catheter into a male patient a. advance to the bifurcation of the drainage and balloon ports then inflate the balloon b. quickly inflate the catheter balloon with sterile saline c. secure the catheter drainage tubing to the bed sheets when inserted d. advance until urine flows then insert 1-2 more inches then inflate balloon

d

which initial nursing actions will minimize the patient risk for injury during the insertion of an indwelling catheter a. throughly cleansing the patient's penile meatus with butadiene in a spiral motion before inserting the catheter b. terminating the insertion if the patient reports pain at any time during the process c. providing lubricant to the catheter prior to insertion d. assess the patient for allergies related to latex, antiseptic, tape and iodine based substances

d

3. The client asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in MOST instances, cystitis is caused by: a. Congenital structures in the urethra b. An infection elsewhere in the body c. Urinary stasis in the urinary bladder d. An ascending infection from the urethra

4 Although various conditions may result in cystitis, the most common cause is an ascending infection from the urethra.

1. To prevent catheter associated urinary tract infection the nurse should do which of the following? Select all that apply. a. Change the catheter daily b. Provide perineal care several times a day c. Assess the client for signs of infection d. Encourage the client to drink 3000ml fluids daily e. Recommended the health care provider prescribe antibiotics

B C D Catheter-acquired urinary tract infections is the most frequent type of health care acquired infection & represents as much as 80% of health care acquired infections.

2. A 24yo female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of acute cystitis. When obtaining the client's history, the nurse should ask the client if she has had: a. Fever & chills b. Frequency & burning on urination c. Flank pain & nausea d. Hematuria

B The classic symptoms of cystitis are severe burning with urination, urgency & frequent urination. Systemic symptoms, such as fever, nausea, and vomiting are more likely to be pyelonephritis.

Which of the following actions by the nurse shows the effective handling of disposable equipment after oropharyngeal suction has been completed? a. place dirty treatment gives in biohazard receptacle in the patient's room b. place all disposable equipment into the wrapper of the suction catheter before placing it in the trash receptacle c. fold the paper drape with the other surface inward and dispose of it in a biohazard receptacle d. hold the used suction catheter in the palm of the gloves hand, and then carefully pull the glove off inside out over the catheter and dispose in the regular trash

D