Foundations lab module 6 quiz
A patient has undergone diagnostic testing that involved the insertion of a lighted tube with a telescopic lens. The nurse identifies this test as which of the following?
Cystoscopy
A nurse is caring for a patient who recently underwent a tracheostomy. The first priority when caring for a patient with a tracheostomy is:
My urine will be eliminated through a stoma
During a routine assessment, the client states; "I wake up all night long to go the bathroom." The nurse documents this finding as which condition? Nocturia Oliguria Dysuria Polyuria
Nocturia
The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now." Explanation: When performing CPT, the nurse ensures that the client is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration, splints any incision, and provides pillows for support, as needed. A goal of CPT is for the client to be able to mobilize secretions; the client who has an unproductive cough is a candidate for CPT
A patient has a history of multiple urinary tract infections. The nurse catheterized the patient and confirmed the presence of residual urine. Select the urine volume that is significantly associated with the risk of infection. 25 mL 100 mL 150 mL 50 mL
100 mL
A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery?
A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are given.
A 47-year-old female patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should a. place ice packs around the stoma. b. notify the surgeon about the stoma. c. monitor the stoma every 30 minutes. d. document stoma assessment findings.
ANS: D The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.
A nurse provides care for a patient receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?
Assessing the patients respiratory status, orientation, and skin color
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?
Correct and safe use of oxygen therapy equipment
nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices? A)Empty the collection bag when it is between one-half and two-thirds full. B) Limit fluid intake to prevent production of large volumes of dilute urine. C) Reinforce the appliance with tape if small leaks are detected. D) Avoid using moisturizing soaps and body washes when cleaning the peristomal area.
D
The nurse caring for a patient with a urinary diversion notices mucus around the stents and in the patient's urine. Which is the appropriate nursing intervention?
Document presence of mucus in the urine
A patient with recurrent urinary tract infections has just undergone a cystoscopy and reports slight hematuria during the first void after the procedureWhat is the nurse's most appropriate action?
Document the finding and continue to monitor
The nurse is assessing a patient one day after a colostomy is placed. The abdomen is soft and non-tender and there is no drainage present in the colostomy pouch. Which is the best action? Encourage oral intake Irrigate the stoma Document the findings Call the surgeon
Document the findings
After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?
Effective breathing at a rate of 16 breaths/minute through the established airway Explanation: Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.
The nurse is working in a diagnostic testing unit focusing on gastrointestinal studiesFor which testing procedure is the nurse correct to assess the gag reflex before offering fluids?
Egd
The nurse is teaching a patient scheduled for a colonoscopy. Which of the following should be included as part of the preparation for the procedure?
Follow the dietary and fluid restrictions and bowel preparation procedures.
A nurse is applying an ostomy appliance to the ileostomy of a patient with ulcerative colitis. Which action is appropriate?
Gently washing the area surrounding the stoma using a facecloth and mild soap
The nurse is caring for a 36-year old female with multiple sclerosis . Which continence management approach is most appropriate
Intermittent self-catheterization
What is the most important thing to remember when using a nasal cannula?
It can cause the nasal mucosa to dry in case of high flow. When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.
A nurse is caring for a patient who recently underwent a tracheostomy. The first priority when caring for a patient with a tracheostomy is:
Keeping his airway patent
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? a) Percuss the patient's lungs and thorax. b) Determine whether the patient can now perform forced expiratory technique (FET). c) Measure the patient's oxygen saturation. d) Have the patient perform incentive spirometry.
Measure the patient's oxygen saturation. The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.
The nurse is caring for a 72-year-old client with shortness of breath (SOB), who is prescribed 100% oxygen by nasal cannula at 4 L/min . Which finding indicates an expected outcome of oxygen therapy?
Pulse ox 97%
The patient is postoperative for a total laryngectomy and has recovered from anesthesia. The patient's respirations are 32 breaths /minuete, blood pressure is 102/58 , and pulse rate is 104 beats / minuete. Pulse oximetry is 90%. The patient is receiving humidified oxygen. To aid in the patient's respiratory status, the nurse places the patient in which of the following positions.
Semi- Fowler's The client is in respiratory distress. The best position for the client who has a tracheostomy and recovered from anesthesia is semi-Fowler's.
Which position is recommended for a patient with dyspnea?
Semi-Fowler's
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning.
A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?
The widest part of the stoma
The nurse is instructing a patient prior to a colonoscopy. The patient states, "Why do have to drink this disgusting liquid? The nurse is most correct to verbalize the goal of the oral preparation as which of the following?
To cleanse the bowel to promote clear visualization of structures.
Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis? a. Restrict fluid intake to prevent constant liquid drainage from the stoma. b. Use care when eating high-fiber foods to avoid obstruction of the ileum. c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance. d. Change the pouch every day to prevent leakage of contents onto the skin.
Use care when eating high-fiber foods to avoid obstruction of the ileum.
The nurse is determining the length of the tubing that will be needed to reach the stomach or small intestine. The nurse needs to measure the tube so that it corresponds to which point on the patients anterior chest wall? A. Suprasternal notch B. Manubrium C. Mid sternum D. Xiphoid process
Xiphoid process
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
increasing fluid intake to prevent dehydration.
