HESI Remediation PN- Elimination - #2
A nurse is caring for a client with ureteral calculus. Which are the most important nursing actions? Select all that apply. 1. Limiting fluid intake at night 2. Monitoring intake and output 3. Straining the urine at each voiding 4. Recording the client's blood pressure 5. Administering the prescribed analgesic
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A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. What should the nurse include in the home care instructions? A) Drink at least 3 L of fluid daily for four weeks B) Eliminate organ meats from the diet for six weeks C) Increase the intake of dairy products for five days D) Restrict movement for three days before resuming usual activities
A) Drink at least 3 L of fluid daily for four weeks
A nurse is assessing a toddler with vesicoureteral reflux. What clinical finding does the nurse expect to identify? A) Dysuria B) Oliguria C) Glycosuria D) Proteinuria
A) Dysuria Discomfort during urination (dysuria) is a symptom of a urinary tract infection (UTI), which is common with vesicoureteral reflux. During voiding, urine is swept up the ureters and then flows back to the bladder, resulting in a residual volume that provides a medium for the development of a UTI. Oliguria, glycosuria, and proteinuria usually do not occur with vesicoureteral reflux.
A client will be taking nitrofurantoin 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client? A) Increase the intake of fluids B) Strain the urine for crystals and stones C) Stop the drug if urinary output increases D) Maintain the exact time schedule for taking the drug
A) Increase the intake of fluids To prevent crystal formation, the client should have sufficient intake to produce 1000 to 1500 mL of urine daily while taking this drug.
A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate that her toddler: A) Presence of bulky, foul, frothy stools B History of drinking large amounts of fluid C) Reported as irritable throughout the day D) History of voiding strong, concentrated urine
A) Presence of bulky, foul, frothy stools
Which statement is true regarding ulcerative colitis? A) Ulcerative colitis may cause rectal bleeding and abdominal cramping. B) May occurs anywhere along the GI tract C) The stool of a client with UC contains an excess amount of fats D) Inflammation in clients with UC may extend through all layers of the bowels
A) Ulcerative colitis may cause rectal bleeding and abdominal cramping. Rationale: The clinical manifestations of ulcerative colitis are rectal bleeding and abdominal cramping. Ulcerative colitis is confined to the mucosa or submucosa of the colon. An excess amount of fats in the stool is associated with Crohn's disease. The inflammation in clients with ulcerative colitis is limited to the mucosal lining.
Which drugs are contraindicated in a patient with infectious diarrhea? Select all that apply. A) Nizatidine B) Loperamide C) Misoprostol D) Lansoprazole E) Diphenoxylate with atropine
Answer: B , E Loperamide and Diphenoxylate with atropine
A client has a permanent colostomy. During the first 24 hours, there is no drainage from the colostomy. The nurse concludes that this is a result of the: A) Edema after the surgery B) Absence of intestinal peristalsis C) Decrease in fluid intake before surgery D) Effective function of the nasogastric tube
B) Absence of intestinal peristalsis
A health care provider prescribes psyllium (Metamucil) 3.5 g twice a day for constipation. What is most important for the nurse to teach this client? A) Urine may be discolored. B) Each dose should be taken with a full glass of water. C) Use only when necessary because it can cause dependence. D) Daily use may inhibit the absorption of some fat-soluble vitamins.
B) Each dose should be taken with a full glass of water.
During the fourth stage of labor, the assessment of a primipara who has had a vaginal birth reveals a moderate to large amount of lochia rubra, a firm fundus that is at the umbilicus and deviated to the right, and pain that she rates as a 3 on a scale of 1 to 10. What is the priority nursing action? A) Massaging the fundus B) Helping the client void C) Increasing the rate of the oxytocin fusion D) Administering the prescribed pain medication
B) Helping the client void A fundus that is deviated to the right during the fourth stage of labor commonly is caused by a distended bladder; if the bladder remains distended, involution will be inhibited, resulting in a boggy uterus that is prone to hemorrhage.
A nurse is caring for an older bedridden male client who is incontinent of urine. Which action should the nurse take first? A) Restrict fluid intake. B) Offer the urinal regularly. C) Apply incontinence pants. D) Insert an indwelling urinary catheter.
B) Offer the urinal regularly. Rationale: Retaining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response.
When a client returns from the postanesthesia care unit after a kidney transplant, the nurse should plan to measure the client's urinary output every: A) 15 minutes B) One hour C) Two hours D) Three hours
B) One hour
One week after beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. The client is admitted with a diagnosis of thyrotoxic crisis. The nurse determines that the most important intervention for this client is: A) Limiting fluid intake B) Reducing body temperature and heart rate C) Observing for an exaggerated response to sedatives D) Treating the associated hyperglycemia and ketoacidosis
B) Reducing body temperature and heart rate Immediate treatment in this emergency focuses on reduction of oxygen demands and thus cardiac workload to prevent cardiac decompensation. The need is for an increase, not decrease, in fluid intake to compensate for that lost because of the high metabolic rate. A response to sedatives is not likely because drugs are metabolized more rapidly with thyrotoxic crisis; there is a danger of exaggerated effects of the drug with hypothyroidism. Clients with thyrotoxic crisis are more apt to develop hypoglycemia from the high metabolic rate.
A client who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the client to obtain a stool specimen. When assessing the client's stool, what would the nurse expect to observe? A) Melena B) Steatorrhea C) Hard, dry stool D) Ribbon-shaped stool
B) Steatorrhea Rationale: Decreased secretion of lipase from the pancreas limits fat breakdown in the small intestine, resulting in increased fat content in feces; steatorrhea is soft, frothy, foul-smelling feces. Melena refers to black, tarry stool containing digested blood; melena is caused by upper gastrointestinal bleeding. Hard, dry stool reflects constipation; stools associated with pancreatitis are soft and frothy. Ribbon-shaped stool is associated with obstruction of the descending or sigmoid colon.
The nurse is providing care to a client being treated for bacterial cystitis. What is the goal before discharge for this client? A) Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration B) Be able to identify dietary restrictions and plan menus C) Achieve relief of symptoms and maintain kidney function D) Recognize signs of bleeding, a complication associated with this type of procedure
C) Achieve relief of symptoms and maintain kidney function Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this procedure.
A client undergoing treatment for a medical condition gave birth to a baby with renal failure as a result of the teratogenic effect of the medications. Which medical condition is the client likely getting treated for? A) Cancer B) Epilepsy C) Hypertension D) Microbial infection
C) Hypertension Angiotensin-converting enzyme inhibitors used for treating hypertension may cause renal failure as a teratogenic effect. Treatment of cancer may cause central nervous system malformations. Treatment of epilepsy may cause growth delay. Antimicrobials may cause heart defects.
A client experiences difficulty in voiding after an indwelling urinary catheter is removed. The nurse determines that this difficulty most likely is related to: A) Fluid imbalance B) Sedentary lifestyle C) Interruption in previous voiding habits D) Nervous tension following the procedure
C) Interruption in previous voiding habits
A client has an excision of a thrombosed external hemorrhoid. What should the nurse teach the client to use when cleaning the anus after a bowel movement? A) Betadine pads B) Soft facial tissue C) Medicated pads (Tucks) D) Sterile 4×4-inch gauze pads
C) Medicated pads (Tucks)
A client who had a recent brain attack (CVA) has not had a bowel movement for five days. After addressing this problem, what does the nurse anticipate will be prescribed daily to prevent this from occurring in the future? A) Fleet enema to stimulate peristalsis B) Tap-water enema to evacuate the bowel C) Mild stool softener to make stool easier to pass D) Lubricant laxative to create more bulk in the intestines
C) Mild stool softener to make stool easier to pass
A nurse is planning care for a client admitted to the hospital with abdominal spasms and pain associated with severe diarrhea. What primary serum blood level should the nurse monitor? A) Urea B) Chloride C) Potassium D) Creatinine
C) Potassium Rationale: Potassium moves quickly through the GI tract of a client with diarrhea and is not absorbed therefore, serum potassium can become dangerously low and cause cardiac dysrhythmias.
The mother of a 2-year-old toddler tells the nurse that her child is frequently constipated. The nurse asks the mother how she handles the child's toileting. Which response indicates to the nurse that the mother requires further education? A) "My child drinks a lot of fluids." B) "I give my child high-fibterm-2er foods." C) "My child has one bowel movement a day." D) "I schedule my child's toileting for before each meal."
D) "I schedule my child's toileting for before each meal." Scheduling toileting before meals does not take advantage of the gastrocolic reflex; having the child go to the toilet after meals will probably be more successful. Increasing fluid intake may help relieve constipation; no additional teaching is needed. High-fiber foods help prevent constipation; no additional teaching is needed. One bowel movement per day makes scheduling easier; no additional intervention is needed.
Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. The most appropriate response by the nurse is: A) "You will have an abdominal incision and a dressing." B) "Your urine will be pink and free of clots." C) "There will be an incision between your scrotum and rectum." D) "There will be an indwelling urinary catheter and a continuous bladder irrigation in place."
D) "There will be an indwelling urinary catheter and a continuous bladder irrigation in place."
A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. What should be the nurse's initial intervention? A) Strain all urine output B) Increase oral fluid intake C) Obtain a urine specimen for culture D) Administer the prescribed analgesic
D) Administer the prescribed analgesic Pain of renal colic may be excruciating; unless relief is obtained, the client will be unable to cooperate with other therapy. Urine can be saved and strained after the client's priority needs are met. Increasing fluid intake may or may not be helpful. If the stone is large the fluid can build up, leading to hydronephrosis; however, if the stone is small, fluids may help flush the stone. Although a culture generally is prescribed, this is not the priority when a client has severe pain.
The parents of a boy born with hypospadias ask the nurse at what age the repair of this congenital defect is performed. What is the most appropriate response by the nurse? A) Shortly after birth B) Between 4 and 5 years of age C) Just before the onset of puberty D) After 6 months and before 1 year
D) After 6 months and before 1 year During infancy is the preferred age, before the development of body image and fear of castration. The phallus is not developed enough for surgery to be performed shortly after birth. Children 4 to 5 years of age are in the stage of development that is accompanied by fear of mutilation.
A client is diagnosed with a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report what kind of stools? A) Frothy B) Ribbon shaped C) Pale or clay colored D) Dark brown or black
D) Dark brown or black
A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. What is a nursing responsibility common to preparing both of these clients for these procedures? A)Withholding food for several hours B) Giving castor oil the afternoon before C) Administering soapsuds enemas until clear D) Ensuring an understand of the procedure
D) Ensuring an understand of the procedure
A client who recently experienced a brain attack (CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation? A) Presence of distention B) Extent of weight gained C) Amount of high-fiber food consumed D) Length of time this problem has existed
D) Length of time this problem has existed
A client with a history of ulcerative colitis has a large portion of the large intestine removed, and an ileostomy is created. For which potential life-threatening complication should the nurse assess the client after this surgery? A) Infection caused by the excretion of feces B) Injury caused by exposed intestinal mucosa C) Altered bowel elimination caused by the ostomy D) Limited water reabsorption caused by removal of intestine
D) Limited water reabsorption caused by removal of intestine
A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the health care provider? A) Prepare for urinary catheterization. B) Teach the client how to perform perineal care. C) Start a 24-hour urine collection. D) Obtain a urine specimen for culture and sensitivity.
D) Obtain a urine specimen for culture and sensitivity.
An older adult client who is accustomed to taking enemas periodically to avoid constipation is admitted to a long-term care facility. In addition to medications, the health care provider prescribes bed rest and a regular diet. Which action should be implemented to help prevent the client from developing constipation? A) Arrange to have enemas prescribed for the client B) Obtain a prescription for a daily laxative for the client C) Place a commode by the bedside to facilitate defecation D) Offer a large glass of prune juice with warm water each morning.
D) Offer a large glass of prune juice with warm water each morning.
A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as: A) Urge incontinence B) Stress incontinence C) Reflex Incontinence D) Overflow incontinence
D) Overflow incontinence Rationale: Overflow incontinence describes what is happening with this client; overflow incontinence occurs with retention of urine with overflow of urine.
The health care provider prescribes mebendazole (Vermox) for a 4-year-old child with pinworms. For which expected response to the medication does the nurse teach the parents to be alert? A) Blood B) Constipation C) Yellow stools D) Passage of worms
D) Passage of worms
fter a subtotal gastrectomy for cancer of the stomach, a client develops dumping syndrome. The client says, "What does it mean when the healthcare provider says that I am experiencing dumping syndrome?" What information should the nurse include in a response to this question? A) Nausea resulting from a full stomach B) Reflux of gastric contents into the esophagus C) Buildup of flatulence within the large intestine D) Rapid passage of concentrated fluid into the small
D) Rapid passage of concentrated fluid into the small
A health care provider prescribes bisacodyl (Dulcolax) for a client with cardiac disease. The nurse explains to the client that this drug acts by doing what? A) Producing bulk B) Softening feces C) Lubricating feces D) Stimulating peristalsis
D) Stimulating peristalsis Rationale: Bisacodyl stimulates nerve endings in the intestinal mucosa, precipitating a bowel movement.
The postoperative prescriptions for a client who had repair of an inguinal hernia include docusate sodium (Colace) daily. Before discharge, the nurse teaches the client that an intermittent side effect of this medication may be: A) rectal bleeding B) fecal impaction C) nausea and vomiting D) mild abdominal cramping
D) mild abdominal cramping