NUR 114 PrepU Week 12-13 Ch. 23, 28, 32, 34
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?
hypokalemia
A nurse administers pain medication to clients on a med-surg ward. The client that would benefit from a PRN drug regimen as an effective method of pain control would be the client:
in the postoperative stage with occasional pain.
A client has not voided for 8 hours after surgery. Which finding indicates the client has a distended bladder?
A bulge between the symphysis pubis and the umbilicus
A nurse is educating a client about regional anesthesia. Which statement is accurate about this type of anesthesia?
"You will be awake and will not have sensation of the procedure."
A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which position would the nurse place the client?
Supine
The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response?
Apply pressure to the surgical site to decrease bleeding.
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
The nurse is taking a history for a pregnant client who has been seen for chronic headaches for 2 years. Today, the client reports a headache that feels different than the normal headaches she has experienced in the past. Which assessment question helps the nurse assess quality of pain?
"Can you describe the type of pain you are having?"
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?
"Granulocytes are a type of white blood cell that can help fight infection."
A client has been taught relaxation exercises before a painful procedure. Which does the nurse explain to the client about the value of doing relaxation exercises before the procedure?
"Hormones are released during relaxation exercises that can prolong analgesia and produce euphoria."
Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?
"I make sure to limit how much I drink so that I don't have accidents."
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid."
In order to prevent the possibility of venous stasis, a nurse is educating a surgical client on how to perform leg exercises. Which statement by the client indicates a sound understanding of leg exercises?
"I'll practice these now and try to start them as soon as I can after my surgery."
A nurse is preparing a client for discharge from the ambulatory surgical center. Which client statement would indicate a problem with the client's discharge?
"I'm going to take a taxi home."
The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about deep breathing. The client asks, "Why am I practicing breathing when I'm having hernia surgery." What is the appropriate nursing response?
"It decreases the postoperative risk for respiratory complications."
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?
3.5 cm H2O
A nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to:
45 degrees
A male client informs the nurse that he is concerned about dribbling and incontinence of small amounts of urine after the removal of an indwelling urinary catheter. The nurse is aware that the catheter was in place for 3 weeks prior to being removed. Which is the nurse's best response to the client?
"It will take a little while for the bladder to reestablish control as the strength of the muscle improves, and an accident is not unusual."
A client reports an episode of losing control of urination when a bathroom was not close by. The client states, "I am worried this means that I am 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."
A nurse is assessing a client with arthritis. Which question will the nurse ask first to establish the client's baseline pain experience?
"On a scale of 1 to 10, what is your pain level?"
The nurse has entered the room of a client who is postoperative day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's offer of PRN analgesia and, on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns?
"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery."
A nurse is reviewing the arterial blood gas results of a client. Which pH value would the nurse document as indicating acidosis?
7.30
A client will be undergoing outpatient surgery in a few weeks. During this presurgical appointment, the nurse educates the client on necessary items regarding discharge to home after the procedure. What discharge information does the nurse teach the client?
"The center will not allow you to drive a car home. You should ask a responsible person to be available to accompany you home."
The licensed practical nurse (LPN) is observed by the registered nurse (RN) engaging in the reinforcement of teaching related to therapeutic deep breathing and coughing with a client who is recovering from abdominal surgery. Which statement by the RN best supports the LPN's role in the implementation of this intervention?
"You served as a good role model while showing the client the proper technique for this intervention."
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?
24-hour specimen
A nurse attempts to arouse a postoperative client and finds him frequently drowsy and drifting off during conversation. What would be the sedation score for this client?
3
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
3,000
The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?
Administration of 0.4 mg of naloxone
A postoperative client has developed thrombophlebitis in the right leg. What new plan of care will need to be added because of this complication?
Anticoagulant treatment and education about the increased risk of bleeding
The nurse is preparing to apply a transcutaneous electrical nerve stimulation (TENS) unit. Arrange the following steps in the correct order. Use all options. Assure that client can feel the tingling sensation. Turn on the TENS unit. Plug electrodes into the TENS unit. Apply electrodes to the prescribed location.
Apply electrodes to the prescribed location. Plug electrodes into the TENS unit. Turn on the TENS unit. Assure that client can feel the tingling sensation.
The nurse has been closely monitoring a client who has recently had their indwelling urinary catheter removed. In the 6 hours since the catheter was removed, the client has yet to void. How should the nurse first respond to this assessment finding?
Assess the client's bladder by palpation and bedside ultrasound.
Which statement accurately describes pain experienced by the older adult?
Boredom and depression may affect an older person's perception of pain.
While reviewing the medical record of a client who has had abdominal surgery, the nurse notes that the client has developed a paralytic ileus. The nurse interprets this information as indicative of what?
Bowel functioning is significantly decreased.
The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply. Polyuria Muscle weakness Nausea and vomiting Cardiac arrythmia Polydipsia
Cardiac arrhythmia Muscle weakness
A client could experience increased urination when using which classification of medication?
Cholinergic agents
The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. Advance the catheter until there is a return of urine. Discard used supplies. Insert the lubricated catheter into the urethra. Clean each labial fold, then the area directly over the meatus. Inflate the balloon with the correct amount of sterile saline.
Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.
A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility?
Client safety
An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client?
Delirium
The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?
Diarrhea
The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching? Select all that apply. Client is allowed to have one drink of alcohol each day. For better absorption, take your pain medication on an empty stomach. You may smoke cigarettes during the day but not at night. You must check with your primary care provider before breast-feeding your infant. Do not drive a vehicle while taking this medication. Keep a diary to record level of pain and time medication is taken.
Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken.
A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?
Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter?
Fasten the condom securely enough to prevent leakage without constricting blood flow.
Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?
Infants have more total body fluid and ECF than adults.
A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery?
Inability to ambulate
A nurse is caring for a client who is preparing to have a hip replacement. What is the responsibility(ies) of the nurse related to informed consent? Select all that apply. Inspecting the informed consent documentation for completeness Explaining the surgical procedure prior to obtaining informed consent Confirming the informed consent documentation is a part of the client's medical record before surgery Ensuring the informed consent documentation is signed by client and a witness Acting as a witness for the client's signature on the informed consent
Inspecting the informed consent documentation for completeness Ensuring the informed consent documentation is signed by client and a witness Confirming the informed consent documentation is a part of the client's medical record before surgery
Which statement is true of chronic pain?
It interferes with normal functioning.
Why is acute pain said to be protective in nature?
It warns an individual of tissue damage or disease.
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.
A client is scheduled for liposuction surgery to reduce weight. Which action should the nurse take immediately after surgery?
Listen to bowel sounds
A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?
Naloxone
A client reports severe pain following a mastectomy. The nurse would expect to administer what type of pain medication to this client?
Opioid analgesics
A cleansing enema is prescribed for a client who is scheduled to have colon surgery. What is the rationale for this procedure?
Peristalsis does not return for 24 to 48 hours after surgery.
Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?
Place graduated compression stockings on the client.
A client is admitted to the intensive care unit with a calcium level of 4.2 mg/dL. What is the priority action by the nurse?
Prepare to administer calcium gluconate as prescribed
The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?
Preventing constipation
The nurse is providing postoperative education to a client with an abdominal incision and is coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action?
Provide the client with a pillow or folded blanket to hug.
A nurse is caring for a female client who will undergo a curative surgery for cholecystectomy. Which precaution should the nurse take before surgery to prevent venous stasis?
Recommend that the client wear antiembolism stockings.
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?
Remove the IV.
An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence?
Stress
Which of the following describes the correct use of a TENS unit? For acute pain, a recommended pulse of 30 to 50 microseconds should be used. The electrodes should be placed over the carotid sinus nerves or over pharyngeal muscles. The unit should be turned on when repositioning or removing electrodes. TENS should not be used when the etiology of the pain is unknown.
TENS should not be used when the etiology of the pain is unknown.
Which statement accurately represents a consideration when using an epidural analgesia for client pain management?
The anesthesiologist/pain management team should be notified immediately if the client exhibits a respiratory rate below 10 breaths/min.
Which is not true of urine color?
The appearance of urine streaked with blood is always abnormal.
The nurse is providing education to a client who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the client?
The catheter can be connected to a smaller leg bag for ambulation.
A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. What is a recommended guideline for initiating this training?
The child should be able to communicate the need to void.
A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective?
The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.
A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?
The client will be admitted the day of surgery and return home the same day.
The nurse is caring for a male client with weakness who has been ordered to stay on bed rest for several days. Which method for urinary elimination does the nurse provide?
urinal
Which client would a nurse monitor most closely for postoperative respiratory complications?
a 55-year-old client with a history of asthma who had a colon resection
The nurse is performing a preoperative screening of laboratory work prior to a client's surgery in the morning. What test results should be immediately discussed with the surgeon and anesthesia care provider? Select all that apply. a sodium level of 128 mEq/L a BUN of 9 mg/dL increased hemoglobin level, indicating infection a hemoglobin of 7.2 gm/dL a potassium level of 4.2 mEq/L a white blood cell count of 18,000
a white blood cell count of 18,000 a hemoglobin of 7.2 gm/dL a sodium level of 128 mEq/L
At 1930 the client reports experiencing neuropathic pain in the legs. The client has a history of neuropathic pain following chemotherapy. The client describes the pain as burning and rates the pain as a 7 on the pain scale of 1 to 10. Based on the client's medication orders (above), which medication would the nurse administer to the client for a report of pain? Amitriptyline 20 mg PO hs daily given 2100 Pantoprazole 40 mg PO daily given 0900 CAB Acetaminophen 650 mg PO q4h prn for mild aches rated 1-4 Acetaminophen 300 mg/Codeine 15 mg 2 tablets po q4h prn for severe pain rated 8-10 Acetaminophen 300 mg/Codeine 15 mg 1 tablet po q4h prn for moderate pain rated 5-7
acetaminophen/codeine 1 tablet
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
A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:
biofeedback.
A client is prescribed oxycodone for pain relief. After teaching the client about the medication and common side effects, the nurse determines that the education was successful when the client identifies which side effect as most common?
constipation
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
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
cardiac irregularities
Which is a common anion?
chloride
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?
cloudy, foul odor
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?
decreased fluid volume risk
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?
dehydration
By which route do oxygen and carbon dioxide exchange in the lung?
diffusion
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:
fluid volume excess.
A nurse is caring for a client with acute back pain. When should the nurse assess the client's pain?
individualized based on the client's situation
A client is undergoing conscious sedation for an endoscopy. When the client becomes overly sedated, which medication does the nurse anticipate will be required?
naloxone
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?
procedural pause (time-out)
Following a successful coronary artery bypass graft (CABG), a 71-year-old male client has been transferred to the postanesthesia care unit (PACU). What is the priority for the client's nursing care during this stage of his recovery?
protecting and maintaining the client's airway
Which term is most closely associated with an acute urinary tract infection?
pyuria
While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. What would the nurse document as an abnormal finding?
reddened meatal skin
When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease?
slow wound healing
An older adult client has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which nursing concern?
social isolation
Which assessments would a nurse make for a client preadmission or on admission of a client to a surgical center? Select all that apply. social support systems signs of abuse or neglect cultural factors medication history baseline mental status recreational preferences
social support systems signs of abuse or neglect cultural factors medication history baseline mental status
The nurse is caring for a client who reports muscular and joint pain after an ankle sprain when playing soccer last week. How will the nurse document this type of pain? Select all that apply. cutaneous somatic visceral referred acute
somatic acute
A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?
straight catheter
Who is the authority on the presence and extent of pain experienced by a client?
the client
A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?
the release of endorphins
The nurse recognizes that palliative surgery is performed for what purpose?
to lessen the intensity of an illness
A nurse is providing education to a client who is scheduled for a cystoscopy as an outpatient procedure. Which description would the nurse include when discussing this procedure?
use of a flexible tube that is guided into the bladder
A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge?
void normally
