Nursing 1 Exam 4
Bonus question: A nurse is teaching the guardian of an 18-month-old toddler about optic medication administration. Which of the following statements should the nurse make? "Administer the drops immediately after removing the medication from the fridge." "Place the child in a seated position with the head tilted to the side for administration." "Gently pull the ear cartilage down and back when administering the medication." "Position the medication bottle so the drops do no touch the side of the ear canal."
"Gently pull the ear cartilage down and back when administering the medication."
Bonus Question: A nurse is teaching the parents of a 3- year- old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching. "My child should not play around others who have ear infections." "We should not smoke around our child." "My child should not swim this summer." "I will encourage my child to blow his nose forcefully when he has a cold."
"We should not smoke around our child."
Bonus Question: A nurse is teaching a client how to perform personal ileostomy care prior to discharge. The client says, "I can't, I think I am going to be able to take care of this myself." Which of the following responses should the nurse make? In time, you will become better at this than I am." "Don't worry about it. Most clients feel like that at first." "What part of the ileostomy care are you having trouble with?" "I agree. This is a difficult process."
"What part of the ileostomy care are you having trouble with?"
What is dark urine a sign of?
*Dark urine is a sign of urine concentration and can be a sign of dehydration. Alcohol and caffeinated beverages such as cola, coffee, and tea all increase urine production and can be dehydrating if not balanced with water consumption.*
Specific Gravity:
1.005 to 1.030
Normal Platelet Count
150,000- 450,000
Urine output
20-30 mL/hr Less than 30 mL/hr for more than 2 hours is a cause for concern
Normal White Blood Cells (WBC) Count
4,800-10,800
BUN:
: 10-20 mg/dL
Bonus Question: When assigning clients to rooms for admission, to which of the following should the charge nurse give the highest priority for a private room? A client with HIV and osteomyelitis A client with varicella zoster (shingles) localized to the T12 dermatome. A client with a UTI who had a positive vancomycin-resistant enterococcus this morning, necessitating a change in antibiotic therapy. A client with meningitis with positive cultures for Neisseria meningitidis who has been treated with appropriate antibiotics for 2 days.
A client with a UTI who had a positive vancomycin-resistant enterococcus this morning, necessitating a change in antibiotic therapy.
GI Assessment Unexpected Findings during Inspection
A yellow hue to the skin could indiciate jaundice or a liver condition Glistening or taut skin could be attributed to ascites, which is the buildup of fluid in the abdomen Pink or purple straie (stretch marks) indicate recent strecting of the skin due to weight gain or abdominal distention Dilated viens of the abdomen and spider angiomas suggests the presence of liver disease. Flat ase
Cellulitis
Acute inflammation of the dermis and subcutaneous tissue; usually caused by an infection.
External Catheters:
Also known as condom catheter, mainly used for males who are able to drain their bladder but can't controlling when it's released Most commonly used in young children when the mother is suspected with the use of opioids
Conjunctivitis
Also known as pink eye, is an irritation or infection of the membrane that covers the white of the eye and the inside of the eye. The membrane swells and the blood vessels in the membrane dilate. **Contact precaution**
Otitis Media:
An ear infection of the middle ear, the air-filled space behind the eardrum that contains the tiny vibrating bones of the ear. Children are more likely than adults to get ear infections. Smoking around children are more at risk for developing ear infections
Conjunctivitis Treatment
Antibiotics and Steroids Warm or cool compress Meticulous hand hygiene to prevent transmission
VRE Treatment
Antibiotics/Antimicrobials
Bonus Question: A nurse is performing discharge teaching with a client who has cellulitis due to a bacterial infection. Which of the following information should the nurse include in the teaching? Bathe daily with moisturizing soap. Apply the antibacterial topical medication to the crusted exudate. Apply warm compresses to the affected area. Cover the affected area with a tight-fitting sock.
Apply warm compresses to the affected area.
Straight Catheters
Are small hollow, flexible tubes that are used to empty the urine from the bladder intermittently Only used one time and then thrown away
Indwelling Catheters
Are used short-term and provide a closed drainage system for urine Most common type of catheter that causes infection; occurs while in place or up to 48 hours after discontinuing.
Bonus Question: A nurse is teaching a client about urinary tract infections. Which of the following manifestations should the nurse include? Weight gain Back pain Vaginal discharge Muscle cramps
Back Pain
Urinary Tract Infections (UTI) Manifestations
Burning sensation when urinating Passing frequent or small amount of urine Urine that appears to be cloudy, foul smelling, red, or bright pink Lower back Pain
Bonus Question: A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet? Calcium Phosphorous Potassium Sodium
Calcium
Overflow Incontinence: urinary retention from bladder overdistention and frequent loss of small amounts of urine due to obstruction of the urinary outlet or an impaired detrusor muscle
Can lead to a neurogenic (flaccid) bladder Spinal cord injury, Multiple sclerosis, or enlarged prostate
Urge Incontinence: Inability to stop urine flow long enough to reach the bathroom due to overactive detrusor muscle.
Can occur due to bladder irritation from a UTI or an overactive bladder
Bonus Question: Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk? Avoid laying the infant in his abdomen Avoiding tucking the appliance into the infant's diaper Check the bag for stool every 4 hour Replace the appliance every 3 day
Check the bag for stool every 4 hour
Bonus Question: A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? Apply a fecal collection system Apply a barrier cream Cleanse and dry the area Check the client's perineum
Check the client's perineum
Bonus Question: A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? Withdraw the specimen from the drainage bag Cleanse the collection port with soap and water Place the specimen in a clean specimen cup Clamp the tubing below the collection port
Clamp the tubing below the collection port
Preventing Catheter Infections
Clean the area around the catheter opening every day Clean the catheter with soap and water Clean the rectal area thoroughly after every bowel movement Keep the drainage bag lower than the bladder
Bonus Question: A nurse is instructing a female client to collect a midstream urine sample. Which of the following should the nurse include in the instructions? Ask the client to urinate a small amount and then hold the stream while the specimen cup is placed. Cleanse the vaginal area by wiping from front to back. Collect a minimum of 20 mL of urine into the specimen cup. Avoid using a single cleansing wipe more than two times.
Cleanse the vaginal area by wiping from front to back.
Functional Incontinence: Loss of urine due to factors that interfere with responding to the need to urinate
Cognitive, mobility and environmental behaviors
Catheter Insertion
Confirm prescription for an indwelling catheter ○ Gather all supplies needed for the procedure ○ Explain the procedure to the patient Apply clean gloves to perform perineal care Use the sterile technique to prepare equipment and apply sterile gloves ○ Cleanse the meatus using sterile technique Females: Cleanse the labia and urinary meatus with sterile antiseptic. Use only one cotton swab or cotton ball for each area cleansed. Male: Retract foreskin (if uncircumcised). Clean the meatus with sterile antiseptic(iodine), using a circular motion. Repeat at least three times, using one cotton swab or cotton ball each time. Insert catheter Females: Advance catheter approximately 2 inches after urine appears in the tubing. Males: Advance catheter all the way to the tubing bifurcation. ○ ** Always fit collection bags to a non-movable part of the client's bed or to the client's wheelchair** ○ **Use silicon or teflon products for clients who have latex allergies
Conjunctivitis Risk Factors
Contact with another person having the eye infection Contact lens use Exposure to allergen
Clostridium Difficile (c-diff) Nursing Interventions
Contact/Standard Precautions Do not use alcohol based hand hygiene, wash hands with soap and water always.
24 Hour Urine Sample
Discard the first urination of the day. Refrigerate (keep on ice), label, and transport the specimen
Bonus Question: A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? Obtain an audiology referral Document this as an expected finding Irrigate the ear with warm water Document mild inflammation
Document this as an expected finding
What to not forget during stool specimen collection?
Don't forget to LABEL your specimen collection Use a tongue depressor to transfer stool DON gloves
Colostomy
Empty pouch at ⅓ to ½ full. Change system approximately 3-7 days depending on individual's needs. Stoma should be pink/red. Regular elimination patterns should begin before the patient goes home or is discharged to an extended care facility. Small serving of small soft foods is recommended, there are no diet restrictions.
Bonus Question: A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? Place the drainage bag on the client's abdomen when transferring from a bed to a cart. Empty the drainage bag when half-full of urine. Rest the drainage bag on the floor when closing the drainage spigot during emptying. Disconnect the drainage bag when obtaining a urine specimen.
Empty the drainage bag when half-full of urine
Bonus Question: A nurse is performing discharge teaching about ostomy care while at home for a client who has a newly placed ileostomy. Which of the following instructions should the nurse include in the teaching? "Empty your ostomy pouch when it becomes half full." "Place an aspirin in the ostomy pouch to eliminate odor." "Change the ostomy appliance every week." "Cleanse the site around the stoma with hydrogen peroxide and water.
Empty your ostomy pouch when it becomes half full
What is a last resort?
Enemas
How to apply medication for Conjunctivitis
Eye Drops: Apply pressure to the inner canthus of the eye after medication administration will block the lacrimal punctum
Complication of constipation
Fecal impaction: stool becomes wedges in the rectum and can involve diarrhea fluid leaking around the impacted stool. Administer enemas and suppositories or stool softeners as prescribed to promote relief of fecal impaction Use gloved, lubricated finger for digital remove of stool Stop the procedure if the heart rate drops significantly or the heart rhythm changes. Hemorrhoids and rectal fissures
Serum Creatinine
Females: 0.5- 1.1 mg/dL Males: 0.6- 1.2 mg/dL
Creatinine
Females: 0.74-125 mg/dL Males: 90- 139 mg/dL
Normal Hemoglobin (Hgb)
Females: 12-16 Males: 13-18
Normal Hematocrit
Females: 37%-47% Males: 42%-52%
Normal Red Blood Cells (RBC)
Females: 4.2- 5.7 cells/mcL Males: 4.7- 6.1 cells/mcL
Assessment for dehydration
Fluid and electrolyte disturbances: Metabolic acidosis from excessive loss of bicarbonate
Test for stool specimen collection
Guaiac Test( fecal occult blood test): Obtain a fecal sample using medical asepsis while wearing gloves. Collect stool specimens three times from three different defications. Some foods (red meat, citrus fruit, raw veggies) and medication can cause false positives . Blue color indicated the stool is positive for blood
Ottis Media symptoms
Hearing difficulty, fever, ear pain, unusual irritability, difficulty sleeping or staying asleep, loss of balance, fluid draining from ear. In children, fever is most common as well as tugging or pulling at one or both ears
Bonus Question: A nurse is assessing a client who is brought to the emergency department following a motor-vehicle crash. Which of the following findings is a manifestation of bladder trauma? Stress incontinence Hematuria Pyuria Fever
Hematuria
GI Assessment Auscultation Normal Sounds
High - pitched and gurgling with a frequency of less than 1 minute. This could be related to side effects of medication from medication or anesthesia, constipation or bowel obstruction.
Bonus Question: A nurse is caring for a female adolescent who is being treated for frequent urinary tract infections. Which of the following statements by the adolescent indicates a possible cause of the UTI? I have bowel movements every 4 to 5 days." "My mom taught me to wipe from front to back after going to the bathroom." "I urinate every 2 to 3 hr during the day." "I don't wear nylon underwear."
I have bowel movements every 4 to 5 days."
What should I do if I don't hear bowel sounds in the Righter Lower Quadrant (RLQ)?
If bowel sounds are not heard in the RLQ, you should listen to the other quadrants moving clockwise: right upper, left upper, and left lower
How to prevent constipation
Increase fluids, fiber, regular exercise
Bonus Question: A nurse is teaching a healthy older adult client who has a chronic constipation about establishing a bowel-retraining program. Which of the following statements should the nurse include in the teaching? Limit physical activity during the day. Set a time limit of 10 min when attempting to defecate Increase the fiber content of your diet Increase your fluid intake to 5,000 mL per day
Increase the fiber content of your diet
GI Assessment
Inspect, Auscultate, Percuss, Palpate
Bonus Question: A nurse is caring for a client who has a skin graft that has developed cellulitis. Which of the following manifestations should the nurse expect?
Intense redness and itching Inflammation of the skin Streak-like rash
Ileostomy Care
Keep the patient as free from odors as possible Inspect the stoma regularly Pink or Red Keep the skin around the stoma clean and dry Measure I & O Explain each aspect of care to the patient and encourage the patient to look and care for their ostomies
Midstream/Clean Catch Urine Sample:
Label the container with the client's identifying information, and follow the facilities policy for transporting the specimen to the laboratory. Thoroughly cleansing the urethral meatus, clients will then collect the midstream sample. First pass a small amount of urine into the toilet Collect urine midstream
GI Assessment Auscultation Absent
Listen for 5 minutes. This an unexpected finding and can be related to an intestinal obstruction
GI Assessment Ausculatition
Listen for bowel sounds in all quadrants of the abdomen.
What can cause constipation?
Medications such as Opioids/Narcotics Iron Surgery and Anesthesia
If you listen to bowel sounds in one quadrant of the stomach do you need to listen to bowel sounds in the other?
No, Current evidence suggests that if you hear bowel sounds in one quadrant (RLQ), it is not necessary to listen to other quadrants because bowel sounds are conveyed throughout the abdomen.
Bonus Question: A nurse is providing teaching to the parent of a toddler who has bacterial conjunctivitis. Which of the following instructions should the nurse include? Clean secretions from the infected eye by wiping from the outer canthus toward the inner canthus and upward. Keep the infected eye covered with warm compresses for the first 24 to 48 hr Notify the provider immediately if the sclera becomes inflamed Apply pressure to the outer canthus of the eye for 1 min after administering the eye drops
Notify the provider immediately if the sclera becomes inflamed
Culture and Sensitivity Collection
Obtain a sterile specimen from a straight or indwelling catheter using surgical asepsis(sterile technique)
Urinary Tract Infections (UTI) Prevention
Personal hygiene (front to back) Wear cotton underwear Urinate before and after sex Increase fluid intake Do not ignore the urge to void
Bonus Question: A nurse is caring for a 40-year-old female client who is diagnosed with a urinary tract infection due to vancomycin-resistant enterococcus. Which of the following is an important nursing consideration when caring for the client. Institute standard precautions Avoid antibiotics, as they cannot effectively treat the client Assign the client to a semi-private room Place the client on contact isolation precautions
Place the client on contact isolation precautions
Vancomycin-Resistant Enterococcus(VRE) Nursing Interventions
Place the patient in a private room and minimize the number of staff caring for that patient. Use standard and contact precautions Use disposable equipment when possible; use non-disposable items only on the infected patient. Ensure judicious and careful use of antibiotics. Encourage physicians to limit the use of antibiotics. Double bag all specimens for transport. Enlist the aid of an infection control specialist as indicated. Remove any invasive devices that are used for the shortest time possible. Administer fluids as ordered. Encourage frequent turning and position changes. Obtain specimens as ordered to evaluate the course of the infection and ineffectiveness of the treatment.
Flu
Precaution : Droplet **Aspirin warning in children- can cause Reye's syndrome**
Flu vaccine contraindications
Pregnancy Immunocompromised patients Pneumonia Children under 12 months
Urinary Tract Infections (UTI) Risk Factors
Pregnancy/ postpartum Neurogenic Bladder Intercourse Diabetes Incontinence/ stop or flow of urine Bladder catheters
Tympanic Membrane Rupture:
Puss filled or bloody drainage from the ear, hearing loss, ringing in the ear, vertigo (spinning sensation), or ear discomfort.
Conjunctivitis Manifestations
Redness in one or both eyes; itchiness
GI Assessment Things to know about shape and contour
Rounded Distended occurrence 5-30 times per minute Hyperactive( increased) : louder and more intense than expected, you might hear rushing sounds or tinkling at a frequency of about 3 times per second. Hypoactive ( decreased): diminished, soft sounds that Scaphoid
Bonus Question: A nurse is reviewing laboratory reports for a client who has Clostridium difficile infection and is receiving vancomycin. Which of the following results should the nurse report to the provider before administering the next dose? Hematocrit 46% Serum glucose 110 mg/dL Serum creatinine 2.5 mg/dL Serum potassium 4.8 mEq.L
Serum creatinine 2.5 mg/dL
What are normal electrolyte values?
Sodium: 135-145 mEq/L Calcium: 9-10.5 mg/dL Potassium: 3.5-5.0 mEq/L Chloride: 95-105 mEq/L Magnesium: 1.3- 2.1 mEq/L Phosphorus: 3- 4.5 mEq/L
VRE Precautions:
Standard/Contact precautions including hand washing and gloves should be followed
Urinary Incontinence
Stress Incontinence: Loss of small amounts of urine from increased abdominal pressure without muscle contraction. Females: Can occur due to weak pelvic floor muscles following childbirth or after menopause Males: Due to alterations in the urethra following a prostatectomy Laughing, sneezing, or lifting
Bonus Question: A nurse is teaching a client about physiological changes that occur with menopause. Which of the following changes should the nurse include? Urinary hesitancy Hematuria Stress incontinence Increased vaginal moisture
Stress incontinence
Indications (why would you need) for Urinary Catheters
Sudden or complete inability to void Need for immediate and rapid bladder decompression Monitor of I & O (intake and output) Patients with acute illness, surgery or impaired function of the urinary tract may require interventions that support urinary elimination
Cellulitis Symptoms
Swelling, tenderness, pain, warmth, fever, blisters, red area in the skin that expands
Surgical Site Infection
Symptoms & Signs: Redness, fever/chills, pain, tenderness, warmth, or swelling. Pus or drainage. Foul odor.
Bonus Question: An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicated a need for further teaching. The AP uses soap and water to clean the perineal area. The AP tapes the catheter to the client's inner thigh. The AP hangs the collection bag at the level of the bladder. The AP ensures there are no kinks in the drainage tubing.
The AP hangs the collection bag at the level of the bladder.
What does the presence of vascular swishing sounds suggest?
The presence of any vascular swishing sounds suggest blood vessel or liver disorder and should be reported to the provider.
Bonus Question: A nurse is teaching a client who has urinary incontinence about bladder training. Which of the following instructions should the nurse include? "Wake up every 2 hr to urinate during the night "Drink citrus juices throughout the day." "Try to block the urge to urinate until the next scheduled time." Limit fluids to no more than 1 L (34 oz) during waking hours
Try to block the urge to urinate until the next scheduled time
Bonus Question: A nurse is reviewing a bowel training routine with a client with constipation. Which of the following instructions should the nurse give the client? Use the toilet when you feel the urge to defecate Try to defecate every 4 hr while you are awake Strain during defecation Drink 1,200 milliliters of fluid every day
Use the toilet when you feel the urge to defecate
Reflex Incontinence: involuntary loss of a moderate amount of urine usually without warning due to hyperreflexia of the detrusor muscle
Usually from spinal cord dysfunction Impaired central nervous system: Stroke, multiple sclerosis, or spinal cord lesions
Vancomycin-Resistant Enterococcus(VRE)
VRE is naturally present in the intestinal tract, female genital tract, and environment (normal flora) Precautions:
Cellulitis Treatment
Vancomycin hydrochloride and gentamicin sulfate for cellulitis related to iv drug use or burns. Cefoxitin sodium or clindamycin hydrochloride and gentamicin sulfate for diabetes- associated cellulitis.
Bonus Question: A nurse is following standard policy and procedure for reporting a client who has a communicable disease. Which of the following infections should the nurse plan to report to the CDC? Clostridioides difficile Candidiasis Vancomycin-resistant Staphylococcus aureus Trichomoniasis
Vancomycin-resistant Staphylococcus aureus
Cellulitis Risk Factors
Venous and lymphatic compromise Peripheral Arterial Disease (PAD) Diabetes Trauma, burns Age: Facial cellulitis is more common in patients older than age 50.
What produces Vitamin K?
Vitamin K is produced by bacteria within the large intestine
Manifestations of Dehydration
Weak, rapid pulse, hypotension, poor skin turgor, elevated body temperature ■ Hyper-NA-tremia: muscle weakness, lethargy, swollen red tongue.*INCREASED SODIUM* ■ Hypo-K-alemia: leg cramps, muscle weakness, nausea, vomiting, cardiac dysrhythmias. *DECREASED POTASSIUM* ■ Urine specific gravity increased concentration. Greater than 1.030
Colon Cancer screening
When diagnosed early, colorectal cancer can be treated and eliminated.
Elevated creatinine and BUN is
an indication for renal dysfunction*
Foley (retention) Catheters
most commonly used postoperatively because they have multiple lumens to allow for the drainage of urine, irrigation of the bladder, and instillation of medications into the bladder
Transient Incontinence:
reversible incontinence due to inflammation or irritation (UTI), temporary cognitive impairment, disease process (hyperglycemia), medications (diuretics, anticholinergics, sedatives)
Patient History - Questions to ask your patient
■ Do you have any chronic conditions that affect the GI system such as diabetes, hepatitis, or cirrhosis? ■ Are you experiencing any abdominal pain? ■ What is your normal bowel pattern?
