prep U test 2, funds test 2
assessment for bowel elimination
-Assess normal bowel elimination patterns. -Any changes in bowel elimination patterns? -Physical Assessment: 1. Inspection, 2. Auscultation, 3. Percussion, 4. Palpation -Assess for distention and pain -Assess rectal area for hemorrhoids, fissures, sores -Ask your patient about bowel elimination each shift -Document size, color, character of stool
examples of macronutrients
-Carbohydrates -Lipids (Fats) -Proteins
Urinary functioning-related diagnosis
-Caregiver role strain -Impaired skin integrity (Actual or Risk for) -Acute Pain -Disturbed body image -Self care deficit
BOWEL elimination diagnoses relating to other areas
-Deficient fluid volume r/t diarrhea -Impaired skin integrity r/t diarrhea -Ineffective coping r/t new ostomy appliance
influencing variables of bowel elimination
-Developmental Consideration -Breast fed vs. formula fed infants -Bowel control by around 30 months -Bowel patterns vary for older child through adults -Older adults often have constipation -Food and fluid intake -High fiber/ fluid >2000 ml /day -Psychological - stress, privacy, sociocultural -Activity and Muscle tone- childbearing, muscle atrophy, immobility, lifestyle -Bowel dysfunction or infections -Medications - opioids, antacids, iron, antibiotics
Diarrhea Nursing Interventions
-Eliminate cause&replace fluids slowly -Monitor Vital signs -Check labs for electrolytes -Large amounts of fluid& electrolytes are lost. Lab test - CMP -Check for C-diff -Maintain skin integrity -Teach abt food safety -Maintain fluid balance
implementing nursing interventions; bowel
-Enemas Cleansing Enema Retention Enema -Digital Removal -Suppository -Indwelling Rectal tube -Fecal Incontinence Device
developmental variable
-Food and fluid intake -Psychological stress, privacy, sociocultural -Renal dysfunction or infections -Medications *nephrotoxic meds, diuretics, sedatives
CAUTI bundle pt 2
-Review catheter necessity daily ▪Increase water and activity ▪Monitor intake/output every 12 hours
elimination
-Stomach/ small intestine/ large intestine -Large intestine absorbs water, forms feces, eliminates feces -Elimination varies in individuals -Average is one stool per day
complications from chronic diarrhea
-malnourishment -mineral deficiencies -vitamin deficiencies -anemia -colitis& crohn's disease -higher risk of cancer -prescription side effects
Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply. children of middle-income parents people with substance use problems older adults living on fixed incomes pregnant teenagers individuals who prefer to purchase food from local farmers
-people with substance use problems -older adults living on fixed incomes -pregnant teenagers
functions of the nutrients in the body
-supply energy -promote growth&repair of body tissues -assists in the function of various bodily processes
culturally competent nursing care
1. developing a self awareness 2. demonstrate knowledge and an understanding of other cultures 3. accommodate cultural practices in health care 4. respect culturally based family roles 5. avoid mandating change 6. seek cultural assisstance
A nurse is establishing an ideal body weight for a 5'9" (175 cm) healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?
145 lb/ 65.7 kg
normal BMI
18.5-24.9 kg/m^2
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? clean-catch specimen intermittent specimen random specimen 24-hour specimen
24-hour specimen
When catheterizing a female patient, what size catheter would the RN chose? 1)25 cm 2)46 cm 3)Same size for both patients
25 cm
The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter? "This is what your health care provider has prescribed." "This is the only option for catheterization." "Let me talk to your health care provider about a condom catheter." "Indwelling catheters do not hurt, and I will be careful placing it."
"Let me talk to your health care provider about a condom catheter."
A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? "It would be best just to get some adult diapers." "Let's explore structuring activities and toileting breaks." "Don't worry, this is a normal condition for older adults." "Let me refer you to a urologist who can help you."
"Let's explore structuring activities and toileting breaks."
A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response? "This only happened one time, so it is nothing to worry about." "I agree; please make an appointment with your health care provider." "I suggest that you invest in incontinence undergarments." "Let's review your medication history and whether you consume bladder irritants."
"Let's review your medication history and whether you consume bladder irritants."
A client with diabetes mellitus must monitor carbohydrate intake. Which client statement requires nursing intervention? "I like to eat eggs for breakfast." "At every meal, I eat a small portion of lean meat." "I'll monitor my intake of fruit juice." "My favorite drink is coffee with sugar."
"My favorite drink is coffee with sugar."
The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client? "You will have a catheter put in to collect the urine." "Save all urine for the next 24 hours." "Void into the specimen hat in the toilet bowl." "Void a small amount, stop, and discard it."
"Void a small amount, stop, and discard it."
The nurse cares for a client who is a member of a different culture from the nurse's. Which question is most important for the nurse to ask to assess the client's beliefs about treatment? "What do you eat for breakfast?" "What are your expectations about being in the hospital?" "How do you feel about being in the hospital?" "What do you believe about health care?"
"What are your expectations about being in the hospital?"
The nurse is caring for a client 4 days after total hip arthroplasty and notes the client has lost weight. The unlicensed assistive personnel reports the client's food intake has decreased. Which question will the nurse ask the client to determine if cultural causes are responsible for the weight loss? "Can you ask your family to bring you something you like?" "Is there something wrong with the food?" "What type of food do you like to eat at home?" "Would you like to speak with a nutritionist?"
"What type of food do you like to eat at home?"
serum albumin normal range
3.5-5.5 g/dL), decreased in malnutrition
normal adult output
60-100 mL per hour or 1-2 mL per kilo
fat soluble vitamins
A, D, E, K
A nurse documents a client's hemoglobin as 8 g/dL (80 g/L). What nutritional condition does this biochemical data signify? Malabsorption Dehydration Malnutrition Anemia
Anemia
The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment will the nurse perform to gather additional information? Auscultate for bowel sounds. Observe the abdominal dressing. Ask when the client last had a bowel movement. Measure abdominal girth.
Auscultate for bowel sounds.
Which behavior by the nurse is stereotyping? Explaining to others that Western medicine is always superior Grouping care assignments to allow ample time to care for complex clients Avoiding older adult clients because their care is time consuming Openly ridiculing the practice of acupuncture
Avoiding older adult clients because their care is time consuming
Which symptom will have a great impact on the extracellular fluid for water conservation? Small laceration Burns Pain Fracture
Burns
variables affecting nutritional status: chronic diseases
DM, cancer, depression, digestive disorders
A nurse is assessing a client and determines that the client belongs to a minority group. Based on the nurse's understanding about minority groups, the nurse would anticipate that the client would likely experience which effects? Select all that apply. Improved access to care Health disparities Less power Greater advantages Increased economic privileges
Health disparities Less power
A nurse is caring for a client in a long-term care facility. The nurse is reviewing the laboratory data for this client. The nurse should notify the primary care provider if which laboratory result is observed? Hemoglobin 12 mg/dL Blood urea nitrogen (BUN) 17 mg/dL Transferrin 360 mg/dL Hematocrit 35%
Hematocrit 35%
The nurse is caring for a client who does not speak the dominant language. In order to facilitate unencumbered communication with the client, the nurse will take which action(s)? Select all that apply. Determine in which language the client communicates effectively. Schedule a certified interpreter when collecting client health history. Review facility policy on communication with clients who do not speak the dominant language. Ask the client's child, who speaks the dominant language, to explain treatment options to the client. Request that the client's spouse carries out language interpretation at discharge.
Determine in which language the client communicates effectively. Schedule a certified interpreter when collecting client health history. Review facility policy on communication with clients who do not speak the dominant language.
The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response? Bring the client's spouse into the hallway to discuss surgical options for the client. Explain to the client that the client is required to make all decisions related to the client's own health care. Document the client's request in the nursing care plan. Explain to the client that it is not a good idea to have the spouse in the room when discussing such a private matter.
Document the client's request in the nursing care plan.
A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved? Nephron Glomerulus Bowman's capsule Loop of Henle
Nephron
▪Medications-
Nephrotoxic meds include NSAIDS, Ace Inhibitors, AND ALSO SOME antibiotics: gentamicin (Gentak) & Levofloxacin (Levaquin)
expected outcome for bowel elimination
Patient will ..... -Have a soft, formed BM every 1 to 3 days -Learn how dietary, exercise&fluid intake factors effect elimination -Learn importance of reporting changes in BM color or consistency to medical personnel
goals for nutrition
Patient will: }Maintain ideal body weight (BMI-body mass index) }Maintain a diet with adequate nutrients }Follow illness related diets as prescribed
PPN
Peripheral Parenteral Nutrition - a superficial vein usually in arm
A nurse is working with a 46-year-old woman who is working to lose weight. Based on recommendations from the USDA regarding diet modification, which is not appropriate advice for this client? Drink nonfat or 1% milk. Make fruits and vegetables at least half of total food intake. Drink juice for majority of fluid intake. Eat a variety of enjoyable foods, but less quantity.
Drink juice for majority of fluid intake.
The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next? Place the client on either side and rescan. Have the client drink 8 ounces of water every 15 minutes for 1 hour. Ensure proper positioning of the scanner head and rescan. Wipe off some of the ultrasound gel and rescan.
Ensure proper positioning of the scanner head and rescan.
T/F: A nurse documents that a patient has anuria when the 24-hour urine output is less than 400 mL.
False
How is culture learned by each new generation? Belonging to a subculture Ethnic heritage Involvement in religious activities Formal and informal experiences
Formal and informal experiences
A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs? Nasogastric tube Gastrostomy tube Nasointestinal (NI) tube Salem sump tube
Gastrostomy tube
A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation? Cultural blindness Cultural conflict Stereotyping Cultural imposition
Stereotyping
macronutrients
Supply energy and build tissue
The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client? The birth can cause perineal swelling. A urinary tract infection results from the birth process. A neurogenic bladder results from local anesthesia. Catheterization is necessary for 1 week.
The birth can cause perineal swelling.
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? The client has an enlarged prostate. The client has an occult abscess in the urethra. The diameter of the catheter is too large. The nurse failed to deflate the retention balloon after pretesting it for integrity.
The client has an enlarged prostate.
• Phenazopyridine (Pyridium)-
a URINARY TRACT ANALGESIC causes urine to turn ORANGE
At what period of life do nutrient needs stabilize?
adulthood
variables affecting nutritional status: medications
alters absorption., motility, pH, and nutrient availability
Vitamin D
antioxidant; Regulation of calcium and phosphate metabolism
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? nocturia anuria oliguria urinary retention
anuria
minerals
are inorganic elements found in all body fluids and tissues in the form of salts
essential nutrients
are not synthesized in our bodies. We need to provide them through diet or supplements.
stereotyping
assigning characteristics to a group of people without considering specific individuality
A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume? chocolate egg yolks brown rice chicken
brown rice
• Amitriptyline (Elavil) - antidepressant [and B Vitamins] effecting urine
can cause urine to turn GREEN or BLUE-GREEN
vitamin B
cell metabolism, green leafy and unprocessed foods, helps with stress
physiological variation
certain racial and ethnic groups are more prone to certain diseases
A nurse is conducting a cultural assessment of a client. Which person would the nurse identify as the expert? Nurse Older family member Client Health care provider
client
eye contact in some cultures
considered impolite
A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? dark brown, cloudy reddish-brown, clear aromatic, green clear, light yellow
dark brown, cloudy
voluntary control of sphincters
develops at 18-24 months
When a home-bound client expresses the client's past-oriented ancestral heritage and family rituals, the nurse recognizes that the client is expressing: subculture. race. ethnic identity. assimilation.
ethnic identity.
When reviewing the chart of an older adult client, the nurse notes that the client identifies as Japanese. The nurse realizes the client is referring to which ancestral and cultural factor? ethnicity race ethnocentrism values
ethnicity
nocturia
excessive urination at night
native americans prone to
fetal alcohol syndrome, heart disease, diabetes, cirrhosis of the liver
Symptoms of Cystitis
frequency, urgency, hematuria, bacteriuria, pain
cultural competency
hold a deep respect for the cultural differences and are eager to learn, and are willing to accept that there are many ways of viewing the world
catheter types
intermittent, indwelling, suprapubic, external (condom)
incontinence
involuntary loss of urine
trace minerals include
iron, iodine, zinc, copper, fluoride
daytime control (infants)
is achieved before night time control
An example of a disease often diagnosed in a specific population is Tay--Sachs disease, which is associated with individuals of Eastern European ______ descent.
jewish
gender roles with cultural diversity
knowing who is the dominant figure and decision maker is very important
colonoscopy
large intestines
A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? right side-lying supine left side-lying prone
left side-lying
vitamins
main function is to be a catalyst for metabolic functions and chemical reactions
patriarchal culture
male dominated.
chinese families with mental health
may consider seeking psychiatric help disgraceful
A 45-year-old client on the inpatient unit has just resumed eating a normal diet. The nurse checks a blood sugar with the morning labs and the result is 99.10 mg/dL (5.5 mmol/L). How would the nurse interpret this blood glucose? mildly elevated low normal severely elevated
normal
vitamin K
normal clotting, found in green leafy vegetables
blood urea nitrogen (BUN) normal range
normal=17-18 mg/dL) increased in starvation, dehydration
gender roles: asian
oldest male is often the decision maker
catheter-associated urinary tract infection (CAUTI)
one of the most common infections a person can contract in the hospital, Indwelling catheters are the cause of this infection.
A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in? overweight obese underweight healthy weight
overweight
dysuria
painful urination
proteinuria
protein in the urine
functional urinary incontinence
r/t altered environmental factors
overflow incontinence
r/t over distension of the bladder
total incontinence
resulting from trauma, surgery or physical malformation
oliguria
scanty urination, < 400 ml in 24 hr
Blood triglycerides
should be less than 150
blood cholesterol
should be less than 200
Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? suprapubic catheter Foley catheter indwelling urethral catheter straight catheter
straight catheter
Which type of incontinence is caused by pelvic floor muscle weakness? functional stress urge overflow
stress
URGENCY
strong desire to void
stoic
surpress pain (Asians, Navajo Indians)
mixed incontinence
symptoms of urge and stress incontinence
urostomy
the general term used for any surgical procedure that diverts the passage of urine by redirecting the ureters
EGD
upper GI tract
An athlete wants to increase the intake of complex carbohydrates and asks the nurse about potential sources. Which food is considered a complex carbohydrate? Honey Eggs Whole grain pasta Peanuts
whole grain pasta
dysphagia precautions
}Consult a speech and swallow therapist }Elevate HOB as high as tolerated }Chopping /mincing/puree/small pieces }Thicken fluids }Watch for signs of aspiration }Chew slowly and carefully }Avoid thin liquids }Alternate solids and liquids }Inspect oral cavity for retained food }Supervision }Assess comprehension, LOC }Provide rest period before meals
hospital diets
}Modified Consistency Diets: }High fiber diet }Low fiber diet }Renal diet }Diabetic diet- Consistent Carbohydrate diet
cognitive considerations (nutrition)
}Open all items }Encourage patient throughout meal to eat }Small pieces, cut up }Adaptive equipment }Ensure glasses, hearing aides and dentures are in use
enteral feedings
}Short Term - NGT }Long Term - PEG }Confirm NGT placement- XRAY, tube length, tube markings, visual aspiration of gastric secretions, PH testing }Check residuals every 4 hours •Feedings - intermittent or continuous •Full strength •Increase as tolerated to target rate •Pump or Bolus feedings
parenteral nutrition-PPN
}isotonic solution ◦similar to TPN, but less concentrated ◦less dextrose, amino acids, calories ◦Supplements inadequate oral intake ◦Short term, less than 2 weeks
urinary diversions
▪Stoma care - should appear dark pink to red and moist ▪Protect surrounding skin ▪Measure intake and output ▪Urine may have sediment or mucus with ileal conduit ▪May have drainage bag or may have to self-catheterize the stoma ▪Patient education crucial ▪Ostomy nurse and support group
major minerals
◦occur in large amounts in the body sodium, potassium, chloride, calcium, magnesium, phosphorus and sulfur
creatinine normal range
(normal 0.4-1.5 mg/dL) increased in dehydration, decreased in muscle wasting conditions
enuresis
- involuntary urination that occurs after an age when continence is usually present (bed wetting)
CAUTI bundle
-Avoid unnecessary catheterizations -Insert catheter using aseptic technique -Maintain a closed drainage system -Wash hands before handling catheter -Secure catheter to leg -Maintain unobstructed urine flow -Keep drainage bag below bladder at all times -Don't let bag fall or lay on the floor -Individually labeled collection container in room
complications; paralytic lleus
-Inhibited peristalsis post surgery usually lasts 3 to 5 days -Usually NPO during this time, sometimes a NGT to suction is necessary -Assess bowel sounds, distention and comfort -Increase activity -Get post op patients out of bed! -Walk
How long is a man's urethra?
20 cm
how long is a woman's urethra?
4 cm
blood glucose normal
70-100 mg
Nocturnal ______ , known as nighttime bedwetting, usually subsides by 6 years of age.
Enuresis
cultural competence
care delivered with an awareness of the aspects of the patient's culture
variables affecting nutritional status: alcohol abuse
decrease absorption-liver damage
Normal waist circumference for women
less than 35 inches
A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced? reflex stress total urge
total
urinary output and lab specimens
▪Measure output at least every 8 hours - but don't wait to evaluate output until end of shift- use calibrated measuring cup for foley, urinal or hat in toilet ▪Critical care patients, Post-op patients - measure hourly
Which statement best conveys the relationship between race and ethnicity? Race and ethnicity can be considered to be synonymous in the context of health care. Race and ethnicity are both culturally determined concepts. Race denotes physical characteristics, while ethnicity is rooted in a common heritage. Race is based on an individual's cultural history and is independent of ethnicity.
Race denotes physical characteristics, while ethnicity is rooted in a common heritage.
Which is a cultural norm of the health care system? There is the use of a systematic approach and problem-solving methodology. There is a tolerance of tardiness, disorderliness, and disorganization. The omnipotence of technology is yet to be recognized. There are rigid procedures attending birth and death.
There is the use of a systematic approach and problem-solving methodology.
endoscopy
Upper and Lower direct visualization
A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? "All four abdominal quadrants auscultated. Inaudible bowel sounds." "Client may have bowel sounds, but they can't be heard." "Auscultated abdomen for bowel sounds. Bowel not functioning." "Bowel sounds auscultated. Client has no bowel sounds."
"All four abdominal quadrants auscultated. Inaudible bowel sounds."
A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? "Auscultated abdomen for bowel sounds. Bowel not functioning." "All four abdominal quadrants auscultated. Inaudible bowel sounds." "Client may have bowel sounds, but they can't be heard." "Bowel sounds auscultated. Client has no bowel sounds."
"All four abdominal quadrants auscultated. Inaudible bowel sounds."
After a visit with the health care provider, the nurse calculates the client's body mass index (BMI). Which statement by the nurse best informs the client of the purpose of BMI? "BMI reflects a weight that is predetermined for all people." "BMI is the weight at which one feels most comfortable." "BMI is used to screen for weight categories that can lead to health problems." "BMI is a screening tool that is used by insurance companies to screen for obesity."
"BMI is used to screen for weight categories that can lead to health problems."
The nurse is caring for a client who is postoperative 24 hours from an appendectomy. The client is hesitant to get out of bed. How should the nurse respond? "Can you describe what you are feeling when you try to move?" "Would like to wait until your family arrives to get out of bed?" "I will come back later and help you get up." "You need to get up and walk to prevent complications."
"Can you describe what you are feeling when you try to move?"
The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus? "Parasites in your stool can cause persistent flatus." "Flatus is a natural action and the cause is unknown." "Certain vegetables can cause flatus, as they are more difficult to digest." "Drinking alcoholic beverages can cause flatus."
"Certain vegetables can cause flatus, as they are more difficult to digest."
A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states, "I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse? "You are putting too much pressure on yourself and your child to toilet train." "There is nothing to worry about. Just keep the child in diapers until they stop having accidents." "There may be something wrong since your child should be toilet trained by 2 years-old." "Children vary in their readiness but daytime bowel control may be attained at 30 months."
"Children vary in their readiness but daytime bowel control may be attained at 30 months."
The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment? "Do you dribble urine throughout the day?" "Do you lose control of your urine all day?" "Do you have the sensation to urinate?" "Do you leak urine with strain or coughing?"
"Do you have the sensation to urinate?"
The nurse just attended a seminar on cultural diversity. Which statement by the nurse would require further education? "Ethnicity and race are the same thing and are affected by cultural practice." "People of the same ethnicity share many of the same cultural and social beliefs." "Ethnicity begins at birth or through adoption of characteristics." "Ethnicity can often determine dialect and political interests."
"Ethnicity and race are the same thing and are affected by cultural practice."
A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause? "Have you ever had kidney disease?" "Have you ever had urinary retention before?" "Have you ever had an elevated blood sugar?" "Is it uncomfortable to urinate?"
"Have you ever had an elevated blood sugar?"
The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching? "Having sexual relationships does not put a woman at risk for developing a UTI." "A woman using an intrauterine device for contraceptive reason is at risk for developing a UTI." "I will make sure to teach my clients with diabetes mellitus to control their glucose level to help prevent a UTI." "Due to the physiologic changes with aging, the elderly are at risk for developing a UTI."
"Having sexual relationships does not put a woman at risk for developing a UTI."
A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client? "Are you on any blood pressure medications?" "How often do you have a bowel movement?" "How frequently do you urinate each day?" "Are you on any type of special diet at home?"
"How frequently do you urinate each day?"
The staff nurse overhears the charge nurse, who is of Italian heritage, talking to the unlicensed assistive personnel. Which statement made by the charge nurse is an example of ethnocentrism? "Asian people are bad drivers." "Italians are best at everything." "Hispanics are usually lazy." "People who are Irish are usually alcoholics."
"Italians are best at everything."
A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test? "This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer." "This test detects heme, an iron compound in blood within the stool." "This test will help determine whether you have an infectious process in the intestines." "This will determine what foods you are allergic to that affect digestion and elimination."
"This test detects heme, an iron compound in blood within the stool."
The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the best response by the nurse? "I will leave the questionnaire here. Please fill it out when your spiritual healer arrives." "I can wait until your spiritual healer arrives, but you are the only one who can answer these questions." "We can wait until your spiritual healer arrives and work together to answer these questions." "These questions need to be answered so we can provide you with the best care."
"We can wait until your spiritual healer arrives and work together to answer these questions."
Which questions should the nurse include in a cultural assessment? Select all that apply. "What religion do you belong to?" "What do you do to promote good health?" "Do have a particular name for this illness?" "What do you think is causing your illness?" "What do you think about religions other than your own?"
"What do you think is causing your illness?" "What religion do you belong to?" "What do you do to promote good health?" "Do have a particular name for this illness?"
A client has been admitted to the unit for chest pain. A nurse told the family that they could not be with the client. The family became very upset, and now the client wants to leave. What is the most culturally appropriate response by the charge nurse? "If you leave, you will be asked to sign a form indicating that you are leaving against medical advice." "Why do you think you need to leave?" "Sometimes family can cause stress, and we try to maintain a stress-free care environment." "Would you feel more comfortable with your family with you?"
"Would you feel more comfortable with your family with you?"
bowel elimination
-Bowel system review -Influencing variables for bowel elimination -Assessment variables -Bowel promotion and incontinence -Nursing interventions
bowel diversions
-Dark pink to red, moist & round stoma appearance -Physical and psychological support -Protect surrounding skin- keep clean & dry -Empty pouch when it is 1/3 full -Replace the pouch every 3 to 7 days -Measure intake & output -Consult ostomy nurse -Patient Education is essential
nursing diagnosis urinary elimination-NANDA
-Impaired urinary elimination -Functional urinary incontinence -Stress urinary incontinence -Urinary retention
incontinence
-Offer bedpans or toileting routinely -Increase fiber in diet -Maintain skin integrity -Avoid moisture in linens -Use of suppositories /enemas may be needed -Bowel training program
outcome identification and planning: patient will
-Produce 60 ml of urine each hour every day throughout hospitalization -Empty the bladder q4h x3 each shift throughout hospital stay. -Report 2 signs or symptoms of decreased or inability to release urine independently daily.
bowel; implementing nursing interventions
-Promote regular bowel habits -Positioning and Privacy -Stool chart -Nutrition -Exercise -Decreasing Flatulence
Carbohydrates
-Simple sugars, Starch and Fiber ◦Ideally provides 45-65% total calories/day. ◦Provide most of the energy for cellular work. ◦Each gram produces 4 kcal. ◦Helps regulate protein and fat metabolism. ◦Essential for cardiac and CNS functioning.
physical assessment for urinary
-Skin, urethral meatus -urine for COCA + Ketone? ▪Odor ▪Turbidity ▪pH ▪Specific gravity ▪Constituents ▪Does patient complain of pain, pressure, or frequency? ▪Ask PERMISSION to lightly palpate bladder for distention or pain
bowel elimination: tests and studies
-Stool Samples: Occult Blood -Stool Culture ; Stool for WBC -Stool for O & P -Endoscopy -Colonoscopy -EGD -Barium Studies: Upper GI, Small Bowel Series, and Barium Enemas -Ultrasound -CT Scan of abdomen
complications from chronic constipation
-bowel toxicity -elevated cholesterol -arthritis -mega colon -breast cancer -prescription side effects
hemoglobin normal range
12-18 g/dL) decreased in anemia
Prealbumin normal range
23-43 mg/dL), decreased in protein depletion
The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? 42-year-old client with diarrhea twice weekly 50-year-old client with a family history of polyps 67-year-old client with constipation 33-year-old client who reports painful elimination
50-year-old client with a family history of polyps
A nurse caring for clients of different cultures in a hospital setting attempts to make eye contact with clients when performing the initial assessment. What assumption might the nurse make based on common cultural practices? A Native American/First Nations man stares at the floor while talking with the nurse. Assumption: The client is embarrassed by the conversation. A Hasidic Jewish man listens intently to a male physician, making direct eye contact with him, but refuses to make eye contact with a female nursing student. Assumption: Jewish men consider women inferior to men. A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest. A Black man rolls his eyes when asked how he copes with stress in the workplace. Assumption: He may feel he has already answered this question and has become impatient.
A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest.
example of culturally competent nursing care
Accepting cultural differences in the assessment of health care needs
What is the priority assessment for the nurse when developing a plan of care for a client living in poverty? Access to affordable housing Access to financial assistance Access to health insurance Access to care
Access to care
CAUTI prevention
Adherence to general infection control principles (e.g., hand hygiene, surveillance and feedback, aseptic insertion, proper maintenance, education) is important. Bladder ultrasound may avoid indwelling catheterization. Condom catheters, Purewick devices or other alternatives than an indwelling catheter such as intermittent catheterization should be considered in appropriate patients. Do not use the indwelling catheter unless you must! Early removal of the catheter using a reminder or nurse-initiated removal protocol appears warranted.
A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? Administer analgesia 30 minutes before the procedure. Warm the solution for 40 seconds in a microwave to prevent chilling the client. Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. Administer the solution gradually over 5 to 10 minutes.
Administer the solution gradually over 5 to 10 minutes.
A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide? Wait until the void is almost over to collect a specimen. Collect the entire urinary output. After the initial stream is initiated, collect the sample. Collect the first urine expelled.
After the initial stream is initiated, collect the sample.
A nurse is conducting an ethnographic interview with a client. Which step would the nurse do first? Document the client's view of self Request clarification of a key term Identify clues to what may be important Ask an open-ended, general question
Ask an open-ended, general question
A nurse is providing care to a client from a culture different from the nurse's own. The nurse is having difficulty relating to the client. What intervention by the nurse is most appropriate? Ask another nurse to take over the client's care. Look up the client's culture online and try to figure out methods to relate. Consult the Office of Minority Health Resource Center to help in the provision of care. Ask the client how the client wants to be treated based on the client's values and beliefs.
Ask the client how the client wants to be treated based on the client's values and beliefs.
The nurse is caring for a terminally ill client who immigrated from Mexico. Which nursing intervention regarding spiritual care is appropriate? Ask the client if a spiritual leader is desired. Call a Roman Catholic priest to visit the client. Inquire if the client desires the Sacrament of the Sick. Do nothing unless the client requests spiritual assistance.
Ask the client if a spiritual leader is desired.
The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take? Continue to place the indwelling catheter because it has been prescribed. Gather appropriate supplies to teach the client to perform straight catheterization. Inform the client that the health care provider will be contacted. Ask the client why he or she does not want a catheter.
Ask the client why he or she does not want a catheter.
A nurse delivers a tray of food to an older adult client and sets it on the overbed table. The client shows no interest in the food, however. Which actions should the nurse take? Select all that apply. Ask why the client does not want to eat anything on the tray. Consult a dietitian if the problem persists. Assess the client for signs of depression. Remove the tray from the client's room without further comment. Administer an antiemetic as prescribed. Provide the client with crackers and ginger ale.
Ask why the client does not want to eat anything on the tray. Consult a dietitian if the problem persists. Assess the client for signs of depression.
Which behaviors demonstrated by the client would the nurse consider reflections of the client's pride in ethnicity? Select all that apply. Asking to wear unique clothing Listening to folk music and dance Requesting assistance when transferring from bed to chair Crying when given a diagnosis of cancer Requesting native cuisine
Asking to wear unique clothing Listening to folk music and dance Requesting native cuisine
The nurse has obtained a client's capillary blood glucose sample and the results are significantly lower than reference range. What is the nurse's priority action? Obtain a sample from the opposite hand for comparison. Promptly inform the primary care provider. Assess the client for signs and symptoms of hypoglycemia. Obtain a full set of vital signs.
Assess the client for signs and symptoms of hypoglycemia.
The nurse admits a client to the critical care unit to rule out a myocardial infarction. The client has several family members in the waiting room. Which nursing action is most appropriate? Assess the client's beliefs about family support during hospitalization. Insist that only one family member can be in the room at a time. Explain to the family that too many visitors will tire the client. Allow all the visitors into the room.
Assess the client's beliefs about family support during hospitalization.
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? Administer an IV on the arm high above the access site. Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Measure the client's blood pressure on the arm above the access site. Perform venipuncture below the access site to obtain a blood sample for laboratory testing.
Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.
water soluble vitamins
B and C
Removal of a client's NG tube has been ordered. Which action should the nurse perform during this intervention? Place the client in a protective supine position to facilitate easy removal. Quickly and carefully remove tube while the client breathes out. Attach a syringe and flush with 50 mL of water or normal saline before removal. Before removing the tube, discontinue suction and separate the tube from suction.
Before removing the tube, discontinue suction and separate the tube from suction.
A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? v Position the bed flat and assist the client onto his or her left side. Administer an oral analgesia 30 to 45 minutes before attempting insertion. Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.
Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.
The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next? Intake and output Frequency of urine Blood pressure Blood sugar
Blood sugar
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? Boys may take longer for daytime continence than girls. Daytime continence is usually not achieved by boys until age 5. Boys may walk by 1 year and should be continent by 3 years. Incontinence after the age of 3 years is not normal.
Boys may take longer for daytime continence than girls.
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? Boys may take longer for daytime continence than girls. Incontinence after the age of 3 years is not normal. Daytime continence is usually not achieved by boys until age 5. Boys may walk by 1 year and should be continent by 3 years.
Boys may take longer for daytime continence than girls.
Which nursing action associated with successful tube feedings follows recommended guidelines? Check the residual before each feeding or every 4 to 6 hours during a continuous feeding. Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract. Prevent contamination during enteral feedings by using an open system. Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid.
Check the residual before each feeding or every 4 to 6 hours during a continuous feeding.
A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? If the specimen contains barium or enema solution, document this on the container. If portions of the stool include visible blood, mucus, or pus, discard the stool. Refrigerate the specimen until it is cooled before sending it to the laboratory. Collect 15 to 30 mL of the client's liquid stool.
Collect 15 to 30 mL of the client's liquid stool.
The home health nurse is conducting the health history interview with a client who does not speak the dominant language. What would be the best action made by the nurse? Conduct the health history utilizing a telephonic interpreter (over-the-phone translation). If the client does not answer, repeat the question again using a louder tone. Use simple words with simple actions. Write out all questions using appropriate medical terms.
Conduct the health history utilizing a telephonic interpreter (over-the-phone translation).
The nurse is preparing to administer an intermittent feeding to a client who has a feeding tube. The nurse is unable to aspirate gastric contents and realizes that the tube is clogged. Which action is correct? Insert a stylet until resistance is felt, and then gently rotate the stylet until resistance decreases. Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure. Advance the tube no more than 4 in (10 cm), auscultate for bowel sounds, and then attempt to aspirate again. Mix meat tenderizer with 30 mL of warm water, instill the mixture into the feeding tube, wait 15 minutes, and then flush vigorously.
Connect a syringe filled with warm water to the feeding tube and flush it out using gentle pressure.
Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). Discontinue to catheter and report this to the healthcare provider. Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily. Ensure that the drainage bag is above the level of the bladder at all times.
Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily.
A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women? Squat down and then jump up to a standing position. Contract abdominal muscles 10 times per day. Lie on the floor, raise, then lower your legs 20 times per day. Contract the pubic muscles for 3 seconds, then relax.
Contract the pubic muscles for 3 seconds, then relax.
A family recently immigrated to a new country. The parent reports that the teenager is showing signs of fear, has vague reports of stomach pain, and feels humiliated by peers because of their culture. What is the priority assessment for the nurse? Culture shock Cultural blindness Cultural assimilation Cultural imposition
Culture shock
Constipation Nursing Interventions
Daily activity Increase fluids Increase fiber Monitor meds&diet Limit use of laxatives Patient education Enemas Disimpaction
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? Allow the low intermittent suction to continue during the assessment of bowel sounds. Disconnect the nasogastric tube from suction during the assessment of bowel sounds. Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds. Apply continuous suction to the nasogastric tube during assessment of bowel sounds.
Disconnect the nasogastric tube from suction during the assessment of bowel sounds.
After teaching the client about a low-fat diet, which items selected by the client would indicate to the nurse that the client comprehends the nutritional teaching? Peanut-butter sandwich Coffee with non-dairy creamer Egg white omelet with vegetables Frozen hash browns with vegetables
Egg white omelet with vegetables
The nurse is creating a plan of care for an older adult client at risk for constipation. Which intervention by the nurse will decrease this risk? Advise increasing milk or milk products in the diet to provide stool bulk. Suggest use of warm compresses on the abdomen to increase gastrointestinal motility. Advise decreasing dietary fiber in the diet to enhance stooling. Encourage physical activity to improve bowel regularity.
Encourage physical activity to improve bowel regularity.
A client with dysphagia prepares to eat dinner. How does the nurse best help this client? Play the client's favorite music or video. Ensure the head of the bed is high-Fowler. Converse with the client during the meal. Prepare the foods on the client's tray.
Ensure the head of the bed is high-Fowler.
A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual? Immediately after each flush that is administered Every 4 hours for the first 24 hours after tube placement and every 24 hours thereafter Every 4 to 6 hours Once per shift
Every 4 to 6 hours
The nurse provides teaching to a client experiencing constipation. Which food choice on the client's breakfast tray indicates effective teaching? Eggs Bacon Grapefruit Whole milk
Grapefruit
asians prone to
HTN, liver cancer, lactose intolerance, thalasemia
What is an appropriate intervention when unexpected situations occur during the administration of a tube feeding? If the tube is found to be in the stomach instead of the esophagus, follow the recommended steps to replace the tube. When checking for residue, if a large amount is aspirated, replace the residue before proceeding with feeding. If the client complains of nausea after tube feeding, lower the head of the bed and administer an antiemetic. If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog.
If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog.
Which nursing intervention reflects practice according to Madeline Leininger's transcultural nursing theory? Incorporating the client's request for complementary treatment therapy Providing the same care to each client who has had a myocardial infarction Planning dietary interventions according to physiological condition Contacting a chaplain for every client
Incorporating the client's request for complementary treatment therapy
A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan? Drink a soft drink daily to prevent gas and allow fiber to break down. Include more protein in the diet to increase fiber and decrease gas. Eat more cabbage and brussels sprouts to decrease gas and add fiber. Increase fiber slowly over a period of time to prevent gas.
Increase fiber slowly over a period of time to prevent gas.
Diuretics: Furosemide (Lasix) -
Increases UOP
The nurse is educating a client with an ileal conduit about the effects of food and fluid intake on the amount and quality of urine produced by the body. Which teaching points should the nurse include? Select all that apply. Fluid overload leads to excretion of a large quantity of dilute urine. Ingestion of foods and beverages high in sodium content leads to increased urine formation. Consumption of alcoholic beverages leads to increased urine production due to their stimulation of antidiuretic hormone. Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine. Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production.
Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine. Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. Fluid overload leads to excretion of a large quantity of dilute urine.
T/F: Incontinence that results from weakness of the pelvic floor muscles can be treated by teaching the patient to perform ______ exercises.
Kegel
A nurse is working in a clinic that serves a community with a high population of immigrants. Which nursing assessment is the priority? Spiritual assessment Blood sugar assessment Language assessment Blood pressure assessment
Language assessment
Which nursing action displays linguistic competence? Repeating statements to a client who speaks only a language different from the nurse Asking a family member to interpret for a client who does not speak the dominant language Speaking loudly to a client who does not speak the dominant language Learning pertinent words and phrases in the client's language
Learning pertinent words and phrases in the client's language
The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Ask the client to bear down until the catheter is expelled. Remove the catheter from the vagina and attempt to insert it into the bladder. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics.
Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
The nurse is caring for a client who perceives time differently. What action should the nurse take for this client? Set all interventions to be done at specific times. Have the client set all times for the interventions. Maintain flexibility when the client requests interventions at specific times. Perform interventions at random times during shift.
Maintain flexibility when the client requests interventions at specific times.
touching is not acceptable between a member of the opposite gender in the
Muslim culture
NGT
Nasogastric tube A special tube that carries food and medicine to the stomach through the nose
adult-related changes in the older adult; urinary
Nocturia, frequency, urgency, incontinence, decreased contractility, neuromuscular problems, UTIs
A nurse is providing care to a client who is from a different culture. Which aspect about culture would be most important for the nurse to integrate into the client's care? Culture is relatively static and unchanging. Not all members of the same culture act and think alike. Individuals learn culture in a purposeful manner. Individuals can easily describe their culture.
Not all members of the same culture act and think alike.
A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority? Placing the client as N.P.O. status Checking for blood return in the CVC Notifying the health care provider of the assessment findings Obtaining laboratory studies
Notifying the health care provider of the assessment findings
A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include? Will include fish one to two times per week. Will includes a pat of butter with eggs for breakfast. Plans to eat a snack of fruit twice per day. Plans to eat 4 ounces of protein 3 times per day.
Plans to eat 4 ounces of protein 3 times per day.
A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? Have the client rest for 15 minutes before the assessment. Position the client in a supine position. Administer a diuretic, as ordered. Assess the client's need for analgesia.
Position the client in a supine position.
Which urinary care teaching will the nurse provide to a young adult female client? If you do not feel like voiding, still strain to make sure the bladder is empty. Refrain from douching unless ordered by a health care provider. Drink water more frequently in the morning and evening to facilitate hydration. Wipe from the back to the front.
Refrain from douching unless ordered by a health care provider.
micronutrients
Regulate and control body processes
The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse? Administer a PRN dose of laxative to the client to collect new sample. Collect stool and send to laboratory for culture per regular protocol. Inform the client that the culture prescription will now be cancelled. Reinstruct the client on use of collection container for next bowel movement.
Reinstruct the client on use of collection container for next bowel movement.
A nurse is performing a client's intermittent closed catheter irrigation and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's best response to this situation? Prepare to change the catheter. Repeat the irrigation. Wait 1 hour and repeat the irrigation. Notify the primary care provider promptly.
Repeat the irrigation.
The nurse overhears a colleague state, "All people from that client's country are rude." What is the appropriate nursing response? Respond by saying, "Stereotypes keep us from accepting others as unique individuals." Say nothing and ignore the comment. Agree and state, "Yes, I've noticed the same thing." Report the colleague to the nurse manager.
Respond by saying, "Stereotypes keep us from accepting others as unique individuals."
The labor and delivery nurse is getting report from the previous shift regarding a client with Asian heritage. The departing nurse states that the client did not ask for pain medication because "Asian people can handle pain." The nurse receiving report understands that this an example of what? Ethnocentrism Culture shock Stereotyping Ageism
Stereotyping
T/F: Patients with reflex incontinence experience emptying of the bladder without the sensation of the need to void.
TRUE
A family has immigrated and settled in a neighborhood that primarily speaks their native language. The nurse caring for this family recognizes that which family member will likely require the greatest amount of time to learn the dominant language? The 12-year-old son in the family who attends public school The 45-year-old mother in the family who does not work outside the home The 58-year-old father in the family who works in a nearby factory The 18-year-old daughter in the family who works at a restaurant in a neighboring town
The 45-year-old mother in the family who does not work outside the home
cultural imposition
The belief that everyone should conform to your own belief system.
The younger nurses on a unit, who seem to adapt easily to the new technology presented, are perceived as threatening by two nurses who have worked on the unit for years. The older nurses begin to ridicule the younger nurses, saying, "You might be able to work a computer, but we know how to provide real care." How should the charge nurse respond? The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit. The charge nurse should recognize that this is cultural imposition and the younger nurses are forcing new technology on the older nurses. The charge nurse should understand that this is stereotyping in the form of racism and intervene immediately. The charge nurse should demonstrate cultural blindness and pretend that the issue does not exist.
The charge nurse should discuss the concept of cultural conflict and help both parties see their respective value to the unit.
The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal? The client was treated for kidney stones a few months earlier. The client has a history of benign prostatic hyperplasia (BPH; prostate enlargement). The client is acutely confused and has been diagnosed with delirium. The client has had urinary catheters in place repeatedly during previous admissions.
The client is acutely confused and has been diagnosed with delirium.
The nurse is assessing a client for pain and suspects that the client's culture may be affecting the pain response. What nonverbal indicator of pain would the nurse expect to observe? The client is holding pressure on the abdomen when speaking. The client requests to take a walk outside. The client is laughing loudly with family. The client is praying with members of the clergy.
The client is holding pressure on the abdomen when speaking.
When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? The client returned from a foreign country 2 days ago. The client consumes large qualities of fresh vegetables. The client repeatedly ignores the urge to defecate. The client has a daily fluid intake of 2,000 to 3,000 mL.
The client returned from a foreign country 2 days ago.
A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions? Sterile technique must be observed by the client in the home setting. The client should avoid wearing tight clothes or belts near the site. The client may bathe rather than shower, provided the site is covered with gauze. A dressing should always be worn over the site to avoid leaking.
The client should avoid wearing tight clothes or belts near the site.
A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change? The client states, "Why isn't blood administration forced on all who need that treatment?" The client states, "I am glad that nurse told me what to do." The client states, "I feel like I abandoned my religion." The client states, "I can't get over my feelings of legalism as a Jehovah's Witness."
The client states, "I feel like I abandoned my religion."
A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client? Urination can be voluntarily controlled after the stoma heals from the initial surgery. The client will have to wear an external appliance to collect urine. This urinary diversion is only temporary. The client will need to change the urinary pouch every 4 hours.
The client will have to wear an external appliance to collect urine.
The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? The graduate uses a room temperature solution. The graduate takes this opportunity to teach about the function of the intestinal tract. The graduate places the client in Fowler's position. The graduate advises the client that the enema should not be expelled immediately.
The graduate places the client in Fowler's position.
A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse drapes the client's chest and pubic area and extends the client's legs flat against the bed. The nurse encourages the client to drink fluids before the assessment so that the bladder is full and can be examined. The nurse auscultates the abdomen before inspection and palpation are performed. The nurse places the client in the supine position with the abdomen exposed.
The nurse places the client in the supine position with the abdomen exposed. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants.
A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason? To rest the gastrointestinal tract and promote healing To increase mucus in the bowel that helps to promote healing To prevent gas from forming in the bowel and interfere with healing To allow gas to accumulate and promote healing
To rest the gastrointestinal tract and promote healing
A nurse is checking a client's capillary blood glucose level. Which nursing action is most appropriate? Have the client make a fist to encourage blood flow. Cleanse the test strip with an alcohol swab prior to inserting it in the meter. Wipe the test site with an alcohol swab after testing. Touch the test strip directly to a drop of blood.
Touch the test strip directly to a drop of blood.
urinary output and lab specimens; types of samples
Urinalysis - U/A (10 ml) Urine Culture - Sterile specimen (3ml) 24 hour Urine Collection Midstream catch or clean-catch
A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? Perform hand hygiene between cleansing the woman's labia and inserting the catheter. Insert the catheter with her left hand while supporting the woman with her right hand. Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted.
Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted.
A nurse is educating a group of adolescent girls on bone and teeth growth. Which fat-soluble vitamin assists to build bone and teeth? Vitamin A Vitamin K Vitamin D Vitamin E
Vitamin D
A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity? Avoid using commercial skin preparations. Avoid applying a barrier substance. Wash it with a mild cleanser and water. Clean it with a dry, cotton bandage.
Wash it with a mild cleanser and water.
The nursing researcher is studying so-called "unnatural illnesses." What cause of such illnesses would be included in the study? Impurities in water Food Cold air Witchcraft
Witchcraft
A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic.
Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique.
The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers? Onions and garlic Fish and dried lentils Asparagus and turnip Yogurt and buttermilk
Yogurt and buttermilk
ethnicity refers to
a group of people who share a geographic area, religion, culture, or language
Ethnicity is
a sense of identification with a collective cultural group based on the groups common heritage
A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching? a. Blood from the fingertips shows changes in glucose more quickly than other testing sites. b. Glucose levels will decrease with illness and stress. c. Calibrate the glucose meter every six months. d. Use a forearm sample with signs and symptoms of hypoglycemia.
a. Blood from the fingertips shows changes in glucose more quickly than other testing sites.
anuria
absence of urine, < 50 ml in 24 hrs
The process of cultural assimilation or _______ occurs when a minority group, living within a dominant group, takes on the values of the dominant culture.
acculturation
The nurse works in an urban hospital and cares for a diverse population of clients. Which action(s) by the nurse demonstrates the delivery of culturally sensitive care to clients? Select all that apply. allowing the client to keep a religious necklace on until going into the operating room indicating that the cultural groups should adapt to the Anglo-American culture integrating the client's cultural practices when assisting with the creation of the plan of care asking the client questions regarding health care beliefs related to the client's culture maintaining direct eye contact during conversations with all cultural groups
allowing the client to keep a religious necklace on until going into the operating room integrating the client's cultural practices when assisting with the creation of the plan of care asking the client questions regarding health care beliefs related to the client's culture
You are the nurse assessing a patient with complaints of burning and frequency following use of the toilet. The patient states she has back pain and "feels hot." Upon assessment you note she is febrile with a temperature of 101.2 degrees F, orally. The patient states, "I have back pain." What type of Urinary Tract Infection might the patient be complaining of? a)Glomerulonephritis b)Pyelonephritis c)Cystitis d)Kidney disease
b)Pyelonephritis
A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate? a. grilled shrimp for a client who practices Orthodox Judaism b. vegetable plate for a client who practice Hinduism c. toast with coffee for a client who practices the restored gospel of Jesus Christ d. grilled pork chop for a client who practices Orthodox Judaism
b. vegetable plate for a client who practice Hinduism
The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas buildup in the colostomy bag? Fresh lettuce Cooked pasta Baked beans Steamed rice
baked beans
when is toilet training accomplished
between ages of 2-5 years
Culture conflict occurs when people become aware of cultural differences; cultural ________ occurs when one ignores differences and proceeds as though they do not exist.
blindness
hematuria
blood in the urine
caucasians prone to
breast cancer, obesity, HTN, diabetes
A woman is reporting bladder urgency. It is most important to assess: weight. exercise. caffeine intake. vitamin supplements.
caffeine intake.
Anticoagulants
can cause BLOOD in the urine (HEMATURIA)
• Levodopa (Sinemet) effecting urine
can cause urine to turn BROWN or BLACK
The nurse is preparing the discharge plan for a new mother and her newborn son. Which new teaching should the nurse ensure is included after noting the family is Jewish? proper breastfeeding techniques care following the scheduled circumcision the proper sleeping position for the newborn when to schedule the next follow-up appointment
care following the scheduled circumcision
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? maintaining the client without liquids before the procedure inserting a Foley catheter the morning of the procedure checking that the client has signed a consent form for the procedure explaining to the client that the procedure will be painful
checking that the client has signed a consent form for the procedure
muscle tone
childbearing, muscle atrophy, immobility, long term catheters
monitor for complications
choking, aspiration, residual, diarrhea, constipation, vomiting, dumping syndrome
A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? cleansing enema return-flow enema retention enema carminative enema
cleansing enema
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? clear, dark amber cloudy, foul odor light yellow, clear strongly aromatic, amber
cloudy, foul odor
race refers to
common characteristics passed down through genes
A client who practices Islam dies at the hospital surrounded by family members. Which action by the nurse demonstrates cultural sensitivity related to the client's death? having the family members consult with the funeral home for transport consulting the family member prior to performing post-mortem care allowing the family to remain present when the nurse washes the client prior to shrouding informing the family members they may say their goodbyes so that care can be provided
consulting the family member prior to performing post-mortem care
ileal conduit
continent diversion, which involves the creation of a pouch or bladder inside the body, usually using part of the digestive tract
A nurse is caring for a client who has been ordered a clear liquid diet. Which liquid can be included in the client's diet? Tomato soup Cranberry juice Low-fat milk Orange juice
cranberry juice
A nurse is caring for a client with bacterial pneumonia and a temperature of 104°F (40.0°C). Yesterday, the client's temperature was 102°F (38.9°C). The health care provider on call prescribes cool compresses for the client to help lower the fever. The client insists that the nurse bring warm blankets because they will help the client to recover more quickly. The nurse recognizes that the client's request is an example of: cultural competence. cultural ritual. ethnocentrism. cultural stereotyping.
cultural ritual.
Lipids are available from
dark meat, dairy, oils, poultry skin
What is known to increase the risk of developing a urinary tract infection?
dehydration
hispanic prone to
diabetes , lactose intolerance
peritoneal dialysis
dialysis in which the lining of the peritoneal cavity acts as the filter to remove waste from the blood
lack of access to health care
discrimination, cultural barriers, geographic isolation, economics, mistrust of western medicine
A urinary ____ involves the surgical creation of an alternative route for excretion of urine.
diversion
A woman consumes pasta, grains, and other carbohydrates for which purpose? source of fiber weight loss energy weight gain
energy
polyuria
excessive urination
family roles
extended family may have significant influence
Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is: normal weight. extremely obese. obese. underweight.
extremely obese.
T/F: Stereotyping describes the feels of a person experiences when placed in a different culture.
false
T/F: When providing care to people from different cultures, it is important to allow past experiences to guide solutions to all cultural situations.
false
TRUE/FALSE: The urinary bladder muscle is innervated by the sympathetic nervous system, which carries motor impulses to the bladder and inhibitory impulses to the internal sphincter.
false
matriarchal
family ruled by a woman such as a mother, grandmother, or aunt
The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? endoscopic examination, barium studies, fecal occult blood test barium studies, endoscopic examination, fecal occult blood test barium studies, fecal occult blood test, endoscopic examination fecal occult blood test, barium studies, endoscopic examination
fecal occult blood test, barium studies, endoscopic examination
Symptoms of pyelonephritis
fever, back or flank pain, freq and burning
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? afternoon before bedtime first thing in the morning evening
first thing in the morning
how to clean an indwelling catheter
front to back, -Use soap and water for daily metal hygiene
The specific _____ of urine is a measure of the density of urine compared with the density of water.
gravity
infants (urinary)
have no voluntary control of urine and decreased ability to concentrate urine until 6 weeks of age
Nurses are socialized into the: diagnostic process. nursing specialties. healthcare culture. caring paradigm.
healthcare culture.
A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing? diarrhea paralytic ileus constipation hemorrhoids
hemorrhoids
punctuality
in some south asian cultures being late is considered a sign of respect
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? Foley catheter intermittent urethral catheter indwelling urethral catheter retention catheter
intermittent urethral catheter
urge incontinence
involuntary loss of urine associated with an abrupt and strong desire to void
vitamin C
iron absorption, citrus fruits and vegetables, wound healing
normal waist circumference for men
less than 40 in
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be: bloody. liquid consistency. mucus-filled. soft semi-formed.
liquid consistency.
mexican-american
listen more to women because they assume primary responsibility for maintaining family health
A client says to the nurse, "Why don't you wear a white cap like nurses do on the soap operas?" This is an ethnocentric statement based on the: past history. nursing personality. genetics. media.
media
NGT Inteventions
monitor nares, oral care, throat irritation- hard candy, secure tube well
PEG interventions
monitor skin integrity around stoma
NI tube
nasointestinal tube; tube inserted through the nose and into the upper portion of the small intestine
The ____is the basic structural and functional unit of the kidneys.
nephron
hematocrit normal range
normal=40%-50 %), decreased anemia, increased dehydration
culture shock
occurs when a person is placed in a different culture perceived as strange
reflex incontinence
occurs when the bladder muscle contracts and urine leaks without any warning or urge.
asians with mental illness
often stigmatized and seen as a source of shame
The community nurse is educating client groups about nutrition. Which group does the nurse identify that will benefit most from nutritional counseling and intervention? older adults living on a fixed income people who live in farming communities double income, married individuals married, pregnant women over 30 years of age
older adults living on a fixed income
PEG tube
percutaneous endoscopic gastrostomy tube - feeding tube
The area around a person regarded as _____ space is the area into which others should not intrude during personal interactions.
personal
glycosuria
presence of glucose in the urine
pyuria
presence of pus in the urine
cultural assimilation
process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different
most important risk factor for developing a CAUTI is
prolonged use of the urinary catheter
A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms: require an individualized approach by the nurse. allow nurses to predict a client's response. can be generalized to anyone of that culture. are fairly consistent across cultural groups.
require an individualized approach by the nurse.
african americans prone to
sickle cell anemia, HTN, CVA, keloids, lactose intolerance
A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? reflect total urge stress
stress
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? Functional Urge Stress Overflow
stress
The nurse is teaching four clients in a community health center. Which client does the nurse identify as needing more servings per day of milk? new mother who is bottle-feeding a baby older adult who lives with grown children teenager who is in the second trimester of pregnancy middle-age male who works night shift
teenager who is in the second trimester of pregnancy
Ethnocentrism
the belief that the ideas, beliefs, and practices of one's own culture are superior to those of another's culture.
TPN
total parenteral nutrition
T/F: A cutaneous ureterostomy is a type of incontinent cutaneous urinary diversion in which the ureters are directed through the abdominal wall and attached to an opening in the skin.
true
T/F: A sterile urine specimen is obtained by catheterizing the patient's bladder or by taking the specimen from an indwelling catheter already in place.
true
T/F: One of the most culturally variable forms of nonverbal communication is eye contact.
true
Use of an indwelling urinary catheter leads to the loss of bladder tone. True False
true
Sources of carbohydrates
vegetables, grains, milks, sugar
emotive
verbalize expression of pain (Hispanic/Latino)
The nurse is assessing the arm of her patient with chronic kidney disease who is on hemodialysis three times per week. He checks the patient's arm and expects to: Feel a ____________ and hear a _____________ with his stethoscope.
vibration, bruit
vitamin A
vision and tissue strength
cystoscopy
visual examination of the urinary bladder
examples of micronutrients
vitamins, minerals, water
nursing assessment for urinary
voiding patterns, recent changes, past/ present difficulities
The nurse is admitting a new client who is a member of the Navajo Nation. Which action should the nurse consider while conducting the interview? write notes after the interview include the shaman in the assessment process allow client to view notes after interview ask which family member should also be included
write notes after the interview
enteral feeding interventions
}Check tube placement- XRAY first, aspirate consistency, pH testing, monitor for respiratory distress }Check gastric residual amount every 4 hours }Assess patient's abdomen and bowel sounds -Assess patient's tolerance -Keep upright during and one hour post feeding -Prevent contamination -Flush with 30 mL water before and after feedings and medication }Label all equipment name, date, time; replace every 24 hours }Liquify all meds }Flush with 30 ml of water before and after meds }Flush with 30 ml of water every 4 hours
variables affecting nutritional status
}Developmental Stage }Economic factors }Education/knowledge }Culture/Religion }Meaning of food/ social context
clinical observation nutrition
}General appearance }Hair }Skin }Gums / Teeth }Muscle Tone }Abdomen }Dysphagia
Parenteral Nutrition- TPN
}IV only- always use IV pump }Central line- hypertonic }Used if bowels or stomach needs rest }Strict aseptic technique is used }Prepared by pharmacy- hung by RN }Very expensive- has severe complications }Monitor v/s q4 and blood glucose level q6h }Daily weights and labs
age related risks- older adults (nutrition)
}Loss of teeth, ill fitting dentures, weaker jaw }Decreased smell and taste }Decreased salivation, gastric acids and enzymes }Decreased appetite and thirst sensation }Increased use of medications }Social isolation }Depression }Loneliness }Decreased peristalsis }Gastro-esophageal reflux }Physical Handicaps }Generalized weakness
Dementia and cognitive considerations (nutrition)
}Routine - same time and same place }Calm environment }Supervision }Slowed time- well spaced and relaxed }Place foods within easy reach }Up in chair - sitting straight
hospital diets. (nutrition)
}Sodium-restricted (heart healthy) diet }Fat-restricted diet (Low Fat) }TLC diet (Therapeutic Lifestyle Change) }NPO }Vegetarian diet
food safety
}Wash hands and fruits/veggies }Separate meats and clean surfaces that meat is placed on }Teach to cook foods to a safe temp to kill microorganisms -Avoid raw meat, unpasteurized milk and raw eggs
proteins
}are provided by animal and plant sources ◦Recommended dietary requirement is 10% to 35% of daily intake. Provides 4 kcal/g. ◦Proteins are classified as complete or incomplete. ◦Proteins are necessary for the formation of all body structures- made up from 22 basic building blocks, the amino acids.
water
}is crucial for all fluid and cellular functions. }Replaces loses through perspiration, elimination, and respiration. ◦The recommended daily fluid intake is 3 to 4 L/day for men and 2 to 3 L/day for women (half should be water)
nursing interventions for nutrition
•Modify diet instructions for each individual •Encourage adequate fluid intake with nutrients •Teach MyPlate food guide and balance
Reasons for urinary catheterization
•Urinary Retention •Obtaining a sterile urine specimen •Emptying the bladder for a procedure or surgery •Monitoring renal function in critically ill patients •End of life comfort
stress incontinence
•r/t increased intra-abdominal pressure: childbearing, laughing, obesity, coughing, sneezing
Anatomy and Physiology of the Urinary System
▪Kidneys ▪Ureters ▪Bladder ▪Urethra ▪Removal of waste products ▪Kidneys maintain and regulate fluid balance ▪Urinary elimination occurs every 3-4 hours
skills
▪Operating a bladder scanner ▪Bedpan / Urinal ▪Catheterization of female bladder ▪Catheterization of male bladder ▪Straight (Intermittent) Catheterization ▪Closed continuous bladder irrigation ▪Emptying / Changing stoma appliance ▪AV fistula/graft care ▪Emptying foley catheter ▪Collection of sterile urine via foley
nursing interventions
▪Schedule ▪Privacy ▪Hygiene ▪Positioning ▪Encourage adequate fluid intake ▪Pelvic floor muscle training - PFMT, Kegel exercises ▪Assistance when needed ▪Having objects available- urinal, commode, call bell, bed in low position, IV pole that is able to move easily in room
hemodialysis
▪Treatment for patients with severely decreased or total loss of kidney function -Blood is filtered through a machine via an arteriovenous (AV) fistula, graphs, or a double lumen central venous catheter -Palpate AV fistula for thrill, auscultate for bruit -No BP or IV on arm with AV fistula
Urinary System
▪Urinary system ▪Urinary Assessment ▪Influencing variables ▪Problems ▪Catheterization ▪Urinary Diversions ▪Urinary Skills
urinary retention
▪Urine production is normal but not appropriately excreted from the bladder •BPH , Post op
urinary tract infection (UTI)
▪Women are more at risk ▪Foley catheter ▪Diabetes ▪Elderly ▪E-coli ▪Drink water, cleanse front to back, avoid baths, wear loose cotton underwear, drink cranberry or blueberry juice ▪If incontinent- keep skin clean and dry
Modified Consistency Diets
◦Clear liquid diet ◦Full liquid diet ◦Pureed ◦Mechanically modified
lipids
◦Is a concentrated form of energy - 9 kcal./g ◦Less than 10% of calories per day should come from saturated fats and keep intake of trans fats to as low as possible. ◦Necessary for hormone production, structural material for cell walls, protective padding for vital organs, insulation to maintain body temperature, covering for nerve fibers, absorption of fat-soluble vitamins
