Reduction of Risk Potential

A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Prior to surgery, what comment by the client indicates that the client understands the procedure? "This is a temporary procedure that can be reversed later." "I will urinate through my rectum." "My urine will come out through an opening on my abdomen." "My urine will go from my bladder into a drainage bag."

Correct response: "My urine will come out through an opening on my abdomen." Explanation: An ileal conduit is a permanent urinary diversion in which a portion of the ileum is surgically resected and one end of the segment is closed. The ureters are surgically attached to this segment of the ileum, and the open end of the ileum is brought to the skin surface on the abdomen to form the stoma. The client must wear a pouch to collect the urine that continually flows through the conduit. The bladder is removed during the surgical procedure, and the ileal conduit is not reversible. Diversion of urine to the sigmoid colon is called a ureteroileosigmoidostomy. An opening in the bladder that allows urine to drain externally is called a cystostomy.

A nurse assesses a client for signs and symptoms of ectopic pregnancy. Which assessment finding should the nurse expect? Temperature elevation Vaginal bleeding Nausea and vomiting Abdominal pain

Abdominal pain

Which findings in a client who is receiving venlafaxine would require a nurse to take immediate action? Select all that apply. Hyperthermia Hypertension Bradycardia Miosis Fatigue

Correct response: Hyperthermia Hypertension Hyperthermia and hypertension may indicate serotonin syndrome, a potentially life-threatening condition. Other side effects of serotonin syndrome include tachycardia and mydriasis, not bradycardia and miosis. Fatigue can be a common side effect of venlafaxine and should be further assessed.

The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication? cataracts glaucoma ophthalmia neonatorum retinopathy of prematurity

Correct response: retinopathy of prematurity Explanation: High levels of oxygen delivered to a preterm neonate can result in retinopathy of prematurity. The immature blood vessels in the eye constrict, then overgrow, resulting in edema and hemorrhage that produce scarring, retinal detachment, and eventual blindness.

Which activity should the nurse encourage the client with a peptic ulcer to avoid? chewing gum smoking cigarettes eating chocolate taking acetaminophen

smoking

A client has been diagnosed with cirrhosis. When obtaining a health history, the nurse should specifically determine if the client takes? Acetaminophen. Cimetidine. Neomycin sulfate. Spironolactone.

Correct response: Acetaminophen. Explanation: The client with cirrhosis should be cautioned against taking any over-the-counter medications that may be hepatotoxic, because the liver will not be able to metabolize these drugs. Acetaminophen is an example of such a drug. Cimetidine, neomycin, and spironolactone are not hepatoxic, and the client can use these drugs.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? Single-hole nipple Plastic spoon Paper straw Rubber dropper

Rubber dropper Explanation: An infant with a surgically repaired cleft lip must be fed with a rubber dropper or Breck feeder to prevent sucking or suture line trauma. A single-hole nipple, a plastic spoon, and a paper straw wouldn't prevent these actions.

A physician placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement? Time of fetal scalp electrode placement, name of the physician who placed the electrode, and frequency of uterine contractions Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR) The name of the physician who applied the electrode, Doppler transducer placement, and FHR The maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR

Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR)

A primigravid adolescent client at approximately 15 weeks' gestation is visiting the prenatal clinic to undergo maternal quad screening. What information should the nurse include in the teaching plan for this client? Ultrasonography usually accompanies maternal quad screen testing. Results are usually very accurate until 20 weeks' gestation. A clean-catch midstream urine specimen is needed. Increased levels of alpha fetoprotein are associated with neural tube defects.

increased alpha fetal protein is associated with neural tube defects

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: metabolic acidosis. metabolic alkalosis. respiratory acidosis. respiratory alkalosis.

respiratory alkalosis.

Foods that are high in phenylakaline

meat, dairy, coke

A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis? Hypotension Tachycardia Hot, dry skin, Constricted pupils

Correct response: Tachycardia Explanation: Amphetamines, which are central nervous system stimulants, cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which complication? hemorrhage rectal spasm urine retention constipation

hemorrhage Explanation: Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help prevent constipation.

A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse? "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh negative baby." "RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh positive baby." "RhoGAM suppresses antibody formation in women with RH negative blood after giving birth to an Rh negative baby."

"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.

The nurse is caring for a 5-year-old child with a congenital heart defect. The nurse is reviewing with the parents the actions that would be necessary if the child experiences cardiopulmonary arrest and needs resuscitation. Which of the following statements by the parents indicate to the nurse that the teaching has been understood? Select all that apply. "The chance of my child arresting is unlikely." "I have to use compressions to circulate the blood." "I will give two breaths for every 30 compressions." "I will check for responsiveness before starting CPR." "I will call 911 before I start resuscitation efforts."

"I have to use compressions to circulate the blood." "I will give two breaths for every 30 compressions." "I will check for responsiveness before starting CPR."

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis? Withholding all oral intake, as ordered, to decrease pancreatic secretions Administering oral pain medications, as ordered, to relieve severe pain Limiting I.V. fluids, as ordered, to decrease cardiac workload Keeping the client supine to increase comfort

Correct response: Withholding all oral intake, as ordered, to decrease pancreatic secretions Explanation: The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although pancreatitis may cause considerable pain, it's treated with I.M. meperidine or morphine, not oral pain medicines. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: hypoxia. fever. visual disturbance. gait alteration.

Correct response: hypoxia. Explanation: Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

A parent reports that his/her school-age child has suddenly begun wetting the bed. Which action should the nurse take? Ask about recent psychosocial changes from the mother and the child. Refer the child to a psychologist for testing. Obtain a urine sample for urinalysis. Assure the mother that this occasionally happens with children.

Correct response: Obtain a urine sample for urinalysis. Explanation: In this situation, the nurse needs more information before proceeding. Physical causes of the enuresis need to be ruled out before psychosocial problems are addressed. Enuresis is not a normal finding in a school age child.

After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should: clamp the urinary appliance at night. empty the urinary appliance before it is one-third full. limit the client's walking with the appliance. change the urinary appliance daily.

empty the urinary appliance before it is one-third full.

Common adverse effects of lithium carbonate

nausea, diarrhea, tremor, lethargy

A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. What instructions should the nurse give the parents? Avoid tub baths until the stent is removed. Measure urinary output in the urinary bag. Avoid giving fruit juice. Clean the tip of the penis three times a day with soap and water.

Correct response: Avoid tub baths until the stent is removed. Explanation: The parents should keep the penis as dry as possible until the stent is removed. Soaking in a tub bath is not recommended. Children this age typically go home voiding directly into a diaper. Infants may be started on juice at 6 months of age. Parents are advised to keep their child well hydrated after a hypospadius repair. Therefore, there is no reason to avoid juice. Cleaning the tip of the penis three times a day may cause unnecessary irritation.

The nurse is planning care with a client with acute leukemia who has mucositis. What should the nurse advise the client to use for mouth care? lemon-glycerin swabs a commercial mouthwash normal saline a commercial toothpaste and brush

Correct response: normal saline Explanation: Simple rinses with saline or baking soda solution are effective and moisten the oral mucosa. Commercial mouthwashes and lemon-glycerin swabs contain glycerin and alcohol, which are drying to the mucosa and should be avoided. Brushing after each meal is recommended, but every 4 hours may be too traumatic. During acute leukemia, the neutrophil and platelet counts are often low and a soft-bristle toothbrush, instead of the client's usual brush, should be used to prevent bleeding gums.

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which finding would indicate fetal hypoxia? Abnormally long uterine contractions Abnormally strong uterine contractions Excessively frequent contractions, with rapid fetal movement Excessive fetal activity and fetal tachycardia

Excessive fetal activity and fetal tachycardia These are first signs of fetal hypoxia

A client who is taking lithium carbonate is going home on a 3-day pass. What is the best health teaching the nurse should provide for this client? Adjust the lithium dosage if mood changes are noted throughout the day. Have a low-sodium, high-protein snack with milk before going to bed. Avoid participation in controversial discussions with friends and family about the medication during the 3-day pass. Continue to maintain normal sodium intake while at home.

Continue to maintain normal sodium intake while at home. Explanation: Lithium decreases sodium reabsorption by the renal tubules. If sodium intake is decreased, sodium depletion can occur. In addition, lithium retention is increased when sodium intake is decreased.

The nurse should give which discharge instructions about thermal injury to a client with peripheral vascular disease? Select all that apply. "Warm the fingers or toes by using an electric heating pad." "Avoid sunburn during the summer." "Wear extra socks in the winter." "Choose loose, soft, cotton socks." "Use an electric blanket when you are sleeping."

Correct response: "Avoid sunburn during the summer." "Wear extra socks in the winter." "Choose loose, soft, cotton socks." Explanation: The client should recognize the signs of potential thermal dangers to prevent skin breakdown and wear clean, loose, soft cotton socks so that the feet are comfortable, air can circulate, and moisture is absorbed. In the winter or if the client has cold feet, the client should be encouraged to wear an extra pair of socks and a larger shoe size. Getting a sunburn during the summer puts the client at risk for tissue injury and skin breakdown. Using a heating pad to warm the feet or using an electric blanket places the client at risk for injury and should be avoided.

A nurse has been teaching a new mother how to feed her infant who was born with a cleft lip and palate. Which action by the mother indicates that the teaching has been successful? Placing the baby flat during feedings Providing fluids with a small spoon Placing the nipple in the cleft palate Burping the baby frequently

Correct response: Burping the baby frequently Explanation: Because an infant with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. An infant with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons shouldn't be used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration.

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched? Tell the mother that excessive analgesia in labor can cause this type of cry. Notify the primary care provider because this may indicate a neurologic problem. Stimulate the neonate to cry to obtain information to document. Continue to monitor the infant periodically for changes in the cry.

Notify the primary care provider because this may indicate a neurologic problem. Explanation: Typically a neonate's cry is loud and lusty. A weak, shrill, or high-pitched cry is not normal, possibly indicating a neurologic problem, such as increased intracranial pressure, infection, or hypoglycemia. Thus, the nurse should notify the primary care provider, so further evaluation can be done.

When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which technique? ultra-high-frequency sound waves catheter placed in the right femoral vein cutdown procedure to place a catheter general anesthesia

catheter placed in the right femoral vein Explanation: In children, cardiac catheterization usually involves a right-sided approach because septal defects permit entry into the left side of the heart. The catheter is usually inserted into the femoral vein through a percutaneous puncture. A cutdown procedure is rarely used. Echocardiography involves the use of ultra-high-frequency sound waves. The catheterization is usually performed under local, not general, anesthesia with sedation.

How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?

q4h The client's body temperature should be assessed every 4 hours during the first 24 hours because the client is still at risk for hypothermia or malignant hyperthermia. The client does not need to be checked every 2 hours unless indicated by an abnormal finding.

To protect a client who has received tissue plasminogen activator (t-PA) or alteplase recombinant therapy, the nurse should: use the radial artery to obtain blood gas samples. maintain arterial pressure for 10 seconds. administer IM injections. encourage physical activity.

use the radial artery to obtain blood gas samples The nurse should use the radial artery to obtain blood gas samples because it is easier to maintain firm pressure there than on the femoral artery. Nursing interventions to protect the client who has received t-PA or alteplase recombinant therapy include maintaining arterial pressure for 30 seconds because it takes longer for coagulation to occur with the thrombolytic agent on board. IM injections are contraindicated during thrombolytic therapy. The nurse should prevent physical manipulation of the client, which can cause bruising.

Which hospitalized client is at risk to develop parotitis? a 50-year-old client with nausea and vomiting who is on nothing-by-mouth status a 75-year-old client with diabetes who has ill-fitting dentures an 80-year-old client who has poor oral hygiene and is dehydrated a 65-year-old client with lung cancer who has a feeding tube in place

Correct response: an 80-year-old client who has poor oral hygiene and is dehydrated Explanation: Parotitis is inflammation of the parotid gland. Although any of the clients listed could develop parotitis, given the data provided, the one most likely to develop parotitis is the elderly client who is dehydrated with poor oral hygiene. Any client who experiences poor oral hygiene is at risk for developing parotitis. To help prevent parotitis, it is essential for the nurse to ensure the client receives oral hygiene at regular intervals and has an adequate fluid intake.

A client recovering from an abdominal hysterectomy has pain in her right calf. The nurse should: palpate the calf to note pain. measure the circumference of both calves and note the difference. have the client flex and extend her leg and note the presence of pain. raise the right leg and lower it to detect changes in skin color.

Correct response: measure the circumference of both calves and note the difference. Explanation: After abdominal pelvic surgery, the client is especially prone to thrombophlebitis. Measuring calf circumference can help detect edema in the affected leg. The calf should not be rubbed or palpated because a clot could be loosened and travel to the lungs as a pulmonary embolism. Homan's sign, which is calf pain on dorsiflexion of the foot when the leg is raised, is sometimes associated with thrombophlebitis. Having the client flex and extend the leg does not provide useful assessment data; the leg will not change color when raised and lowered.

The nurse is teaching a client and family about phenelzine. Which food should the nurse instruct the client to avoid? eggs chicken peanut butter sour cream

Correct response: sour cream Explanation: Because phenelzine is a monoamine oxidase inhibitor, the client should avoid foods high in tyramine to prevent the development of hypertensive crisis. Foods and beverages high in tyramine include sour cream, aged cheeses, yogurt, red wine, beer, bananas, avocados, salami, sausage, bologna, caffeinated coffee and colas, and chocolate. High-protein foods that have undergone protein breakdown by aging, fermentation, pickling, or smoking should be avoided. Hypertensive crisis, evidenced by occipital headache, stiff neck, nausea and vomiting, sweating, nosebleed, dilated pupils, tachycardia, and constricting chest pain, can occur with this food-drug combination. Eggs, chicken, and peanut butter are not foods high in tyramine and can be included in the client's diet.

The nurse is caring for a 9-month-old with Reye syndrome. Which nursing intervention should be included when assisting with the plan of care? Check the skin for signs of breakdown every shift. Perform range-of-motion (ROM) exercises every 4 hours. Monitor the child's intake and output. Place the child in protective isolation.

Correct response: Monitor the child's intake and output. Explanation: Monitoring intake and output alerts the nurse to the development of dehydration and cerebral edema, complications of Reye syndrome. Although checking the skin for signs of breakdown is important because the child may not be as active as normal, it is not as critical as monitoring the infant's intake and output. Active ROM exercises may not be needed and are not as important as monitoring the child's intake and output. Placing the child in protective isolation is not necessary.

When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the nurse understands that the neonate must have been fed what to ensure reliable results? a feeding of an iron-rich formula nothing by mouth for 4 hours before the test initial formula or breast milk at least 24 hours before the test a feeding of glucose water

Correct response: initial formula or breast milk at least 24 hours before the test Explanation: PKU is an autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid phenylalanine to tyrosine. To ensure reliable results, the neonate must have ingested sufficient protein, such as breast milk or formula, for at least 24 hours. Testing the infant before that time, excessive vomiting, or poor intake can yield false-negative results. The infant does not need to fast 4 hours before the test. A loading dose of glucose water does not affect test values.

A parent asks, "How should I bathe my baby now that he has had surgery for his inguinal hernia?" Which instruction should the nurse give the mother? "Clean only his face and diaper area for next 2 weeks." "Use sterile sponges to cleanse the inguinal incision until healed." "Give him a sponge bath daily for 1 week." "Let him take a full tub bath daily."

"Give him a sponge bath daily for 1 week." Explanation: The incision must be kept as clean and dry as possible. Therefore, daily sponge baths are given for about 1 week postoperatively. The infant can have more than just face and diaper area cleaned following surgery. Because this type of surgery results in a wound that heals through primary intention, the skin will heal and cover the wound in 2 to 3 days. Therefore, it is not necessary to use sterile gauze to cleanse the incision; clean technique is acceptable. Because the incision must be kept as clean and dry, full tub baths are inappropriate.

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting: 2 to 5 g of a simple carbohydrate. 15 g of a simple carbohydrate. 18 to 20 g of a simple carbohydrate. 25 to 30 g of a simple carbohydrate.

15 g of a simple carbohydrate.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor? Breathe slowly after each contraction. Avoid the use of analgesics for the labor pain. Remain in a side-lying position with the head elevated. Request local anesthesia for vaginal birth.

Correct response: Remain in a side-lying position with the head elevated. Explanation: The multigravid client with class II heart disease has a slight limitation of physical activity and may become fatigued with ordinary physical activity. A side-lying or semi-Fowler's position with the head elevated helps to ensure cardiac emptying and adequate oxygenation. In addition, oxygen by mask, analgesics and sedatives, diuretics, prophylactic antibiotics, and digitalis may be warranted.

A client has had an hypophysectomy. What signs of a potential complication should the nurse teach the client to report? acromegaly Cushing's disease diabetes mellitus hypopituitarism

Correct response: hypopituitarism Explanation: Most clients who undergo adenoma removal experience a gradual return of normal pituitary secretion and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits.

A client who has a history of bacterial endocarditis is scheduled to have oral surgery to remove a tooth. What should the nurse instruct the client to do? Gargle with a saline solution prior to the appointment. Rinse the mouth with mouth wash the night before and day of the surgery. Contact the health provider to request a sedative. Be sure the dentist prescribes a prophylactic antibiotic prior to the oral surgery.

Be sure the dentist prescribes a prophylactic antibiotic prior to the oral surgery. Clients who are at risk for developing infective endocarditis due to cardiac conditions such as a history of bacterial endocarditis must take prophylactic antibiotics before any dental procedure that may cause bleeding. Gargling with saline or using mouth wash is not sufficient to prevent infection. The client will not need a sedative prior to the surgery.

Which statement by a mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective? "I know that I'll need to keep my child as quiet as possible." "I just went out and bought all I'll need for the special diet." "I've been checking the urine for protein so I'll be able to do it at home." "I'm sure that my child will be back to normal soon and I won't have to worry about this anymore."

Correct response: "I've been checking the urine for protein so I'll be able to do it at home." Explanation: The mother stating that she'll check her toddler's urine for protein indicates effective teaching because such testing helps detect the progression of nephrotic syndrome. The child doesn't need to be kept quiet and usually isn't placed on a specific diet. How the child feels will dictate the child's activity level. Most children return to normal soon but may relapse.

A client with a genitourinary problem is being examined in the emergency department. When palpating the client's kidneys, the nurse should keep in mind which anatomic fact? The left kidney usually is slightly higher than the right one. The kidneys are situated just above the adrenal glands. The average kidney is approximately 5 cm (2?) long and 2 to 3 cm (¾? to 1??) wide. The kidneys lie between the 10th and 12th thoracic vertebrae.

Correct response: The left kidney usually is slightly higher than the right one. Explanation: The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4??) long, 5 to 5.8 cm (2? to 2¼?) wide, and 2.5 cm (1?) thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.

To help minimize calcium loss from a hospitalized client's bones, the nurse should: reposition the client every 2 hours. encourage the client to walk in the hall. provide the client dairy products at frequent intervals. provide supplemental feedings between meals.

Correct response: encourage the client to walk in the hall. Explanation: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation.

The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. What should the nurse tell the client? "After surgery, nasal packing will be in place for 7 to 10 days." "Normal saline nose drops will need to be administered preoperatively." "The results of the surgery will be immediately obvious postoperatively." "Do not take aspirin-containing medications for 2 weeks before surgery."

Correct response: "Do not take aspirin-containing medications for 2 weeks before surgery." Explanation: Aspirin-containing medications should be discontinued for 2 weeks before surgery to decrease the risk of bleeding. Nasal packing is usually removed the day after surgery. Normal saline nose drops are not routinely administered preoperatively. The results of the surgery will not be obvious immediately after surgery because of edema and ecchymosis.

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should: use sterile technique when providing catheter care. ensure that clients who are incontinent have indwelling urinary catheters. minimize urinary catheter use and duration of use in all clients. clean the periurethral area with antiseptics.v

minimize urinary catheter use and duration of use in all clients. Explanation: Minimizing urinary catheter use and duration of use in all clients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly, and clients with impaired immunity, will reduce the opportunity for infection. The nurse should avoid the use of urinary catheters for clients who are incontinent; a bladder training program and frequent use of the toilet are preferred; external catheters may be used if necessary in incontinent clients. The nurse should not clean the periurethral area with antiseptics; cleansing the meatal surface during daily bathing or showering is appropriate. Using sterile technique to help to reduce CAUTI is not necessary. Hand hygiene immediately before and after insertion or any manipulation of the catheter device or site is sufficient.

The home health nurse is completing a screening for elder abuse during a client visit. Which findings would require action by the nurse? Select all that apply. The client who lives with family who is assuming more of their care responsibilities. The client who is frequently scheduling appointments with their primary care provider. A client on apixaban with multiple small bruises on their bilateral arms and legs. A client who reports having excessive sleepiness after their evening medications. A client who is less talkative recently and avoiding eye contact with the nurse.

The client who is frequently scheduling appointments with their primary care provider. A client who reports having excessive sleepiness after their evening medications. A client who is less talkative recently and avoiding eye contact with the nurse. Explanation: The nurse responsible for knowing, screening, recognizing, and reporting elder abuse which can stem from negligent or intentional acts performed by a caregiver or other trusted individual that results in harm to a vulnerable elderly person. Clients making frequent appointments or trips to the ER, who reports having excessive sleepiness after their evening medications may be being abused and over-medicated, and who have become less talkative or avoid eye contact with you are often being abused. The client who lives with family who is assuming more of their care responsibilities is showing signs of improvement and independence. A client on apixaban which is an anticoagulant would be expected to have some small bruises on their body.