Unit 5 test questions

red blood cell

0-30

white blood cells

0-5

serum creatinine range

0.6-1.2

eGFR range

60

BUN

8-25mg/mL

you are providing discharge teaching to a patient with a colostomy. you include the following instructions about applying the colostomy wafer and bag. (select all that apply) a. ensure the opening in the wafer is tight to the stoma to prevent leaking b. leakage of colostomy contents to the surrounding area may lead to skin breakdown c. stoma coloring that is dusky or pale like the surrounding skin is normal d. some bleeding may occur because stoma tissues are fragile

a, b, d a. ensure the opening in the wafer is tight to the stoma to prevent leaking b. leakage of colostomy contents to the surrounding area may lead to skin breakdown d. some bleeding may occur because stoma tissues are fragile dusky or pale suggests inadequate circulation and should be reported.

the wound nurse is visiting a patient with a new colostomy for a final appointment prior to discharge. which patient statement would be most concerning? a. "I can't stand to even look at my stomach" b. "I know that I have to empty the bag when it is one third full" c. "the stoma is beefy red which is normal" d."i have trouble securing the wafer because of the abdominal discomfort"

a. "I can't stand to even look at my stomach" new colostomies can affect body image but continued inability to look at the site by the time of discharge presents barriers to self care

this morning your adult patient reports the new onset of frequent diarrhea with mucus and a foul odor. which medication class would you suspect as being related? a. antibiotic b. dietary supplement c. opioid analgesic d. diuretic

a. antibiotics antibiotics can promote diarrhea by irritating the GI mucosa or by inhibiting the growth of normal intestinal flora. when normal flora is altered C diff can proliferate and release toxins

a patient who regularly walks around the park and includes fiber consistently in their diet reports experiencing constipation. how will the nurse start teaching? a. ask the patient about the amount of fluid intake b. tell the patient to add more fiber from fruits and vegetables during meals c. ask the patient the amount of fiber consumed daily d. tell the patient to replace walking with swimming to make exercise more fun

a. ask the patient about the amount of fluid intake ask the patient about the amount of fluid intake, the nurse needs more data to teach the patient about bowel elimination. feces generally consist of 75% water and 25% solids. if the patient eats more fibrous food then fluid should be increased to smooth the fecal matter for easier elimination

your patient is diagnosed with a UTI. which urinary signs would best support this diagnosis a. cloudy urine b. dark amber color c. no odor from urinal d. sediment in the catheter tubing

a. cloudy urine represents pus in the urine

you are working with an elderly patient with altered mental status and urinary incontinence. what nursing interventions would be most appropriate (select all that apply) a. encourage the patient to avoid smoking and drinking coffee b. schedule toileting at least every 2 hours c. provide medications to improve bowel functions d. request physician order to insert a urinary catheter

a. encourage the patient to avoid smoking and drinking coffee b. schedule toileting at least every 2 hours timed and prompted voiding schedules are effective with cognitively impaired older adults

a nurse is reinforcing discharge teaching with a client who has undergone a transurethral resection of the prostate TURP. which of the following statements should the nurse include in the teaching a. increase fluid intake if urine becomes blood-tinged b. take naproxen for discomfort c. sexual activity is permitted after 2 weeks d. urinary dribbling will resolve in 5 days

a. increase fluid intake if urine becomes blood-tinged

a nurse is reinforcing teaching with a newly licensed nurse about physiological changes in the digestive system that occur with aging. the nurse should include older adults might experience which of the following physiological changes? a. decreased intestinal peristalsis b. increased muscle tone of the bowel c. decreased pH of the stomach d. increased gastric acid production

a. increased intestinal peristalsis

a nurse is collecting data on a patient who has urinary retention. which of the following findings should the nurse expect? a. leakage of urine b. dark colored urine c. cloudy urine d. blood in urine

a. leakage of urine

which patient condition would you expect to have decreased urinary output? a. a postoperative patient in a recovery room b. an elderly patient with urinary frequency c. a pregnant patient with occasional nausea d. a patient following a CVA e. ALL OF THE ABOVE

a. postoperative patient postoperative patients have a decreased fluid volume due to limited intake and loss of body fluid. the stress of surgery also increases release of antidiuretic hormone which decreases urinary output

foods that loosen stool

alcohol beans beer chocolate coffee fried foods prune or grape juice raw fruits and vegetables spicy foods spinach

you are assessing factors related to constipation in your postoperative patient. which of the following could contribute to constipation? (select all that apply) a. opioid analgesics b. decreased mobility c. fear of pain d. supine position e. lack of privacy

all

foods that thicken stool

applesauce bananas bread cheese high-fiber foods marshmallows pasta peanut butter rice tapioca

your patient had a urinary catheter removed at 0600 and has not voided. it is now 1400. what would you do first? a. perform BUS b. assess sensation of fullness and distention c. encourage increased oral intake d. assist the patient to the bathroom to void

b. assess sensation of fullness and distention assessment of sensations of fullness and distention is the first step in the nursing process. bladder ultrasound is an appropriate tool following physical assessment

a nurse is reinforcing teaching with a patient about foods and beverages that can cause diarrhea. which of the following should the nurse include in the teaching? a. white rice b. caffeinated beverages c. low-fiber cereal d. ripe bananas

b. caffeinated beverages

a nurse is reinforcing teaching with a client who is scheduled for lithotripsy about conditions that can contribute to the formation of renal calculi. which of the following conditions should the nurse include? a. protein in the urine b. dehydration c. iron deficiency d. obesity

b. dehydration

you have placed a nasogastric tube for gastric decompression secondary to paralytic ileus. what is the first thing you are going to need to do? a. connect tubing to intermittent suction b. ensure accurate placement c. provide liquid medications via tube d. irrigate tube to maintain patency

b. ensure accurate placement ensuring accurate placement of the NG tube is essential prior to connect suction or administering medications. irrigation should occur after medication administration

a nurse is monitoring a client following a hemodialysis treatment through an AV fistula. which of the following findings should the nurse report to the provider? a. blood pressure of 134/82 b. headache, restlessness c. palpable thrill at AV fistula site d. heart rate 65 bpm

b. headache, restlessness

a nurse is assisting with teaching a patient who has constipation. which of the following statements should the nurse include? a. consume a low-fiber diet b. increase your daily fluid intake c. reduce your daily activity d. try to defecate at different times in the day

b. increase your fluid intake

you are caring for a female patient who is concerned that she has not had a bowel movement since yesterday and hasn't taken her laxative. you assess her abdomen and find bowel tones throughout all four quadrants, reports of flatus, and that the abdomen is soft and not distended or tender. which nursing diagnostic would be most appropriate? a. constipation b. perceived constipation c. deficient fluid volume d. anxiety

b. perceived constipation describes a self-diagnosis of constipation (not supported by nursing assessment) a patient may act on their perception through the abuse of laxatives, enemas and suppositories to ensure daily bowel movement.

which of the following findings are abnormal? a. borborygmi present b. positive FOBT guaiac c. tympany in LUQ d. Convex shape

b. positive FOBT guaiac this indicates blood in the stool and is an abnormal finding

a nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. which of the following should the nurse include in the teaching? a. omit your daily dose of aspirin b. take a laxative the evening before the procedure c. expect to be drowsy for 24 hours following the procedure d. you will feel cold chills after the dye has been injected.

b. take a laxative the evening before the procedure

foods that may cause gas

beans beer cabbage family vegetables carbonated beverages cucumbers dairy products onions radishes

foods that cause odor

beans cheese cabbage family eggs fish onions

micturition occurs when a. glomerular filtration enters the tubule b. increased pressure stretches the detrusor muscle c. pelvic muscles relax and abdominal muscles contract d. sympathetic impulses cause stimulation of the internal sphincter

c. emptying of the bladder occurs when the external bladder sphincter relaxes, abdominal muscles contract and the pelvic floor relaxes.

you determine that your patient is at risk for constipation related to their postoperative status. what intervention can you provide to reduce this risk? a. request high protein foods to be included on the dietary tray b. encourage foods high in magnesium c. promote ambulation as tolerated d. promote intake of cold fluids

c. promote ambulation as tolerated promoting ambulation will assist with the return of gastric motility related to general anesthesia and can begin at the earliest promoting a diet high in fiber is appropriate after the patient's bowel function has returned drink warm fluids

selective reabsorption of water and ions occurs in which part of the nephron? a. bowman capsule b. glomerulus c. tubules d. small intestine

c. tubules the tubules are the passageways that permit urine to flow to the renal pelvis and then to the ureters, selectively reabsorbing or secreting substances from the urine to maintain fluid and electrolyte balance.

you perform a FOBT guaiac test on a stool sample from a patient with a history of GI bleeding. which step would you do first after applying stool to the hemoccult slide? a. open flap on reverse side b. apply developing solution c. wait 3-5 minutes d. document

c. wait 3-5 minutes after applying a smear of stool, close the lid cover and wait 3-5 minutes, then open the reverse side flap and apply two drops of hemoccult developing solution onto each window and one onto the control window. document of results is the final step

foods that may block an ileostomy

celery coconut coleslaw mushrooms corn nuts popcorn raisins raw vegetables and fruit seeds string meats

a nurse is assisting with evaluating a newly licensed nurse to drain an ileostomy bag for a client. which of the following actions by the newly licensed nurse indicated an understanding of the procedure? a. wears sterile gloves to drain the ileostomy bag b. empties the ileostomy bag when it is three-fourths full c. washes the skin surrounding the patients' ileostomy with hot water d. cleans the end of the ileostomy pouch before clamping it

d. cleans the end of the ileostomy pouch before clamping it

a nurse is collecting data on a client who has had diarrhea for several days. which of the following findings should the nurse expect? a. dehydration b. rigid abdomen c. hypothermia d. decreased bowel sounds

d. decreased bowel sounds

which of the following bowel habits are abnormal? a. breastfed infant with stool once every 3 days b. toddler smearing or playing with feces c. preschooler with bowel control but not bladder control d. elderly adult with fecal incontinence

d. elderly adult with fecal incontinence fecal incontinence is always an abnormal finding in adults

a nurse is reviewing the laboratory results for a chronic kidney disease patient. which of the following laboratory findings should the nurse expect? a. hypokalemia b. decreased urine specific gravity c. decreased BUN d. elevated creatinine

d. elevated creatinine

a client has just had surgery to create an ileostomy. the nurse assesses the patient postoperative for which most frequent complication of this type of surgery? a. folate deficiency b. malabsorption of fat c. intestinal obstruction d. fluid and electrolyte imbalance

d. fluid and electrolyte imbalance

indwelling urinary catheters are not indicated in which of the following patient conditions? a. recurrent urinary retention b. urologic surgical procedures with general anesthetic c. incontinence with pressure ulcers d. impaired mobility

d. impaired mobility not an indication without other factors present

which urinary output represents abnormal findings? a. newborn voids 30-40 times per day b. nighttime incontinence in a 6-year-old c. nocturia in an elderly male patient d. incontinence in an elderly female patient

d. incontinence in an elderly female patient incontinence is not a normal or even inevitable part of aging, although aging is a risk factory and is twice as likely in women

a patient had an indwelling catheter removed at 0400 by a night shift nurse. at 0900 the day shift nurse notices that the patient has voided 155mL. What will the nurse do next? a. ambulate the patient to the bathroom b. ask the charge nurse to check the patient c. call the patient's provider for orders d. record the findings in the patient's chart

d. record the findings in the patient's chart the nurse will record the finding. the human kidneys normally drain at least 30mL of urine an hour

the nurse is caring for a patient who has congestive heart failure and is taking diuretic medication. what will the nurse do to prevent the patient from injuries a. encourage the patient to use the bathroom independently b. have the patient take medication in the afternoon c. place the commode right next to the patient bed d. remind patient to dangle feet before getting up

d. remind the patient to dangle their feet before getting up one of the points of patient education is the effect of diuretics on the patient's blood pressure. using diuretics can enhance the excretion of fluid volume thus lowering BP

a patient is refusing to use a bedpan and reports an inability to defecate while using a bedpan in the past. what will the nurse teach the patient? a. drink a lot more water to soften the stool b. it is embarrassing to defecate in places other than the toilet c. it takes time to learn how to use a bedpan d. sit up as much as possible to produce a downward pressure

d. sit up as much as possible to produce a downward pressure this enhances the contraction of the abdominal and pelvic floor muscles

your assessment of an elderly female indicated the following: alert and orientated, ambulates independently, reports urinary frequency, and incontinence with coughing. Which nursing diagnosis would best describe this patient's condition? a. urge incontinence b. functional incontinence c. reflex urinary incontinence d. stress incontinence

d. stress incontinence stress incontinence is the sudden, involuntary loss of small amounts of urine that accompanies a sudden increase in intra-abdominal pressure such as coughing, sneezing, laughing, lifting

which of the following are expected findings? a. polyuria in a patient with poorly managed diabetes b. anuria in a patient with end-stage renal disease c. hematuria in a patient with a UTI d. urinary retention in a patient with thoracic spinal cord injury e. ALL OF THE ABOVE

e. ALL OF THE ABOVE

what is the purpose of testing serum creatinine levels?

testing how kidneys are functioning

lithotripsy procedure

uses shock waves to break up stones in the kidneys and part of the ureters.