A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing? a.Resting energy expenditure (REE) b.Basal metabolic rate (BMR) c.Nutrient density d.Nutrients B. Basal metabolic rate (BMR) The basal metabolic rate (BMR) is the energy needed at rest to maintain life-sustaining activities for a specific period of time. The resting energy expenditure (REE), or resting metabolic rate, is the amount of energy an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest. Nutrients are the elements necessary for body processes and function. Nutrient density is the proportion of essential nutrients to the number of kilocalories. High–nutrient density foods provide a large number of nutrients in relation to kilocalories. In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? a.Weight increases. b.Weight decreases. c.Weight does not change. d.Weight fluctuates daily. C. weight does not change In general, when energy requirements are completely met by kilocalorie (kcal) intake in food, weight does not change. When kilocalories ingested exceed a person’s energy demands, the individual gains weight. If kilocalories ingested fail to meet a person’s energy requirement, the individual loses weight. Fluid, not kilocalories, causes daily weight fluctuations. A nurse is asked how many kcal per gram fats provided. How should the nurse answer? a.3 b.4 c.6 d.9 D. 9 Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Carbohydrates and protein provide 4 kcal/g. A nurse is teaching a patient about proteins that must be obtained through the diet and cannot be synthesized in the body. Which term used by the patient indicates teaching is successful? a.Amino acids b.Triglycerides c.Dispensable amino acids d.Indispensable amino acids D. indispensable amino acids The body does not synthesize indispensable amino acids, so these need to be provided in the diet. The simplest form of protein is the amino acid. The body synthesizes dispensable amino acids. Triglycerides are made up of three fatty acids attached to a glycerol. A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority? a.Reduce dependent nitrogen balance. b.Maintain negative nitrogen balance. c.Promote positive nitrogen balance. d.Facilitate neutral nitrogen balance. C. promote positive nitrogen balance When intake of nitrogen is greater than output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. Negative nitrogen balance occurs when the body loses more nitrogen than the body gains. Neutral nitrogen balance occurs when gain equals loss and is not optimal for tissue healing. There is no such term as dependent nitrogen balance. In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? a.Polyunsaturated fats should be less than 7% of the total calories. b.Trans fat should be less than 7% of the total calories. c.Unsaturated fats are found mostly in animal sources. d.Saturated fats are found mostly in animal sources. D. saturated fats are found mostly in animal sources Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Diet recommendations include limiting saturated fat to less than 7% and trans fat to less than 1%. A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? a.Position in semi-Fowler’s. b.Flex head with chin tuck. c.Place food on left side. d.Offer fruit juice. B. flex head with chin tuck Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the patient has unilateral weakness, teach him or her and the caregiver to place food in the stronger side of the mouth. Provide a 30-minute rest period before eating and position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. Thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated. The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, “How much fat should I have? I guess the less fat, the better.” Which information will the nurse include in the teaching session? a.Cholesterol intake needs to be less than 300 mg/day. b.Fats have no significance in health and the incidence of disease. c.All fats come from external sources so this can be easily controlled. d.Deficiencies occur when fat intake falls below 10% of daily nutrition. D. Deficiencies occur when fat intake falls below 10% of daily nutrition. Deficiency occurs when fat intake falls below 10% of daily nutrition. While keeping cholesterol below 300 mg is correct according to the American Heart Association, it does not answer the patient’s question about fat. Various types of fatty acids have significance for health and for the incidence of disease and are referred to in dietary guidelines. Linoleic acid and arachidonic acid are important for metabolic processes but are manufactured by the body when linoleic acid is available from the diet. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel? a.Measuring capillary blood glucose level b.Measuring nasoenteric tube for insertion c.Measuring pH in gastrointestinal aspirate d.Measuring the patient’s risk for aspiration A. measuring capillary blood glucose levelThe skill of measuring blood glucose level after skin puncture (capillary puncture) can be delegated to nursing assistive personnel. The other skills cannot be delegated. A nurse must measure a nasoenteric tube for insertion, pH in gastrointestinal aspirate, and patient’s risk for aspiration. When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan? a.Increasing carbohydrates to 55% to 60% of total intake b.Providing vitamin and mineral supplements c.Decreasing protein intake to 0.75 g/kg/day d.Limiting water before and after exercise A..Increasing carbohydrates to 55% to 60% of total intake Sports and regular moderate to intense exercise necessitate dietary modification to meet increased energy needs for adolescents. Carbohydrates, both simple and complex, are the main source of energy, providing 55% to 60% of total daily kilocalories. Protein needs increase to 1 to 1.5 g/kg/day. Fat needs do not increase. Adequate hydration is very important. Adolescents need to ingest water before and after exercise to prevent dehydration, especially in hot, humid environments. Vitamin and mineral supplements are not required, but intake of iron-rich foods is required to prevent anemia. he patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide? a.Drink more water to prevent further dehydration. b.Drink more calorie-dense fluids to increase caloric intake. c.Drink more milk and dairy products to decrease the risk of osteoporosis. d.Drink more grapefruit juice to enhance vitamin C intake and medication absorption. a.Drink more water to prevent further dehydration. Thirst sensation diminishes, leading to inadequate fluid intake or dehydration; the patient should be encouraged to drink more water/fluids. Symptoms of dehydration in older adults include confusion,
weakness, hot dry skin, furrowed tongue, and high urinary sodium. Milk continues to be an important food for older woman and men, who need adequate calcium to protect against osteoporosis; the patient’s problem is dehydration, not osteoporosis. Caution older adults to avoid grapefruit and grapefruit juice because these will decrease absorption of many drugs. The patient needs fluids not calories; drinking calorie-dense fluids is unnecessary. The nurse is assessing a patient for nutritional status. Which action will the nurse take? a.Forego the assessment in the presence of chronic disease. b.Use the Mini Nutritional Assessment for pediatric patients. c.Choose a single objective tool that fits the patient’s condition. d.Combine multiple objective measures with subjective measures. D.Combine multiple objective measures with subjective measures. Combine multiple objective measures with subjective measures related to nutrition to adequately screen for nutritional problems. Using a single objective measure is ineffective in predicting risk of nutritional problems. Chronic disease and increased metabolic requirements are risk factors for the development of nutritional problems; these patients may be in critical need of this assessment. The Mini Nutritional Assessment is used for screening older adults in home care programs, nursing homes, and hospitals. The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? a.Normal weight b.Underweight c.Overweight d.Obese d.Obese BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI from 18.5 to 24.9 is normal. BMI under 18.5 is underweight. A nurse is caring for patients with dysphagia. Which patient has neurogenic dysphagia? a.A patient with benign peptic stricture b.A patient with muscular dystrophy c.A patient with myasthenia gravis d.A patient with stroke d.A patient with stroke Stroke is the only cause of dysphagia in this list that is considered neurogenic. Myasthenia gravis and muscular dystrophy are considered myogenic in origin, whereas benign peptic stricture is considered obstructive. The patient has H. pylori. Which action should the nurse take? a.Encourage avoidance of wheat and oats. b.Encourage milkshakes as a nutritious snack. c.Encourage completion of antibiotic therapy. d.Encourage nonsteroidal antiinflammatory drugs C.Encourage completion of antibiotic therapy. H. pylori, a bacterium that causes up to 85% of peptic ulcers, is confirmed by laboratory tests or a biopsy during endoscopy. Antibiotics treat and control the bacterial infection. Avoidance of wheat and oats are required for patients with celiac disease who must follow a gluten-free diet. Encourage patients to avoid foods that increase stomach acidity and pain such as caffeine, decaffeinated coffee, frequent milk intake, citric acid juices, and certain seasonings (hot chili peppers, chili powder, black pepper). Discourage smoking, alcohol, aspirin, and nonsteroidal antiinflammatory drugs (NSAIDs). In determining malnourishment in a patient, which assessment finding is consistent with this disorder? a.Moist lips b.Pink conjunctivae c.Spoon-shaped nails d.Not easily plucked hair C. spoon-shaped nailsSpoon-shaped nails, koilonychia, is an indication of poor nutrition. All the others are normal findings. Lips should be moist, conjunctivae should be pink, and hair should not be easily plucked. A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1.
Elevate head of bed to at least 30 degrees. 1. elevate head of bed to at least 30 degrees 4. verify tube placement 2. check for gastric residual volume 3. flush tubing with 30 mL of water 5. initiate feeding The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding? a.Nasogastric tube b.Jejunostomy tube c.Nasointestinal tube d.Percutaneous endoscopic gastrostomy (PEG) tube B. Jejunostomy tube Patients with gastroparesis or esophageal reflux or with a history of aspiration pneumonia may require placement of tubes beyond the stomach into the intestine. The jejunostomy tube is the only tube in the list that is beyond the stomach and is not contraindicated by facial trauma. The nasogastric tube and the PEG tube are placed in the stomach, and placement could lead to aspiration. The nasointestinal tube and the nasogastric tube may be contraindicated by facial trauma and the broken nose. The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? a.From the tip of the nose to the earlobe b.From the tip of the earlobe to the xiphoid process c.From the tip of the earlobe to the nose to the xiphoid process d.From the tip of the nose to the earlobe to the xiphoid process D.From the tip of the nose to the earlobe to the xiphoid process Measure distance from the tip of the nose to the earlobe to the xiphoid process of the sternum. This approximates the distance from the nose to the stomach in 98% of patients. For duodenal or jejunal placement, an additional 20 to 30 cm is required. Before giving the patient an intermittent gastric tube feeding, what should the nurse do? a.Make sure that the tube is secured to the gown with a safety pin. b.Inject air into the stomach via the tube and auscultate. c.Have the tube feeding at room temperature. d.Check to make sure pH is at least 5. C. Have the tube feeding at room temperature. Be sure that the formula is at room temperature. Cold formula causes gastric cramping and discomfort because the mouth and the esophagus do not warm the liquid. Do not use safety pins. Safety pins can become unfastened and may cause harm to the patient. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach. Gastric fluid of patient who has fasted for at least 4 hours usually has a pH of 1 to 4, especially when the patient is not receiving gastric-acid inhibitor. A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement? a.X-ray b.pH testing c.Auscultation d.Aspiration of contents A. X-ray At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. Aspiration of contents and pH testing are not infallible. The nurse would need a more precise indicator to help differentiate the source of tube feeding aspirate. Auscultation is no longer considered a reliable method for verification of tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus transmits sound similar to that of air entering the stomach. The nurse is concerned about pulmonary aspiration when providing the patient with an intermittent tube feeding. Which action is the priority? a.Observe the color of gastric contents. b.Verify tube placement before feeding. c.Add blue food coloring to the enteral formula. d.Run the formula over 12 hours to decrease overload. B. Verify tube placement before feeding. A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs to verify tube placement and elevate the head of the bed 30 to 45 degrees during feedings and for 2 hours afterward. While observing the color of gastric contents is a component, it is not the priority component; pH is the primary component. The addition of blue food coloring to enteral formula to assist with detection of aspirate is no longer used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium for bacterial growth after that length of time. The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? a.Instill nonliquid medications without diluting. b.Irrigate the tube with 60 mL of water after all medications are given. c.Mix all medications together to decrease the number of administrations. d.Check with the pharmacy for availability of the liquid forms of medications. D. Check with the pharmacy for availability of the liquid forms of medications. Use liquid medications when available to prevent tube occlusion. Irrigate with 30 mL of water before and after each medication per tube. Completely dissolve crushed medications in liquid if liquid medication is not available. Read pharmacological information on compatibility of drugs and formula before mixing medications. The patient has just started on enteral feedings, and the patient is reporting abdominal cramping. Which action will the nurse take next? a.Slow the rate of tube feeding. b.Instill cold formula to “numb” the stomach. c.Change the tube feeding to a high-fat formula. d.Consult with the health care provider about prokinetic medication. A.Slow the rate of tube feeding. One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the rate of delivery may increase tolerance. Another possible cause of abdominal cramping is the use of cold formula. The nurse should warm the formula to room temperature. High-fat formulas are also a cause of abdominal cramping. Consult with the health care provider regarding prokinetic medication for increasing gastric motility for delayed gastric emptying. The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea? a.Antibiotic therapy b.Clostridium difficile c.Formula intolerance d.Bacterial contamination C.Formula intolerance Hyperosmolar formulas can cause diarrhea or formula intolerance. If that is the case, the solution is to lower the rate, dilute the formula, or change to an isotonic formula. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allowing for Clostridium difficile toxin buildup. However, this takes time (more than 2 hours), and no indication suggests that this patient is on antibiotics. Bacterial contamination of the feeding usually occurs when feedings are left hanging for longer than 8 hours A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested? a.Improperly home-canned food b.Undercooked ground beef c.Soft cheese d.Custard B.Undercooked ground beef Undercooked ground beef is the usual food source for Escherichia coli. Botulism is associated with improperly home-canned foods. Soft cheese is the usual food source for listeriosis. Custards are associated with salmonellosis and Staphylococcus. The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? a.Run lipids for no longer than 24 hours. b.Take down a running bag of TPN after 36 hours. c.Clean injection port with alcohol 5 seconds before and after use. d.Wear a sterile mask when changing the central venous catheter dressing. D. Wear a sterile mask when changing the central venous catheter dressing. During central venous catheter dressing changes, always use a sterile mask and gloves, and assess insertion sites for signs and symptoms of infection. To avoid infection, change the TPN infusion tubing every 24 hours, and do not hang a single container of PN for longer than 24 hours or lipids longer than 12 hours. The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do? a.Increase the rate to get the volume caught up before discontinuing. b.Stop the infusion as ordered. c.Taper infusion gradually. d.Hang 5% dextrose. C. Taper infusion gradually. Sudden discontinuation of PN can cause hypoglycemia. PN must be tapered off. Usually, 10% dextrose is infused when PN solution is suddenly discontinued. Too rapid administration of hypertonic dextrose (PN) can result in an osmotic diuresis and dehydration. If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up. The patient is on parenteral nutrition and is lethargic. The patient reports thirst and headache and has had increased urination. Which problem does the nurse prepare to address? a.Hyperglycemia b.Hypoglycemia c.Hypercapnia d.Hypocapnia A. Hyperglycemia Signs and symptoms of hyperglycemia are thirst, headache, lethargy, and increased urination. Hypocapnia is not associated with parenteral nutrition. Hypercapnia increases oxygen consumption and increases CO2 levels. Ventilator-dependent patients are at greatest risk for this. Hypoglycemia is characterized by diaphoresis, shakiness, confusion, and loss of consciousness. In providing diabetic teaching for a patient with type 1 diabetes mellitus, which instructions will the nurse provide to the patient? a.Insulin is the only consideration that must be taken into account. b.Saturated fat should be limited to less than 7% of total calories. c.Nonnutritive sweeteners can be used without restriction. d.Cholesterol intake should be greater than 200 mg/day. b.Saturated fat should be limited to less than 7% of total calories. The diabetic patient should limit saturated fat to less than 7% of total calories and cholesterol intake to less than 200 mg/day. Type 1 diabetes requires both insulin and dietary restrictions for optimal control. Nonnutritive sweeteners can be eaten as long as the recommended daily intake levels are followed. The patient with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful? a.Maintain a prescribed carbohydrate intake. b.Eat fish at least 5 times per week. c.Limit trans fat to less than 1%. d.Avoid high-fiber foods. C. Limit trans fat to less than 1%. American Heart Association guidelines recommend limiting saturated fat to less than 7%, trans fat to less than 1%, and cholesterol to less than 300 mg/day. Diet therapy includes eating fish at least 2 times per week and eating whole grain high-fiber foods. Maintaining a prescribed carbohydrate intake is necessary for diabetes mellitus. The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan? a.Provide small, frequent nutrient-dense meals for maximizing kilocalories. b.Prepare hot meals because they are more easily tolerated by the patient. c.Avoid salty foods and limit liquids to preserve electrolytes. d.Encourage intake of fatty foods to increase caloric intake. A. Provide small, frequent nutrient-dense meals for maximizing kilocalories. Small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods are easier to tolerate. Restorative care of malnutrition resulting from AIDS focuses on maximizing kilocalories and nutrients. Patients benefit from eating cold foods and drier or saltier foods with fluid in between. A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene? a.Custard b.Frozen yogurt c.Pureed vegetables d.Mashed potatoes and gravy D. Mashed potatoes and gravy Mashed potatoes and gravy are on a dysphagia, mechanical soft, soft and regular diet but are not components of a full liquid diet. The nurse will need to provide teaching on what is allowed on the diet. Custard, frozen yogurt, and pureed vegetables are all on a full liquid diet. A nurse is caring for a group of patients. Which patient will the nurse see first? a.Patient receiving total parenteral nutrition of 2-in-1 for 50 hours b.Patient receiving total parenteral nutrition infusing with same tubing for 26 hours c.Patient receiving continuous enteral feeding with same feeding bag for 12 hours d.Patient receiving continuous enteral feeding with same tubing for 24 hours B. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours The nurse should see the patient with total parenteral nutrition that has the same tubing for 26 hours. To prevent infection, change the TPN infusion tubing every 24 hours. Change the administration system every 72 hours when infusing a 2-in-1 solution and every 24 hours for a 3-in-1 solution. Change bag and use a new administration set every 24 hours for a continuous enteral feeding. While the patient with the continuous enteral feeding has the same tubing for 24 hours, it has not extended the time like the total parenteral nutrition has. The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain? a.10-mL Luer-Lok syringe b.Asepto syringe c.Sterile gloves d.Double gloves B. Asepto syringe Cone-tipped or Asepto syringe is needed for testing of gastric aspirate for pH; these syringes are better than a Luer-Lok syringe. Clean gloves are needed, not sterile or double. A nurse is teaching a health class about the nutritional requirements throughout the life span. Which information should the nurse include in the teaching session? (Select all that apply.) a.Infants triple weight at 1 year. b.Toddlers become picky eaters. c.School-age children need to avoid hot dogs and grapes. d.Breastfeeding women need an additional 750 kcal/day. e.Older adults have altered food flavor from a decrease in taste cells. a.Infants triple weight at 1 year. b. Toddlers become picky eaters. e. Older adults have altered food flavor from a decrease in taste cells. An infant usually doubles birth weight at 4 to 5 months and triples it at 1 year. Toddlers exhibit strong food preferences and become picky eaters. Older adults often experience a decrease in taste cells that alters food flavor and may decrease intake. Toddlers need to avoid hot dogs and grapes, not school-age children. The lactating woman needs 500 kcal/day above the usual allowance because the production of milk increases energy requirements. The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient which teaching points? (Select all that apply.) a.Increase physical activity. b.Keep total fat intake to 10% or less. c.Maintain body weight in a healthy range. d.Choose and prepare foods with little salt. e.Increase intake of meat and other high-protein foods. A. Increase physical activity. C.Maintain body weight in a healthy range. D.Choose and prepare foods with little salt. Recommendations include maintaining body weight in a healthy range; increasing physical activity and decreasing sedentary activities; increasing intake of fruits, vegetables, whole grain products, and fat-free or low-fat milk; eating moderate amount of lean meats, poultry, and eggs; keeping fat intake between 20% and 35% of total calories, with most fats coming from polyunsaturated or monounsaturated fatty acids (most meats contain saturated fatty acids); and choosing prepared foods with little salt while at the same time eating potassium-rich foods. When assessing patient with nutritional needs, which patients will require follow-up from the nurse? (Select all that apply.) a.A patient with infection taking tetracycline with milk b.A patient with irritable bowel syndrome increasing fiber c.A patient with diverticulitis following a high-fiber diet daily d.A patient with an enteral feeding and 500 mL of gastric residual e.A patient with dysphagia being referred to a speech-language pathologist A.A patient with infection taking tetracycline with milk C.A patient with diverticulitis following a high-fiber diet daily D. A patient with an enteral feeding and 500 mL of gastric residual The nurse should follow up with the tetracycline, diverticulitis, and enteral feeding. Tetracycline has decreased drug absorption with milk and antacids and has decreased nutrient absorption of calcium from binding. Nutritional treatment for diverticulitis includes a moderate- or low-residue diet until the infection subsides. Afterward, prescribing a high-fiber diet for chronic diverticula problems ensues. A patient with a gastric residual volume of 500 mL needs to have the feeding withheld and reassessed for tolerance to feedings. All the rest are normal and expected and do not require follow-up. Patients manage irritable bowel syndrome by increasing fiber, reducing fat, avoiding large meals, and avoiding lactose or sorbitol-containing foods for susceptible individuals. Initiate consultation with a speech-language pathologist for swallowing exercises and techniques to improve swallowing and reduce risk of aspiration for a patient with dysphagia. To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select all that apply.) a.Allows fasting on Yom Kippur for a Jewish patient b.Allows caffeine drinks for a Mormon patient c.Serves no ham products to a Muslim patient d.Serves kosher foods to a Christian patient e.Serves no meat or fish to a Hindu patient A.Allows fasting on Yom Kippur for a Jewish patient C.Serves no ham products to a Muslim patient E.Serves no meat or fish to a Hindu patient The Jewish religion fasts 24 hours on Yom Kippur and must adhere to kosher food preparation methods. Hinduism requires no meats or fish. Muslims do not eat pork. Mormons do not drink caffeinated or alcoholic drinks. A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine? a.Kidney, urethra, bladder, ureters b.Kidney, ureters, bladder, urethra c.Bladder, kidney, ureters, urethra d.Bladder, kidney, urethra, ureters B .Kidney, ureters, bladder, urethra A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up? a.Protein level of 2 mg/100 mL b.Urine output of 80 mL/hr c.Specific gravity of 1.036 d.pH of 6.4 C. Specific gravity of 1.036 Dehydration, reduced renal blood flow, and increase in antidiuretic hormone secretion elevate specific gravity. Normal specific gravity is 1.0053 to 1.030. An output of 30 mL/hr or less for 2 or more hours would be cause for concern; 80 mL/hr is normal. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease. A patient is experiencing oliguria. Which action should the nurse perform first? a.Assess for bladder distention. b.Request an order for diuretics. c.Increase the patient’s intravenous fluid rate. d.Encourage the patient to drink caffeinated beverages. A. Assess for bladder distention. Oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action. A patient requests the nurse’s help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient’s inability to void? a.The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. b.The patient does not recognize the physiological signals that indicate a need to void. c.The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d.The patient is not drinking enough fluids to produce adequate urine output. A. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. Anxiety can impact bladder emptying due to inadequate relaxation of the pelvic floor muscles and urinary sphincter. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological (does not recognize signals or not drinking enough fluids) or psychological (lonely) condition exists. The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action? a.The patient may void uncontrollably during the procedure. b.Local trauma sometimes promotes excessive urine incontinence. c.Anesthetics can decrease bladder contractility and cause urinary retention. d.The patient will not interrupt the procedure by asking to go to the bathroom. C. Anesthetics can decrease bladder contractility and cause urinary retention. Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness, causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow, requiring temporary use of an indwelling urinary catheter. The patient is more likely to retain urine rather than experience uncontrollable voiding. The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria? a.Blood in the urine b.Burning upon urination c.Immediate, strong desire to void d.Awakes from sleep due to urge to void B. Burning upon urination Dysuria is burning or pain with urination. Hematuria is blood in the urine. Urgency is an immediate and strong desire to void that is not easily deferred. Nocturia is awakening form sleep due to urge to void. An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient’s plan of care? a.Functional urinary incontinence b.Urge urinary incontinence c.Impaired skin integrity d.Urinary retention B. Urge urinary incontinence Urge urinary incontinence is the leakage of urine associated with a strong urge to void. Patients leak urine on the way to or at the toilet and rush or hurry to the toilet. Urinary retention is the inability to empty the bladder. Functional urinary incontinence is incontinence due to causes outside the urinary tract, such as mobility or cognitive impairments. While Impaired skin integrity can occur, it is not the priority at this time, and there is no data to support this diagnosis. A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a.Limit fluid and caffeine intake before bed. b.Leave the bathroom light on to illuminate a pathway. c.Practice Kegel exercises to strengthen bladder muscles. d.Clear the path to the bathroom of all obstacles before bedtime. A. Limit fluid and caffeine intake before bed Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. To prevent nocturia, suggest that the patient avoid drinking fluids 2 hours before bedtime. Clearing a path to the bathroom, illuminating the path, or shortening the distance to the bathroom may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing stress incontinence. A nurse is caring for a male patient with urinary retention. Which action should the nurse take first? a.Limit fluid intake. b.Insert a urinary catheter. c.Assist to a standing position. d.Ask for a diuretic medication. C. Assist to a standing position In some patients just helping them to a normal position to void prompts voiding. A urinary catheter would relieve urinary retention, but it is not the first measure; other nursing interventions should be tried before catheterization. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention and is usually not recommended unless the retention is severe. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most appropriate? a.“Does your urinary problem interfere with any activities?” b.“Do you lose urine when you cough or sneeze?” c.“When was the last time you voided?” d.“Are you experiencing a fever or chills? C.“When was the last time you voided?” To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended; time of last void is most appropriate. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, interference with any activities, and losing urine during coughing or sneezing focus on specific pathological conditions. A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel? a.Obtaining a midstream urine specimen b.Interpreting a bladder scan result c.Inserting a straight catheter d.Irrigating a catheter A.Obtaining a midstream urine specimen The skill of collecting midstream (clean-voided) urine specimens can be delegated to nursing assistive personnel. The nurse must first determine the timing and frequency of the bladder scan measurement and interprets the measurements obtained. Inserting a straight or an indwelling catheter cannot be delegated. Catheter irrigation or instillation cannot be delegated to nursing assistive personnel. While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, which finding will the nurse expect? a.An indwelling Foley catheter b.Reddened irritated skin on buttocks c.Tiny blood clots in the patient’s urine d.Foul-smelling discharge indicative of infection B. Reddened irritated skin on buttocks Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection. A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do? a.Throw the catheter way and begin again. b.Fill the balloon with the recommended sterile water. c.Remove the catheter, wipe with alcohol, and reinsert after lubrication. d.Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter. D. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter. If no urine appears, the catheter may be in the vagina. If misplaced, leave the catheter in the vagina as a landmark to indicate where not to insert, and insert another sterile catheter. The catheter should be left in place until the new, sterile catheter is inserted. The balloon should not be filled since the catheter is in the vagina. The catheter must be sterile; using alcohol will not make the catheter sterile. A patient asks about treatment for stress urinary incontinence. Which is the nurse’s best response? a.Perform pelvic floor exercises. b.Avoid voiding frequently. c.Drink cranberry juice. d.Wear an adult diaper. A. Perform pelvic floor exercises. Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient’s problem. Evidence has shown that patients with urgency, stress, and mixed urinary incontinence can eventually achieve continence when treated with pelvic floor muscle training. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail. The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report? a.Dysuria b.Flank pain c.Frequency d.Fever C. frequency Cystitis is inflammation of the bladder; associated symptoms include hematuria, foul-smelling cloudy urine, and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection (bladder). Flank pain, fever, and chills are all signs of pyelonephritis (upper urinary tract). Which assessment question should the nurse ask if stress incontinence is suspected? a.“Do you think your bladder feels distended?” b.“Do you empty your bladder completely when you void?” c.“Do you experience urine leakage when you cough or sneeze?” d.“Do your symptoms increase with consumption of alcohol or caffeine?” C. “Do you experience urine leakage when you cough or sneeze?” Stress incontinence can be related to intraabdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of the bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence. The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one? 1. Clean injection port. 6. Draw up prescribed amount of sterile solution ordered. 5. Clamp catheter just below specimen port. 1. Clean injection port 3. Twist needleless syringe into port 2. Inject prescribed solution. 4. Remove clamp and allow to drain To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do? a.Cleanse the urethral meatus from the area of most contamination to least. b.Initiate the first part of the urine stream directly into the collection cup. c.Drink fluids 5 minutes before collecting the urine specimen. d.Hold the labia apart while voiding into the specimen cup. D. Hold the labia apart while voiding into the specimen cup. The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front to back). The initial stream flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 minutes before giving a specimen. A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection? a.Casts b.Protein c.Crystals d.Bacteria D. Bacteria Bacteria in the urine along with other symptoms support a diagnosis of urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal disease. Protein indicates kidney function and damage to the glomerular membrane such as in glomerulonephritis. The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect? a.Red color b.Orange color c.Dark amber color d.Intense yellow color B. orange color Some drugs change the color of urine (e.g., phenazopyridine—orange, riboflavin—intense yellow). Eating beets, rhubarb, and blackberries causes red urine. Dark amber urine is the result of high concentrations of bilirubin in patients with liver disease. Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine? a.Reduced urine specific gravity b.Increased blood pressure c.Abnormal blood sugar d.Fever with chills D. fever with chills Fever and chills may be observed. The presence of white blood cells in urine indicates a urinary tract infection or inflammation. Overhydration, early renal disease, and inadequate antidiuretic hormone secretion reduce specific gravity. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine or a patient with diabetes. A patient has severe flank pain. The urinalysis reveals presence of calcium phosphate crystals. The nurse will anticipate an order for which diagnostic test? a.Intravenous pyelogram b.Mid-stream urinalysis c.Bladder scan d.Cystoscopy A. Intravenous pyelogram Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A mid-stream urinalysis is performed for a routine urinalysis or if an infection is suspected; a urinalysis was already performed, a mid-stream would not be obtained again. A cystoscopy is used to detect bladder tumors and obstruction of the bladder outlet and urethra. A bladder scan measures the amount of urine in the bladder. A nurse is caring for a patient who just underwent an intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’s first priority in caring for this patient? a.Turn the patient on the right side to alleviate pressure on the left kidney. b.Encourage the patient to increase fluid intake to flush the obstruction. c.Monitor the patient for fever, rash, and difficulty breathing. d.Administer narcotic medications to the patient for pain. C. Monitor the patient for fever, rash, and difficulty breathing. Assess for delayed hypersensitivity to the contrast media. Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety. Which statement by the patient about an upcoming contrast computed tomography (CT) scan indicates a need for further teaching? a.“I will follow the food and drink restrictions as directed before the test is scheduled.” b.“I will be anesthetized so that I lie perfectly still during the procedure.” c.“I will complete my bowel prep program the night before the scan.” d.“I will be drinking a lot of fluid after the test is over.” B. “I will be anesthetized so that I lie perfectly still during the procedure.” Patients are not put under anesthesia for a CT scan; instead, the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct and require no further teaching. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT scan. Bowel cleansing is often performed before CT scan. Another area to address is food and fluid restriction up to 4 hours prior to the test. After the procedure, encourage fluids to promote dye excretion. The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take? a.Measure bladder before the patient voids. b.Measure bladder within 10 minutes after the patient voids. c.Measure bladder with head of bed raised to 60 degrees. d.Measure bladder with head of bed raised to 90 degrees. B.Measure bladder within 10 minutes after the patient voids. Measurement should be within 10 minutes of voiding. It is a postvoid so the measurement is after the patient voids and the urine volume is recorded. Patient is supine with head slightly elevated. A nurse is watching a nursing assistive personnel (NAP) perform a postvoid bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up? a.Palpates the patient’s symphysis pubis b.Wipes scanner head with alcohol pad c.Applies a generous amount of gel d.Sets the scanner to female D. sets the scanner to female The nurse will follow up if the NAP sets the scanner to female. Women who have had a hysterectomy should be designated as male. All the rest are correct and require no follow-up. The NAP should palpate the symphysis pubis, the scanner head should be cleaned with an alcohol pad, and a generous amount of gel should be applied. A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first? a.Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient’s progress. b.Utilizing the power of suggestion by turning on the faucet and letting the water run. c.Obtaining an order for a Foley catheter. d.Administering diuretic medication. B. Utilizing the power of suggestion by turning on the faucet and letting the water run. To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a.“Set your alarm clock to wake you every 2 hours, so you can get up to void.” b.“Line your bedding with plastic sheets to protect your mattress.” c.“Drink your nightly glass of milk earlier in the evening.” d.“Empty your bladder completely before going to bed.” C. “Drink your nightly glass of milk earlier in the evening.” Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination but will not affect urine produced throughout the night from late-night fluid intake. A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take? a.Hold the shaft of the penis at a 60-degree angle. b.Hold the shaft of the penis with the dominant hand. c.Cleanse the meatus 3 times with the same cotton ball from clean to dirty. d.Cleanse the meatus with circular strokes beginning at the meatus and working outward. D. Cleanse the meatus with circular strokes beginning at the meatus and working outward. Using the uncontaminated dominant hand, cleanse the meatus with cotton balls/swab sticks, using circular strokes, beginning at the meatus and working outward in a spiral motion. Repeat 3 times using a clean cotton ball/swabstick each time. With the nondominant hand (now contaminated), retract the foreskin (if uncircumcised) and gently grasp the penis at the shaft just below the glans. Hold the shaft of the penis at a right angle to the body. The nurse will anticipate inserting a Coudé catheter for which patient? a.An 8-year-old male undergoing anesthesia for a tonsillectomy b.A 24-year-old female who is going into labor cA 56-year-old male admitted for bladder irrigation d.An 86-year-old female admitted for a urinary tract infection C. A 56-year-old male admitted for bladder irrigation A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women. A nurse is evaluating a nursing assistive personnel’s (NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene? a.Emptying the drainage bag when half full b.Kinking the catheter tubing to obtain a urine specimen c.Placing the drainage bag on the side rail of the patient’s bed d.Securing the catheter tubing to the patient’s thigh C. Placing the drainage bag on the side rail of the patient’s bed Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the rest are correct procedures and do not require follow-up. The drainage bag should be emptied when half full; an overfull drainage bag can create tension and pulling on the catheter, resulting in trauma to the urethra and/or urinary meatus and increasing risk for urinary tract infections. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient’s thigh places the patient at risk for tissue injury from catheter dislodgment. A nurse is caring for a patient with a continent urinary reservoir. Which action will the nurse take? a.Teach the patient how to self-cath the pouch. b.Teach the patient how to perform Kegel exercises. c.Teach the patient how to change the collection pouch. d.Teach the patient how to void using the Valsalva technique. A. Teach the patient how to self-cath the pouch. In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using a Valsalva technique. In a ureterostomy or ileal conduit the patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. Kegel exercises are ineffective for a patient with a continent urinary reservoir. The nurse is preparing to apply an external catheter. Which action will the nurse take? a.Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter. b.Spiral wrap the penile shaft using adhesive tape to secure the catheter. c.Twist the catheter before applying drainage tubing to the end of the catheter. d.Shave the pubic area before applying the catheter. A. Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter. When applying an external catheter, allow 2.5 to 5 cm (1 to 2 inches) of space between the tip of the penis and the end of the catheter. Spiral wrap the penile shaft with supplied elastic adhesive. The strip should not overlap. The elastic strip should be snug but not tight. NOTE: Never use adhesive tape. Connect drainage tubing to the end of the condom catheter. Be sure the condom is not twisted. Connect the catheter to a large-volume drainage bag or leg. Clip hair at the base of the penile shaft, as necessary. Do not shave the pubic area. A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection? a.Maintaining a closed urinary drainage system b.Inserting the catheter using strict clean technique c.Disconnecting and replacing the catheter drainage bag once per shift d.Fully inflating the catheter’s balloon according to the manufacturer’s recommendation A. Maintaining a closed urinary drainage system A key intervention to prevent infection is maintaining a closed urinary drainage system. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgment and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection. A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? a.Drapes the urinary drainage tubing with no dependent loops b.Washes the drainage tube toward the meatus with soap and water c.Places the urinary drainage bag gently on the floor below the patient d.Allows the spigot to touch the receptacle when emptying the drainage bag A. Drapes the urinary drainage tubing with no dependent loops Avoid dependent loops in urinary drainage tubing. Prevent the urinary drainage bag from touching or dragging on the floor. When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. Using a clean washcloth, soap, and water, with your dominant hand wipe in a circular motion along the length of the catheter for about 10 cm (4 inches), starting at the meatus and moving away. A nurse is providing care to a group of patients. Which patient will the nurse see first? a.A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence b.A patient with reflex incontinence with elevated blood pressure and pulse rate c.A patient with an indwelling catheter that has stool on the catheter tubing d.A patient who has just voided and needs a postvoid residual test B. A patient with reflex incontinence with elevated blood pressure and pulse rate The nurse should see the patient with reflex incontinence first. Patients with reflex incontinence are at risk for developing autonomic dysreflexia, a life-threatening condition that causes severe elevation of blood pressure and pulse rate and diaphoresis. This is a medical emergency requiring immediate intervention; notify the health care provider immediately. A patient with urge incontinence will dribble, and this is expected. While a patient with a catheter and stool on the tubing does need to be cleaned, it is not life threatening. The nurse has 10 minutes before checking on the patient who has a postvoid residual test. To reduce patient discomfort during a closed intermittent catheter irrigation, what should the nurse do? a.Use room temperature irrigation solution. b.Administer the solution as quickly as possible. c.Allow the solution to sit in the bladder for at least 1 hour. d.Raise the bag of the irrigation solution at least 12 inches above the bladder. A. Use room temperature irrigation solution. To reduce discomfort use room temperature solution. Using cold solutions and instilling solutions too quickly can cause discomfort. During an irrigation, the solution does not sit in the bladder; it is allowed to drain. A container is not raised about the bladder 12 inches when performing a closed intermittent catheter irrigation. Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective? a.Output that is smaller than the amount instilled b.Blood clots or sediment in the drainage bag c.Bright red urine turns pink in the tubing d.Bladder distention with tenderness C. Bright red urine turns pink in the tubing If urine is bright red or has clots, increase irrigation rate until drainage appears pink, indicating successful irrigation. Expect more output than fluid instilled because of urine production. If output is smaller than the amount instilled, suspect that the tube may be clogged. The presence of blood clots indicates the patient is still bleeding, while sediment could mean an infection or bleeding. The bladder should not be distended or tender; the irrigant may not be flowing freely if these occur, or the tube may be kinked or blocked. The nurse anticipates a suprapubic catheter for which patient? a.A patient with recent prostatectomy b.A patient with a urethral stricture c.A patient with an appendectomy d.A patient with menopause B. A patient with a urethral stricture A patient with a urethral stricture is most likely to have a suprapubic catheter. Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urological surgery). A patient with a recent prostatectomy indicates the enlarged prostate was removed and would not need a suprapubic catheter; however, continuous bladder irrigation may be needed. Appendectomies and menopause do not require a suprapubic catheter. Which nursing actions will the nurse implement when collecting a urine specimen from a patient? (Select all that apply.) a.Growing urine cultures for up to 12 hours b.Labeling all specimens with date, time, and initials c.Allowing the patient adequate time and privacy to void d.Wearing gown, gloves, and mask for all specimen handling e.Transporting specimens to the laboratory in a timely manner b.Labeling all specimens with date, time, and initials c.Allowing the patient adequate time and privacy to void e.Transporting specimens to the laboratory in a timely manner All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Urine cultures can take up to 48 to 72 hours to develop. Only gloves are necessary to handle a urine specimen. Gown and mask are not needed unless otherwise indicated. Never collect the specimen from the drainage bag of a catheter; obtain the sample from the special sampling port. The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions should the nurse take? (Select all that apply.) a.Keeping the urine collection container on ice when indicated b.Withholding all patient medications for the day c.Irrigating the sample as needed with sterile solution d.Testing the urine sample with a reagent strip by dipping it in the urine e.Asking the patient to void and discarding that urine to start the collection A. Keeping the urine collection container on ice when indicated E. Asking the patient to void and discarding that urine to start the collection When obtaining a 24-hour urine specimen, it is important to keep the urine in cool conditions, depending upon the test. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution. A 24-hour urine specimen is not tested with a reagent strip. Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply.) a.Increasing fluid intake b.Dribbling of urine c.Voiding in small amounts d.Voiding within 6 hours of catheter removal e.Burning with the first couple of times voiding b.Dribbling of urine c. Voiding in small amounts Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts can indicate inadequate bladder emptying requiring intervention. All the rest are normal and do not require follow-up. The patient should increase intake. The first few times a patient voids after catheter removal may be accompanied by some discomfort, but continued complaints of painful urination indicate possible infection. Patient should void 6 to 8 hours after catheter removal. A nurse administers an antimuscarinic to a patient. Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.) a.Decrease in dysuria b.Decrease in urgency c.Decrease in frequency d.Decrease in prostate size e.Decrease in bladder infection b.Decrease in urgency c. Decrease in frequency When newly started on an antimuscarinic, you should monitor the patient for effectiveness, watching for a decrease in symptoms such as urgency, frequency, and urgency urinary incontinence episodes. Patients with painful urination are sometimes prescribed urinary analgesics that act on the urethral and bladder mucosa (e.g., phenazopyridine). Antibiotics are used to treat bladder infections. Agents that shrink the prostate include finasteride and dutasteride. The nurse is using different toileting schedules. Which principles will the nurse keep in mind when planning care? (Select all that apply.) a.Habit training uses a bladder diary. b.Timed voiding is based upon the patient’s urge to void. c.Prompted voiding includes asking patients if they are wet or dry. d.Elevation of feet in patients with edema can decrease nighttime voiding. e.Bladder retraining teaches patients to follow the urge to void as quickly as possible. A. Habit training uses a bladder diary. C. Prompted voiding includes asking patients if they are wet or dry. Habit training is a toileting schedule based upon the patient’s usual voiding pattern. Using a bladder diary, the usual times a patient voids are identified. It is at these times that the patient is then toileted. Prompted voiding is a program of toileting designed for patients with mild or moderately cognitive impairment. Patients are toileted based upon their usual voiding pattern. Caregivers ask the patient if they are wet or dry, give positive feedback for dryness, prompt the patient to toilet, and reward the patient for desired behavior. Timed voiding or scheduled toileting is toileting based upon a fixed schedule, not the patient’s urge to void. The schedule maybe set by a time interval, every 2 to 3 hours or at times of day such as before and after meals. In bladder retraining, patients are taught to inhibit the urge to void by taking slow and deep breaths to relax, perform 5 to 6 quick strong pelvic muscle exercises (flicks) in quick succession followed by distracting attention from bladder sensations. When the urge to void becomes less severe or subsides, only then should the patient start the trip to the bathroom. Encourage patients with edema to elevate the feet for a minimum of a few hours in the afternoon to help diminish nighttime voiding frequency; while this is helpful, it is not a toileting schedule. The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? a.Ileum b.Cecum c.Stomach d.Duodenum D. Duodenum The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine. The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? a.Sigmoid b.Transverse c.Ascending d.Descending C. Ascending The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool (very liquid) would be in the ascending. A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion? a.Cecum, ascending, transverse, descending, sigmoid, and rectum b.Ascending, transverse, descending, sigmoid, rectum, and cecum c.Cecum, sigmoid, ascending, transverse, descending, and rectum d.Ascending, transverse, descending, rectum, sigmoid, and cecum A.Cecum, ascending, transverse, descending, sigmoid, and rectum The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (NAP)? a.Performing the first postoperative pouch change b.Maintaining a nasogastric tube c.Administering an enema d.Digitally removing stool C.Administering an enema The skill of administering an enema can be delegated to an NAP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an NAP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel. A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? a.Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b.Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c.Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations. d.Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced. A.Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed. A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? a.Preparing to administer a barium enema b.Withholding narcotic pain medication c.Administering laxatives to the patient d.Raising the head of the bed D. Raising the head of the bed Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation. Which patient is most at risk for increased peristalsis? a.A 5-year-old child who ignores the urge to defecate owing to embarrassment b.A 21-year-old female with three final examinations on the same day c.A 40-year-old female with major depressive disorder d.An 80-year-old male in an assisted-living environment B. A 21-year-old female with three final examinations on the same day Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from slowed peristalsis. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a.“This is probably a false negative; we should rerun the test.” b.“You should schedule a colonoscopy as soon as possible.” c.“Are you under a lot of stress?” d.“Do you take iron supplements?” D. “Do you take iron supplements?” Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse’s initial priority. Stress alters GI motility and stool consistency, not color. Which patient will the nurse assess most closely for an ileus? a.A patient with a fecal impaction b.A patient with chronic cathartic abuse c.A patient with surgery for bowel disease and anesthesia d.A patient with suppression of hydrochloric acid from medication C. A patient with surgery for bowel disease and anesthesia Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal impaction, cathartic abuse, and medication to suppress hydrochloric acid will have bowel sounds, but they may be hypoactive or hyperactive. A patient has a fecal impaction. Which portion of the colon will the nurse assess? a.Descending b.Transverse c.Ascending d.Rectum D. Rectum A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass. The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care? a.A 25-year-old patient with diarrhea b.A 30-year-old patient with Clostridium difficile c.A 40-year-old patient with an ileostomy d.A 70-year-old patient with stool incontinence D. A 70-year-old patient with stool incontinence The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs? a.Administer a soapsuds enema every 2 hours. b.Use a mobility device to place the patient on a bedside commode. c.Give the patient a pillow to brace against the abdomen while bearing down. d.Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan. B. Use a mobility device to place the patient on a bedside commode. The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed is appropriate but is not the most effective; closer to 30 to 45 degrees is the proper position for the patient on a bedpan, and the patient is not on bed rest so a bedside commode is the best choice. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soapsuds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation? a.The patient reports eliminating a soft, formed stool. b.The patient has quit taking opioid pain medication. c.The patient’s lower left quadrant is tender to the touch. d.The nurse hears bowel sounds in all four quadrants. A. The patient reports eliminating a soft, formed stool. The nurse’s goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately? a.Liquid consistency of stool b.Presence of blood in the stool c.Malodorous stool d.Continuous output from the stoma B. Presence of blood in the stool Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous. The nurse will anticipate which diagnostic examination for a patient with black tarry stools? a.Ultrasound b.Barium enema c.Endoscopy d.Anorectal manometry C. endoscopy Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action? a.Preparing the patient for a second tap water enema b.Obtaining an order for digital removal of stool c.Positioning the patient on the left side d.Inserting a rectal tube B. Obtaining an order for digital removal of stool When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence or flatus but would not be applicable or effective for this patient. A nurse is checking orders. Which order should the nurse question? a.A normal saline enema to be repeated every 4 hours until stool is produced b.A hypertonic solution enema for a patient with fluid volume excess c.A Kayexalate enema for a patient with severe hypokalemia d.An oil retention enema for a patient with constipation C.A Kayexalate enema for a patient with severe hypokalemia Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Oil retention enemas lubricate the feces in the rectum and colon and are used for constipation. The nurse is performing a fecal occult blood test. Which action should the nurse take? a.Test the quality control section before testing the stool specimens. b.Apply liberal amounts of stool to the guaiac paper. c.Report a positive finding to the provider. d.Don sterile disposable gloves. c.Report a positive finding to the provider. Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative. A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important? a.Ensuring that the patient does not eat or drink 2 hours before the examination. b.Administering a colon cleansing product 6 hours before the examination. c.Obtaining an order for a pain medication before the test is performed. d.Removing all of the patient’s metallic jewelry. D. Removing all of the patient’s metallic jewelry. No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed. A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform
the steps, starting with the first one? 1. Obtain baseline vital signs. 4.Identify patient using two identifiers. 1.Obtain baseline vital signs. 5.Place patient on left side in Sims’ position. 2.Apply clean gloves and lubricate. 3. Insert index finger into the rectum. 6. Massage around the feces and work down to remove. Before administering a cleansing enema to an 80-year-old patient, the patient says “I don’t think I will be able to hold the enema.” Which is the next priority nursing action? a.Rolling the patient into right-lying Sims’ position b.Positioning the patient in the dorsal recumbent position on a bedpan c.Inserting a rectal plug to contain the enema solution after administering d.Assisting the patient to the bedside commode and administering the enema B. Positioning the patient in the dorsal recumbent position on a bedpan If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims’ position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe. A nurse is providing care to a group of patients. Which patient will the nurse see first? a.A child about to receive a normal saline enema b.A teenager about to receive loperamide for diarrhea c.An older patient with glaucoma about to receive an enema d.A middle-aged patient with myocardial infarction about to receive docusate sodium C. An older patient with glaucoma about to receive an enema An enema is contradicted in a patient with glaucoma; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for diarrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent straining. A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression? a.Salem sump b.Small bore c.Levin d.8 Fr A. Salem sump The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent. When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions. While the Levin tube can be used for decompression, it is only a single-lumen tube with holes near the tip. Large-bore tubes, 12 Fr and above, are usually used for gastric decompression or removal of gastric secretions. Fine- or small-bore tubes are frequently used for medication administration and enteral feedings.
A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a.Changing the skin barrier portion of the ostomy pouch daily b.Emptying the pouch if it is more than one-third to one-half full c.Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive d.Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma B. .Emptying the pouch if it is more than one-third to one-half full Pouches must be emptied when they are one-third to one-half full because the weight of the pouch may disrupt the seal of the adhesive on the skin. The barrier device should be changed every 3 to 7 days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Avoid soap. It leaves a residue on skin, which may irritate the skin. The pouch opening should fit around the stoma and cover the peristomal skin to prevent contact with the effluent. Excess space, like 1/2 inch, allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown. The nurse will irrigate a patient’s nasogastric (NG) tube. Which action should the nurse take? a.Instill solution into pigtail slowly. b.Check placement after instillation of solution. c.Immediately aspirate after instilling fluid. d.Prepare 60 mL of tap water into Asepto syringe. C.Immediately aspirate after instilling fluid. After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue “pigtail” air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of irrigating solution into lungs. Draw up 30 mL of normal saline into Asepto syringe to minimize loss of electrolytes from stomach fluids. The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect? a.Reports decreased diarrhea. b.Experiences pain relief. c.Has a bowel movement. d.Passes flatulence. C.Has a bowel movement A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic. An antidiarrheal will provide relief from diarrhea. Pain medications will provide pain relief. Carminative enemas provide relief from gaseous distention (flatulence). An older adult’s perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do? a.Thoroughly scrub the skin with a washcloth and hypoallergenic soap. b.Tape an occlusive moisture barrier pad to the patient’s skin. c.Apply a skin protective ointment after perineal care. d.Massage the skin with light kneading pressure. c.Apply a skin protective ointment after perineal care Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown. Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient’s nose from a nasogastric tube? a.Instill Xylocaine into the nares once a shift. b.Tape tube securely with light pressure on nare. c.Lubricate the nares with water-soluble lubricant. d.Apply a small ice bag to the nose for 5 minutes every 4 hours. c.Lubricate the nares with water-soluble lubricant. The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a.“If I get a blue color that means the test is negative.” b.“I should not get any urine on the stool I am testing.” c.“If I eat red meat before my test, it could give me false results.” d.“I should check with my doctor to stop taking aspirin before the test.” A. “If I get a blue color that means the test is negative.” A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not contaminated with urine. The patient needs to avoid certain foods, like red meat, to rule out a false positive. While the health care provider should be consulted before asking a patient to stop any medication, if there are no contraindications, the patient should be instructed to stop taking aspirin, ibuprofen, naproxen or other nonsteroidal antiinflammatory drugs for 7 days because these could cause a false-positive test result. A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain? a.Ewald b.Dobhoff c.Miller-Abbott d.Sengstaken-Blakemore A. Ewald Lavage is irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation. The types of tubes include Levin, Ewald, and Salem sump. Sengstaken-Blakemore is used for compression by internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhage. Dobhoff is used for enteral feeding. Miller-Abbott is used for gastric decompression. The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria? a.Appropriate disposal of contaminated items in biohazard bags b.Monthly in-services about contact precautions c.Mandatory cultures on all patients d.Proper hand hygiene techniques D. Proper hand hygiene techniques Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding? a.Hypoactive bowel sounds b.Increased fluid intake c.Soft tender abdomen d.Jaundice in sclera A. Hypoactive bowel sounds Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. Increased fluid intake would help the problem; a decreased intake can lead to constipation. Jaundice does not occur with constipation but can occur with liver disease. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect? a.Distended abdomen b.Decreased skin turgor c.Increased energy levels d.Elevated blood pressure B. Decreased skin turgor Chronic diarrhea can result in dehydration. Patients with chronic diarrhea are dehydrated with decreased skin turgor and blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen could indicate constipation. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a.Stoma is protruding from the abdomen. b.Stoma is flush with the skin. c.Stoma is purple. d.Stoma is moist. C.Stoma is purple. A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude.
A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve? a.Prevent gaseous distention b.Prevent constipation c.Prevent colon infection d.Prevent lower bowel inflammation C. Prevent colon infection A medicated enema is a neomycin solution, i.e., an antibiotic used to reduce bacteria in the colon before bowel surgery. Carminative enemas provide relief from gaseous distention. Bulk forming, emollient (wetting), and osmotic laxatives and cathartics help prevent constipation or treat constipation. An enema containing steroid medication may be used for acute inflammation in the lower colon. A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient’s stool? a.Bright red blood b.Dark black blood c.Microscopic d.Mucoid C.Microscopic Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic). This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood, dark black blood, and blood that contains mucus (mucoid) is not the purpose of a guaiac test. A patient is receiving opioids for pain. Which bowel assessment is a priority? a.Clostridium difficile b.Constipation c.Hemorrhoids d.Diarrhea B. Constipation Patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. C. difficile occurs from antibiotics, not opioids. Hemorrhoids are caused by conditions other than opioids. Diarrhea does not occur as frequently as constipation. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy? a.Keep fiber low. b.Eat large meals. c.Increase fluid intake. d.Chew food thoroughly C. Increase fluid intake Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass of fluid when they empty their pouch. This helps patients to remember that they have greater fluid needs than they did before having an ileostomy. A low-fiber diet is not necessary. Eating large meals is not advised. While chewing food thoroughly is correct, it is not the priority; liquid is the priority. A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.) a.Record times when the patient is incontinent. b.Help the patient to the toilet at the designated time. c.Lean backward on the hips while sitting on the toilet. d.Maintain normal exercise within the patient’s physical ability. e.Apply pressure with hands over the abdomen, and strain while pushing. f.Choose a time based on the patient’s pattern to initiate defecation-control measures. A.Record times when the patient is incontinent. B.Help the patient to the toilet at the designated time. D.Maintain normal exercise within the patient’s physical ability F.Choose a time based on the patient’s pattern to initiate defecation-control measures. A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is incontinent. Choosing a time based on the patient’s pattern to initiate defecation-control measures. Maintaining normal exercise within the patient’s physical ability. Helping the patient to the toilet at the designated time. Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time. Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but do not strain to stimulate colon emptying. A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.) a.A risk factor is smoking. b.A risk factor is high intake of animal fats or red meat. c.A warning sign is rectal bleeding. d.A warning sign is a sense of incomplete evacuation. e.Screening with a colonoscopy is every 5 years, starting at age 50. f.Screening with flexible sigmoidoscopy is every 10 years, starting at age 50. A.A risk factor is smoking. B.A risk factor is high intake of animal fats or red meat. C.A warning sign is rectal bleeding. D.A warning sign is a sense of incomplete evacuation. Risk factors for colorectal cancer are a diet high in animal fats or red meat and low intake of fruits and vegetables; smoking and heavy alcohol consumption are also risk factors. Warning signs are change in bowel habits, rectal bleeding, a sensation of incomplete evacuation, and unexplained abdominal or back pain. A flexible sigmoidoscopy is every 5 years, starting at age 50, while a colonoscopy is every 10 years, starting at age 50. A registered nurse (RN) is the group leader of practical nurses and nursing assistive personnel. Which nursing care model is the RN using? a.Case management b.Total patient care c.Primary nursing d.Team nursing D. team nursing In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. A nurse is working in an intensive care unit (critical care). Which type of nursing care delivery model will this nurse most likely use? a.Team nursing b.Total patient care c.Primary nursing d.Case-management B. Total patient care Total patient care is found primarily in critical care areas. Total patient care involves an RN being responsible for all aspects of care for one or more patients. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs. A nurse is overseeing the care of patients with severe diabetes and patients with heart failure to improve cost-effectiveness and quality of care. Which nursing care delivery model is the nurse using? a.Team nursing b.Total patient care c.Primary nursing d.Case management D. Case management Case management is unique because clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with specific, complex health problems or are held accountable for some standard of cost management and quality. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. A nurse is working in a facility that has fewer directors with managers and staff able to make shared decisions. In which type of organizational structure is the nurse employed? a.Delegation b.Research-based c.Decentralization d.Philosophy of care C.Decentralization The decentralized management structure often has fewer directors, and managers and staff are able to make shared decisions. The American Nurses Association defines delegation as transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. Research-based means care is based upon evidence. A philosophy of care includes the professional nursing staff’s values and concerns for the way they view and care for patients. For example, a philosophy addresses the purpose of the nursing unit, how staff works with patients and families, and the standards of care for the work unit. A staff member verbalizes satisfaction in working on a particular nursing unit because of the freedom of choice and responsibility for the choices. This nurse highly values which element of shared decision making? a.Authority b.Autonomy c.Responsibility d.Accountability B. Autonomy Autonomy is freedom of choice and responsibility for the choices. Authority refers to legitimate power to give commands and make final decisions specific to a given position. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability refers to individuals being answerable for their actions. Which approach will be most appropriate for a nurse to take when faced with the challenge of performing many tasks in one shift? a.Do as much as possible by oneself before seeking assistance from others. b.Evaluate the effectiveness of all tasks when all tasks are completed. c.Complete one task before starting another task. d.Delegate tasks the nurse does not like doing. C. Complete one task before starting another task. The appropriate clinical care coordination skill in these options is to complete one task before starting another task. Good time management involves setting goals to help the nurse complete one task before starting another task. Evaluation is ongoing and should not be completed just at the end of task completion. The nurse should not delegate tasks simply because the nurse does not like doing them. The nurse should use delegation skills and time-management skills instead of trying to do as much as possible with no help. A nurse uses the five rights of delegation when providing care. Which “rights” did the nurse use? (Select all that apply.) a.Right task b.Right person c.Right direction d.Right supervision e.Right circumstances f.Right cost-effectiveness a.Right task b.Right person c.Right direction d.Right supervision e.Right circumstances A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and a nasogastric tube. Which question is the priority for the nurse to ask the family before beginning postmortem care? a.“Is an autopsy going to be done?” b.“Which funeral home do you want to use?” c.“Would you like to assist in bathing your loved one?” d.“Do you want me to remove the lines and tubes before you see your loved one?” A. “Is an autopsy going to be done?” An autopsy or postmortem examination may be requested by the patient or the patient’s family, as part of an institutional policy, or if required by law. Because the patient’s death occurred as a result of long-term illness and not under suspicious circumstances, whether to conduct a postmortem examination would be decided by the family, and consent would have to be obtained from the family. The nurse needs to know if the lines can be removed or not depending upon the family’s response to the question. Asking about bathing the deceased patient is a valid question but is not a priority, because the nurse needs to know the protocol to follow if an autopsy is to be done. Finding out which funeral home the deceased patient is to be transported to is valid but is not a priority, because other actions must be taken before the deceased patient is transported from the hospital. Asking about removing the lines may not be an option depending on the response of the family to an autopsy. A nurse is teaching the staff about professional negligence or malpractice. Which criteria to establish negligence will the nurse include in the teaching session? (Select all that apply.) a.Injury did not occur. b.That duty was breached. c.Nurse carried out the duty. d.Duty of care was owed to the patient. e.Patient understands benefits and risks of a procedure B. That duty was breached. D. Duty of care was owed to the patient. Certain criteria are necessary to establish nursing malpractice: (1) the nurse (defendant) owed a duty of care to the patient (plaintiff), (2) the nurse did not carry out or breached that duty, (3) the patient was injured, and (4) the nurse’s failure to carry out the duty caused the injury. If an injury did not occur and the nurse carried out the duty, no malpractice occurred. When a patient understands benefits and risks of the procedure, that is informed consent, not malpractice. A terminally ill patient is experiencing constipation secondary to pain medication. Which is the best method for the nurse to improve the patient’s constipation problem? a.Contact the health care provider to discontinue pain medication. b.Administer enemas twice daily for 7 days. c.Massage the patient’s abdomen. d.Use a laxative. D. Use a laxative. Opioid medication is known to slow peristalsis, which places the patient at high risk for constipation. Laxatives are indicated for opioid-induced constipation. Massaging the patient’s abdomen may cause further discomfort. Discontinuing pain medication is inappropriate for a terminally ill patient. Enema administration twice a day is not the best step in the treatment of opioid-induced constipation. A severely depressed patient cannot state any positive attributes to life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. Which spiritual concept is the nurse trying to promote? a.Time management b.Reminiscence c.Hope d.Faith C. Hope Hope gives a person the ability to see life as enduring or having meaning or purpose. The nurse’s actions do not address time management, reminiscence, or faith. Time management is organizing and prioritizing activities to be completed in a timely manner. Reminiscence is the relationship by mentally or verbally anecdotally relieving and remembering the person and past experiences. Faith is belief in a higher power. In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. Which information will be included in the plan? a.Prepare the body for autopsy. b.Prepare the body for cremation. c.Allow male Muslims to care for the body after death has occurred. d.Allow female Muslims to care for the body after death has occurred. D. Allow female Muslims to care for the body after death has occurred. Muslims of the same gender prepare the body for burial. Muslim faith discourages cremation and autopsy to preserve the sanctity of the soul of the deceased and promote burial as soon as possible after death. Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member’s unexpected death, the surviving family members begin to cry and scream in despair. Which phase does the nurse determine the family is in according to the Attachment Theory? a.Numbing b.Reorganization c.Yearning and searching d.Disorganization and despair
C. Yearning and searching Yearning and searching characterize the second bereavement phase in the Attachment Theory. Emotional outbursts of tearful sobbing and acute distress are common in this phase. During the numbing phase, the family is protected from the full impact of the loss. During disorganization and despair, the reason why the loss occurred is constantly examined. Reorganization is the last stage of the Attachment Theory in which the person accepts the change and builds new relationships. A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient? a.Perceived loss b.Situational loss c.Maturational loss d.Uncomplicated loss B. Situational loss Loss of a body part from injury is a situational loss. Maturational losses occur as part of normal life transitions across the life span. A perceived loss is uniquely defined by the person experiencing the loss and is less obvious to other people. Uncomplicated loss is not a type of loss; it is a description of normal grief. “I know it seems strange, but I feel guilty being pregnant after the death of my son last year,” said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate? a.Providing curative therapy b.Promoting spirituality c.Facilitating mourning d.Eradicating grief C. Facilitating mourning The nurse facilitates mourning in family members who are still surviving. By acknowledging the pregnant woman’s emotions, the nurse helps the mother bond with her fetus and recognizes the emotions that still exist for the deceased child. The nurse is not attempting to help the patient eradicate grief, which would be unrealistic. Curative therapy (curing a disease) and spiritual promotion (belief in a higher power or in the meaning of life) are not addressed by the nurse’s statement. A female nurse is called into the supervisor’s office regarding her deteriorating work performance since the loss of her spouse 2 years ago. The woman begins sobbing and says that she is “falling apart” at home as well. Which type of grief is the female nurse experiencing? a.Normal grief b.Perceived grief c.Complicated grief d.Disenfranchised grief C. Complicated grief In complicated grief, a person has a prolonged or significantly difficult time moving forward after a loss. Normal grief is the most common reaction to death; it involves a complex range of normal coping strategies. Disenfranchised grief involves a relationship that is not socially sanctioned. Perceived grief is not a type of grief; perceived loss is a loss that is less obvious to other people. The mother of a child who died recently keeps the child’s room intact. Family members are encouraging her to redecorate and move forward in life. Which type of grief will the home health nurse recognize the mother is experiencing? a.Normal b.End-of-life c.Abnormal d.Complicated A. normal Family members will grieve differently. One sign of normal grief is keeping the deceased individual’s room intact as a way to keep that person alive in the minds of survivors. This is happening after the family member is deceased, so it is not end-of-life grief. It is not abnormal or complicated grief; the child died recently. A nurse is caring for a dying patient. When is the best time for the nurse to discuss end-of-life care? a.During assessment b.During planning c.During implementation d.During evaluation A. During assessment Because most deaths are now “negotiated” among patients, family members, and the health care team, discuss end-of-life care preferences early in the assessment phase of the nursing process. Doing so during the planning, implementation, and evaluation phases is too late. A nurse is providing postmortem care. Which action will the nurse take? a.Leave dentures in the mouth. b.Lower the head of the bed. c.Cover the body with a sterile sheet. d.Remove all tubes for an autopsy. A. Leave dentures in the mouth Leave dentures in the mouth to maintain facial shape. Raise the head of the bed as soon as possible after death to prevent discoloration of the face. Cover the body with a clean sheet. Autopsy often does not allow removal of tubes, equipment, and indwelling lines. A nurse lets the transplant coordinator make a request for organ and tissue donation from the patient’s family. What is the primary rationale for the nurse’s action? a.The nurse is not as knowledgeable as the coordinator. b.The nurse is uncomfortable asking the family. c.The nurse does not want to upset the family. d.The nurse is following a federal law. D. The nurse is following a federal law. In accordance with federal law, a specially trained professional (e.g., transplant coordinator or social worker) makes requests for organ and tissue donation at the time of every death. Given the complex and sensitive nature of such requests, only specially trained personnel make the requests. Although the nurse may be less knowledgeable than the coordinator, uncomfortable asking the family, or not wanting to upset the family, the primary rationale is to be in accordance with federal law. During a follow-up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler-Ross stage of dying is the patient experiencing? a.Denial b.Anger c.Bargaining d.Depression B. Anger Kübler-Ross’s traditional theory involves five stages of dying. The anger stage of adjustment to an impending death can involve resistance, anger at God, anger at people, and anger at the situation. Denial would involve failure to accept a death. Bargaining is an action to delay acceptance of death by bartering. Depression would present as withdrawal from others. A nurse is documenting end-of-life care. Which information will the nurse include in the patient’s electronic medical record? (Select all that apply.) a.Reason for the death b.Time and date of death c.How ethically the family grieved d.Location of body identification tags e.Time of body transfer and destination B. Time and date of death D.Location of body identification tags
E. Time of body transfer and destination A newly hired experienced nurse is preparing to change a patient’s abdominal dressing and hasn’t done it before at this hospital. Which action by the nurse is best? a.Have another nurse do it so the correct method can be viewed. b.Change the dressing using the method taught in nursing school. c.Ask the patient how the dressing change has been recently done. d.Check the policy and procedure manual for the facility’s method. D. Check the policy and procedure manual for the facility’s method. The Joint Commission requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific and need to be accessible on all nursing units. For example, a policy/procedure outlining the steps to follow when changing a dressing or administering medication provides specific information about how nurses are to perform. The nurse being observed may not be doing the procedure according to the facility’s policy or procedure. The procedure taught in nursing school may not be consistent with the policy or procedure for this facility. The patient is not responsible for maintaining the standards of practice. Patient input is important, but it’s not what directs nursing practice. An obstetric nurse comes across an automobile accident. The driver seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from a purse to provide an airway. The patient survives and has a permanent problem with vocal cords, making it difficult to talk. Which statement is true regarding the nurse’s performance? a.The nurse acted appropriately and saved the patient’s life. b.The nurse stayed within the guidelines of the Good Samaritan Law. c.The nurse took actions beyond those that are standard and appropriate. d.The nurse should have just stayed with the patient and waited for help. C. The nurse took actions beyond those that are standard and appropriate. An obstetric nurse would not have been trained in performing a tracheostomy (cut in the trachea), and doing so would be beyond what the nurse has been trained or educated to do. If you perform a procedure exceeding your scope of practice and for which you have no training, you are liable for injury that may result from that act. You should only provide care that is consistent with your level of expertise. The nurse did not act appropriately. The nurse is not protected by the Good Samaritan Law because the nurse acted outside the scope of practice and training. The nurse should have acted within what was trained and educated to do in this circumstance, not just stay with the patient. A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering and for malpractice. Which key point will the prosecution attempt to prove against the nurse? a.The CPR procedure was done incorrectly. b.The patient would have died if nothing was done. c.The patient was resuscitated according to the policy. d.The older patient with brittle bones might sustain fractures when chest compressions are done. A. The CPR procedure was done incorrectly Certain criteria are necessary to establish nursing malpractice. The prosecution would try to prove that a breach of duty had occurred (CPR done incorrectly), which had caused injury. The defense team, not the prosecution, would explain the correlation between brittle bones and rib fractures during CPR and that the patient was resuscitated according to policy. In this situation, although harm was caused, it was not because of failure of the nurse to perform a duty according to standards, the way other nurses would have performed in the same situation. The fact that the patient sustained injury as a result of age and physical status does not mean the nurse breached any duty to the patient. The nurse would need to make sure the defense attorney knew that the cardiopulmonary resuscitation (CPR) was done correctly. Without intervention, the patient most likely would not have survived. A recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained? a.Ask a family member to translate what the nurse is saying. b.Request an official interpreter to explain the terms of consent. c.Notify the nursing manager that the patient doesn’t speak English. d.Use hand gestures and medical equipment while explaining in English. B. Request an official interpreter to explain the terms of consent. An official interpreter must be present to explain the terms of consent if a patient speaks only a foreign language. A family member or acquaintance who speaks a patient’s language should not interpret health information. Family members can tell those caring for the patient what the patient is saying, but privacy regarding the patient’s condition, assessment, etc., must be protected. A nurse can take care of requesting an interpreter, and the nurse manager is not needed. Using hand gestures and medical equipment is inappropriate when communicating with a patient who does not understand the language spoken. Certain hand gestures may be acceptable in one culture and not appropriate in another. The medical equipment may be unknown and frightening to the patient, and the patient still doesn’t understand what is being said. A pediatric oncology nurse floats to an orthopedic trauma unit. Which action should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse? a.Provide a complete orientation to the functioning of the entire unit. b.Determine patient acuity and care the nurse can safely provide. c.Allow the nurse to choose which mealtime works best. d.Assign nursing assistive personnel to assist with care. B. Determine patient acuity and care the nurse can safely provide Supervisors are liable if they give staff nurses an assignment that they cannot safely handle. Nurses who float must inform the supervisor of any lack of experience in caring for the types of patients on the nursing unit. They should request and receive an orientation to the unit. A basic orientation is needed, whereas a complete orientation of the functioning of the entire unit would take a period of time that would exceed what the nurse has to spend on orientation. Allowing nurses to choose which mealtime they would like is a nice gesture of thanks for the nurse, but it does not enable safe care. Having nursing assistive personnel may help the nurse complete basic tasks such as hygiene and turning, but it does not enable safe nursing care that the nurse and manager are ultimately responsible for. |
A nurse is instructing a client on how to administer cyclic enteral feedings at home
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