The nurse spends time with the patient and family reviewing the dressing change procedure for the patient’s wound. The patient’s spouse demonstrates how to change the dressing. The nurse is acting in which professional role? 1.Educator 2.Advocate 3.Caregiver 4.Case manager

1.Educator More test answers on https://studyhippo.com/brown-mackie-college-intro-to-nursing-chapters-1-6/

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Mosby – IV – Administering IV Fluid Therapy – Flashcards 65 terms

Sonia Kelly

65 terms

Preview

Mosby – IV – Administering IV Fluid Therapy – Flashcards

question

what cannot be delegated

answer

- The skill of initiating intravenous therapy may not be delegated - The skill of caring for an intravenous site may not be delegated - The skill of troubleshooting intravenous infusions may not be delegated - The skill of discontinuing a short peripheral intravenous line may not be delegated

question

Instruct NAP to notify you if

answer

- the dressing becomes wet or if the patient complains of any IV-related complications, such as pain, redness, swelling, or bleeding. - the patient's IV dressing becomes wet. - the level of fluid in the IV bag is low or the electronic infusion device (EID) alarm sounds. - any bleeding at the site after the catheter has been removed - any complaints of pain by the patient or observations of redness at the site.

question

Do not palpate or touch the insertion site after ________.

answer

the skin has been cleansed

question

Use ______ gloves during all aspects of IV care.

answer

clean

question

Do not rub or repeatedly or vigorously tap a vein, especially in an older adult, since doing so can ______.

answer

cause hematoma formation and/or venous constriction

question

Avoid using the superficial dorsal veins because of the ________.

answer

risk for infiltration due to movement

question

Because of the risk for nerve damage, avoid using the veins on the _______ of the wrist.

answer

thumb side and palmar side

question

For comfort and mobility, place the IV in the ______ arm.

answer

nondominant

question

If hair removal is needed, do not shave the area with a razor, which may cause microabrasions that increase the risk for infection. Instead, ________.

answer

clip the hair with scissors

question

Veins on the dorsal and ventral surfaces of the arms, such as the _______, are preferred in adults.

answer

cephalic, basilic, or median

question

Avoid vein selection in:

answer

(1) Areas with tenderness, redness, rash, pain, or infection (2) An extremity affected by previous cerebrovascular accident (CVA), paralysis, dialysis shunt, or mastectomy (3) Any site distal to a previous venipuncture site, sclerosed or hardened veins, a site of infiltrate, areas of venous valves, or phlebitic vessels (4) Fragile dorsal hand veins in older adults

question

Apply a tourniquet (or blood pressure cuff) around the patient's arm ______ above the proposed insertion site.

answer

10 to 15 cm (4 to 6 inches)

question

Select a vein large enough for VAD insertion:

answer

A. Use the most distal site in the nondominant arm if possible. B. Select a well-dilated vein.

question

1. Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm? Remove any clothing that is covering the arm. Apply a warm washcloth to the arm at the proposed site. Elevate the selected arm on a pillow for 2 to 3 minutes. Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.

answer

Remove any clothing that is covering the arm. Apply a warm washcloth to the arm at the proposed site. Elevate the selected arm on a pillow for 2 to 3 minutes. *Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.* CORRECT. Applying a tourniquet will distend the vein, making the intended insertion point more visible and allowing the nurse to determine if the vein can accommodate the IV catheter.

question

2. When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure? Assess the patient's understanding of the placement of the device. Insert the access device as quickly as possible. Ask the patient to select the arm preferred for access. Apply a topical anesthetic to the area before inserting the device.

answer

*Assess the patient's understanding of the placement of the device.* Insert the access device as quickly as possible. Ask the patient to select the arm preferred for access. Apply a topical anesthetic to the area before inserting the device. CORRECT. The nurse would assess the patient's understanding of device placement before inserting the device. Doing so would increase patient compliance with the procedure.

question

3. Which action minimizes the patient's risk for injury when inserting a venous access device into the arm? Wearing clean gloves during the procedure Using a larger vein found on the palmar (ventral) side of the wrist Checking for a radial pulse once the tourniquet has been applied Priming the extension tubing after attaching it to the newly placed venous access device

answer

Wearing clean gloves during the procedure Using a larger vein found on the palmar (ventral) side of the wrist *Checking for a radial pulse once the tourniquet has been applied* Priming the extension tubing after attaching it to the newly placed venous access device CORRECT. Assessing for a radial pulse after the tourniquet is in place ensures that circulation to the distal extremity has not been compromised.

question

4. The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is not an appropriate choice for IV insertion in this patient? Basilic vein Cephalic vein Superficial dorsal vein Median cubital vein

answer

Basilic vein Cephalic vein *Superficial dorsal vein* Median cubital vein CORRECT. Superficial veins located on the dorsal surface of the hand must be avoided because of the risk for infiltration due to excessive movement. They are also more fragile in older adults.

question

5. The nurse is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct? Wash the site with soap and water. Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. Cleanse the site using a circular motion, starting at the insertion site and working outward. Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.

answer

Wash the site with soap and water. Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. Cleanse the site using a circular motion, starting at the insertion site and working outward. *Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.* CORRECT. Chlorhexidine thoroughly cleanses the skin when first horizontal and then vertical swabbing is performed for 30 seconds.

question

A single nurse should not make more than ______ at initiating IV access. After ____ attempts, the nurse should have another nurse attempt the insertion.

answer

two attempts

question

Assess for clinical factors/conditions that will respond to or be affected by administration of IV solutions:

answer

Body weight Clinical markers of vascular volume Clinical markers of interstitial volume Thirst Behavior and level of consciousness

question

After swabbing the insertion site briskly in a_______ pattern, perform venipuncture.

answer

horizontal, then vertical, then circular

question

Anchor the vein below the site by placing your thumb over the vein and gently stretching the skin against the direction of the insertion _______ distal to the site. Ask the patient to relax his hand.

answer

4 to 5 cm (l to 2 inches)

question

Insert the vascular access device with the bevel up at a _____ degree angle slightly distal to the actual site of venipuncture in the direction of the vein.

answer

10 to 30

question

Observe for blood return through the ______, indicating that the bevel of the needle has entered the vein.

answer

flashback chamber of the catheter

question

Observe the patient every 1 to 2 hours after administering an IV or at established intervals per your agency's policies and procedures for the following:

answer

- Verify the type/amount of IV solution that has infused by observing the fluid level in the IV container. - Check the infusion rate on the EID, or count the drip rate (if the solution is infusing by gravity). - Check the patency of the vascular access device. - Observe the patient for signs of discomfort during palpation of the vessel (over the transparent semipermeable membrane [TSM] dressing). - Inspect the insertion site, noting its color, such as redness or pallor. - Inspect the site for the presence of swelling, which is a sign of infiltration, or pain and tenderness, which is a sign of phlebitis. Feel the temperature of the patient's skin above the dressing.

question

under documentation for IV, we would record:

answer

- number of attempts and sites - precisely describing the insertion site, such as "cephalic vein on dorsal surface of right lower arm, 2.5 cm [1 inch] above wrist." - the method of infusion (gravity or electronic infusion device); type and rate of infusion; device identification number (if you are using an electronic infusion device); size, length, and brand of catheter; when the infusion began; and the patient's response to the insertion. Use an infusion therapy flowsheet when available.

question

when changing to oncoming nursing staff, what info about an IV should be reported?

answer

the type of fluid, flow rate, status of the vascular access device, amount of solution remaining in the infusion bag, expected time for completion of infusion and need to hang subsequent IV containers, and the patient's condition.

question

Report to the ________ any signs and symptoms of IV-related complications.

answer

health care provider

question

1. Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? Anchor the vein by placing a thumb 1 to 2 inches below the site. Insert the device tip at a 45-degree angle distal to the proposed site. Place the patient's left arm in a dependent position for 5 minutes before assessment. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.

answer

*Anchor the vein by placing a thumb 1 to 2 inches below the site.* Insert the device tip at a 45-degree angle distal to the proposed site. Place the patient's left arm in a dependent position for 5 minutes before assessment. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site. CORRECT. This action stabilizes the vein, increasing the possibility of a successful insertion.

question

2. How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? Instruct the patient to expect a sharp, quick stick. Insert the access device as quickly as possible. Apply a topical anesthetic to the area before inserting the device. Promise that the procedure will not hurt once the device has been inserted.

answer

*Instruct the patient to expect a sharp, quick stick.* Insert the access device as quickly as possible. Apply a topical anesthetic to the area before inserting the device. Promise that the procedure will not hurt once the device has been inserted. CORRECT. Educating the patient to have reasonable expectations about the possible discomfort will best prepare him or her for it.

question

3. Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? Inserting the needle with the bevel up Using a vein on the dorsal surface of the arm Holding the skin taut directly below the site All of the above

answer

Inserting the needle with the bevel up Using a vein on the dorsal surface of the arm Holding the skin taut directly below the site *All of the above* CORRECT. All of these actions will minimize injury to the patient.

question

4. The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? Loosen or remove the tourniquet. Advance the catheter 1 inch into the vein. Lower the catheter until it is flush with the skin. Thread the catheter into the vein up to the hub.

answer

Loosen or remove the tourniquet. Advance the catheter 1 inch into the vein. *Lower the catheter until it is flush with the skin.* Thread the catheter into the vein up to the hub. CORRECT. Lowering the catheter until it is flush with the skin minimizes the risk of passing the needle through the opposite vessel wall.

question

5. Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with an intravenous access device? "Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." "Let me know when you notice that the IV bag contains less than 100 milliliters." "Explain the symptoms of infection to the patient."

answer

"Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." * "Let me know when you notice that the IV bag contains less than 100 milliliters."* "Explain the symptoms of infection to the patient." CORRECT. The task of reporting when the level of fluid in the IV bag is low may be delegated to NAP.

question

____ the insertion site for tenderness every shift (or according to agency policy) through the intact dressing.

answer

Palpate

question

Directly inspect a catheter site if the patient develops _______.

answer

tenderness at the site, fever without an obvious source, or symptoms of local or bloodstream infection.

question

Gauze dressings that cover a catheter site must be changed every _______. Intravenous tubing administration sets can remain sterile for _____.

answer

48 hours 96 hours

question

Label the IV dressing according to your agency's policy. Include the ________

answer

date and time of the IV insertion, VAD (vascular access device) gauge and length, and your initials.

question

*watch the dressing the infusion site video* it will make more sense to view it.

answer

*watch the dressing the infusion site video*

question

for IV dressing changes, record:

answer

time of dressing change, reason for change, type of dressing material used, patency of system and description of venipuncture site.

question

1. Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse's initials? Reminds the nurse to document the insertion of the device Proves that the access site was assessed Informs the nurse and other staff when the next dressing change is due Reminds the nurse when to change the infusion tubing

answer

Reminds the nurse to document the insertion of the device Proves that the access site was assessed *Informs the nurse and other staff when the next dressing change is due* Reminds the nurse when to change the infusion tubing CORRECT. The gauze dressing over an intravenous access site must be changed every 48 hours. This is the reason for labeling the dressing with the date, time, and nurse's initials.

question

2. Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site? Use aseptic technique throughout the process. Apply a skin protectant to the skin before the intervention. Apply a transparent dressing that allows for visualization of the site. Explain the process to the patient before implementation.

answer

*Use aseptic technique throughout the process.* Apply a skin protectant to the skin before the intervention. Apply a transparent dressing that allows for visualization of the site. Explain the process to the patient before implementation. CORRECT. Following aseptic technique throughout the dressing application will minimize the patient's risk for injury related to infection.

question

3. The nursing assistive personnel (NAP) reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first? Assess the site. Instruct the NAP on how to change the dressing. Remove the device, and insert a new one. Reinforce the dressing with more gauze.

answer

*Assess the site.* Instruct the NAP on how to change the dressing. Remove the device, and insert a new one. Reinforce the dressing with more gauze. CORRECT. The nurse would first assess the site to check for infiltration and to see if the IV has become dislodged.

question

4. When applying a dressing to an infusion site on a patient's left forearm, what will the nurse do to ensure proper maintenance of the tubing? Apply a transparent dressing to the insertion site. Use a catheter stabilizing device when applying the dressing. Apply the dressing proximal to the tubing and catheter hub connector. Secure the tubing to the patient's dressing with 1-inch tape.

answer

Apply a transparent dressing to the insertion site. Use a catheter stabilizing device when applying the dressing. * Apply the dressing proximal to the tubing and catheter hub connector.* Secure the tubing to the patient's dressing with 1-inch tape. CORRECT. Applying the dressing proximal to the tubing and catheter hub connector will allow the tubing to be disconnected and changed when indicated.

question

5. Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site? Avoid encircling the arm with tape Not secure the tubing and catheter hub with tape Secure the tubing in two different locations on the arm Label the dressing with the date and time of application

answer

*Avoid encircling the arm with tape* Not secure the tubing and catheter hub with tape Secure the tubing in two different locations on the arm Label the dressing with the date and time of application CORRECT. The nurse will avoid encircling the arm with tape, because doing so can impede circulation in the arm.

question

To troubleshoot IV infusions, prepare by :

answer

determining the patient's level of comfort and the expected response to IV therapy. Assess the patient's vital signs, fluid status, and intake and output at least every 8 hours or according to agency policy, and more often if indicated.

question

To determine if the correct amount of IV solution has infused, _____.

answer

review the infusion pump record

question

If the volume of fluid that has been infused is less than that which should have been instilled by this time, check for possible causes. First, check the _____.

answer

flow rate on the infusion pump or count the drip rate If the infusion rate is set correctly but the pump is sounding the alarm for "occlusion", look for kinks in the tubing, which can occur if the patient lies on the tubing or if it becomes caught in a side rail. Make sure the entire length of the tubing is patent and intact.

question

If infusion rate and line is clear of occlusions, next check

answer

assess the IV device. The hub connecting the tube to the catheter should be intact, with no signs of leakage or bleeding

question

Bleeding may be caused by:

answer

A. Disconnection of the tubing from the IV device B. A bleeding disorder C. Anticoagulant therapy

question

Inspect the dressing, which should be _____ Also inspect the insertion site for _______.

answer

dry and intact color changes, swelling, and purulent drainage

question

Palpate along the vessel and around the inser tion site to detect venous cords. As you do so, note the skin temperature to be alert for signs of ________. If either of these is supected, stop the infusion and evaluate the severity of the problem.

answer

phlebitis and infiltration

question

If you detect any signs of phlebitis, use a phlebitis scale to grade the severity of the problem. A. ______ represents no signs or symptoms. B. Symptom severity increases up to a score of ____, which reflects pain, redness, and swelling at the site; streaking, which is a _______; and purulent drainage. For phlebitis or infiltration, stop the infusion and discontinue the IV.

answer

Zero four a palpable venous cord more than 1 inch (2.5 cm) long

question

Change the IV device every ____. Change it more frequently if ordered or if complications occur.

answer

72 hours

question

1. The nurse consistently observes that the positioning of a confused patient's arm has a direct effect on the flow rate of the intravenous (IV) solution. What might the nurse do to ensure infusion of the patient's IV fluid at a consistent rate? Restart the IV in another location less affected by the patient's positioning. Include this information in the shift report regarding this patient. Assess the flow rate every 1 to 2 hours. Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution.

answer

*Restart the IV in another location less affected by the patient's positioning.* Include this information in the shift report regarding this patient. Assess the flow rate every 1 to 2 hours. Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution. CORRECT. Restarting the IV in another location is the best option to ensure the effectiveness of the patient's IV therapy.

question

2. Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a venous access device? "Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." "Let me know if you notice that the dressing has become damp." "Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red."

answer

"Assess the IV site frequently for signs of inflammation." "Be sure not to obscure the insertion site with the dressing." * "Let me know if you notice that the dressing has become damp."* "Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red." CORRECT. The task of reporting if a dressing becomes damp may be delegated to NAP.

question

3. What might the nurse do to minimize the risk for injury in a patient receiving IV therapy? Regulate the flow rate of the infusion. Assess the patient frequently for pain at the IV site. Monitor the IV site frequently for signs of infiltration and phlebitis. Educate the patient regarding symptoms of infiltration and phlebitis.

answer

* Regulate the flow rate of the infusion.* Assess the patient frequently for pain at the IV site. Monitor the IV site frequently for signs of infiltration and phlebitis. Educate the patient regarding symptoms of infiltration and phlebitis. CORRECT. Regulating the rate will minimize the risk for fluid overload.

question

4. The nurse observes erythema at the insertion site of a patient's IV infusion device. When asked, the patient denies pain at the site. Using the phlebitis scale, what score does the nurse give the injury? 1 2 3 4

answer

*1* 2 3 4 CORRECT. The nurse would give this injury a score of 1, which indicates redness at the access site with or without pain.

question

5. A patient's IV site has developed phlebitis scored as a 4 on the phlebitis scale. What would the nurse do to help treat the site? Apply a cool compress. Apply a warm compress. Apply a pressure dressing. Apply an elastic compression wrap.

answer

Apply a cool compress. *Apply a warm compress.* Apply a pressure dressing. Apply an elastic compression wrap. CORRECT. An IV site with evidence of phlebitis is to be wrapped with a warm compress.

question

Use caution to avoid breaking off the catheter during removal, since a damaged catheter increases the risk for _____.

answer

embolus formation

question

Never use scissors to remove the tape or dressing because you may accidentally _______.

answer

cut the catheter

question

1. What would the nurse do to assess a patient's risk for embolus when removing a venous access device? Inspect the site for redness. Visualize the tip of the IV device. Palpate the site for possible edema. Ask the patient to rate any pain at the site.

answer

Inspect the site for redness. * Visualize the tip of the IV device.* Palpate the site for possible edema. Ask the patient to rate any pain at the site. CORRECT. Damage to the tip of the device, resulting in a portion of the device remaining in the vessel, may cause an embolus to form.

question

2. Which instruction might the nurse give to nursing assistive personnel (NAP) when caring for a patient whose IV access device is to be removed? "Remember to wear gloves to minimize the risk for infection." "Be sure to keep pressure on the site for at least 2 to 3 minutes." "Let me know if you notice any bleeding on the site dressing." "Make sure the patient knows to notify me if the IV site becomes painful."

answer

"Remember to wear gloves to minimize the risk for infection." "Be sure to keep pressure on the site for at least 2 to 3 minutes." * "Let me know if you notice any bleeding on the site dressing."* "Make sure the patient knows to notify me if the IV site becomes painful." CORRECT. The nurse might offer this instruction because the task of reporting signs of bleeding may be delegated to NAP.

question

3. What might the nurse do to improve a patient's cooperation during the removal of an IV access device? Describe the entire procedure to the patient. Assure the patient that you will remove the IV catheter quickly. Assure the patient that the procedure will take only about 5 minutes. Tell the patient that the procedure will cause only a slight burning sensation.

answer

*Describe the entire procedure to the patient.* Assure the patient that you will remove the IV catheter quickly. Assure the patient that the procedure will take only about 5 minutes. Tell the patient that the procedure will cause only a slight burning sensation. CORRECT. Describing the entire procedure in advance will minimize fear and thus encourage the patient's cooperation.

question

4. Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? Keep the hub parallel to the skin. Cleanse the site with an antibacterial swab. Cut the dressing to facilitate its removal. Turn the IV tubing roller clamp to the "off" position.

answer

* Keep the hub parallel to the skin.* Cleanse the site with an antibacterial swab. Cut the dressing to facilitate its removal. Turn the IV tubing roller clamp to the "off" position. CORRECT. Keeping the hub parallel to the skin minimizes vein trauma during removal of the device.

question

5. What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? Instruct the patient to report immediately any sign of bleeding on the site dressing. Perform hand hygiene and wear clean gloves while removing the device. Encourage the patient to keep a cold compress on the site for 15 minutes. Apply firm pressure to the site with sterile gauze for 10 minutes.

answer

Instruct the patient to report immediately any sign of bleeding on the site dressing. Perform hand hygiene and wear clean gloves while removing the device. Encourage the patient to keep a cold compress on the site for 15 minutes. *Apply firm pressure to the site with sterile gauze for 10 minutes.* CORRECT. Applying firm pressure will facilitate clotting. Maintaining pressure at the site for 5 to 10 minutes is recommended because the patient is receiving medication that prolongs the amount of time it takes for blood to clot.

STUDY

Change The Dressing Fecal Occult Blood Test Nursing Right Lower Quadrant Pain Time And Date

NCLEX Colorectal Cancer Questions – Flashcards 11 terms

Pedro Huang

11 terms

Preview

NCLEX Colorectal Cancer Questions – Flashcards

question

The occupational health nurse is preparing a presentation to a group of factory workers about preventing colon cancer. Which information should be included? 1. Wear a high filtration mask around chemicals. 2. Eat several servings of cruciferous vegetables daily. 3. Take a multivitamin daily. 4. Do not engage in high-risk sexual behavior.

answer

question

The nurse is admitting a male client with a diagnosis of adenocarcinoma of the rectosigmoid colon. Which assessment data support this diagnosis? 1. Reports up to 20 bloody stools per day. 2. States he has a feeling of fullness after a heavy meal. 3. Has diarrhea alternating with constipation. 4. Complains of RLQ pain with rebound tenderness.

answer

3. The most common symptom of CRC is change in bowel habits.

question

The 85 y.o. male client diagnosed with colon cancer asks the nurse, "Why did I get colon cancer?" Which is best response about colon cancer? 1. Lack of fiber in the diet. 2. Greatest incidence among those younger than 50. 3. Has no known risk factors. 4. Rare among male clients.

answer

1. Prolonged transit time due to low fiber diet allows for carcinogens to build up in the lumen of colon.

question

The nurse is planning care of a client who has had an abdominal perineal resection for colon cancer. Which interventions should the nurse implement? Select all that apply: 1. Provide meticlulous skin care to stoma. 2. Assess the flank incision. 3. Maintain the indwelling catheter. 4. Irrigate the JP drains every shift. 5. Position the client semi-recumbent.

answer

1. Correct. Thorough skin care is needed. 2. Wrong. Midline and perineal incisions, not flank. 3. Correct. Perineal wound means a catheter to keep urine out of incision. 4. Wrong. JP drains are emptied every shift, not irrigated. 5. Don't sit upright because it puts pressure on perineum.

question

The client who has had an abdominal perineal resection is being discharged. Which info should nurse teach? 1. The stoma should be a white, blue, or purple color. 2. Limit ambulation to prevent the pouch from coming off. 3. Take pain meds when pain level is at 8. 4. Empty pouch when 1/3 to 1/2 full.

answer

1. Wrong. These colors represent lack of circulation, emergency. Should be pink. 2. Wrong. Encourage ambulation. Pouch shouldn't fall off. 3. Wrong. Pain meds should be taken before pain reaches 5. 4. Correct. Prevent leakage and heaviness.

question

the nurse caring for the pt 1day post op sigmoid resection notes a moderate amount of dark reddish brown drainage on the midline abdominal incision. Which intervention is first? 1. Mark the drainage on the dressing with the time and date. 2. Change the dressing immediately using sterile technique. 3. Notify the health care provider immediately. 4. Reinforce the dressing with a sterile gauze pad.

answer

1.Correct. Mark drainage to determine if active bleeding is occurring because dark reddish brown drainage indicates old blood. 2. Wrong. Surgical dressing is only changed by surgeon until ordered. 3. Wrong. Assess before calling HCP. 4. Wrong. May need to reinforce dressing, but after assessment.

question

The pt complains to the nurse of unhappiness with the HCP. Which intervention should the nurse do next? 1. Call HCP and suggest he or she talk to pt 2. Determine what about he HCP is bothering pt. 3. Notify nursing supervisor to arrange a new HCP to take over. 4. Explain that pt. has to keep HCP till after discharge.

answer

question

The pt with a new colostomy is being discharged. Which statement indicates a need for further teaching? 1. If I notice any skin breakdown I will call HCP. 2. I should drink only liquids until the colostomy starts to work. 3. I should not take a tub bath until the HCP says it's ok. 4. I should not drive or lift more than 5 pounds.

answer

2. Pt should be on a regular diet with working colostomy for several days before discharge.

question

The nurse is caring for pts in an outpatient clinic. Which info should the nurse teach regarding the American Cancer Society's recommendations for early detection of colon cancer? 1. Beginning at age 60, a digital rectal exam should be done annually. 2. After pt reaches middle age, yearly fecal occult test. 3. At age 50, a colonoscopy, then once every 5-10 years. 4. A flexible sigmoidoscopy should be done yearly after age 40.

answer

question

The nurse writes a psychosocial problem of "risk for altered sexual functioning related to new colostomy. Which intervention should the nurse implement? 1. Tell pt. that there should be no intimacy for at least 3 months. 2. Ensure that the pt and partner are able to change the ostomy pouch. 3. Demonstrate with charts possible sexual positions for the pt. to assume. 4. Teach the pt. to protect the pouch from being dislodged during sex.

answer

1. Wrong. Eliminate because of the use of the word "no". 2. Wrong. Not addressing the issue. 3. Wrong. Out of nurse's area of expertise. Doesn't have access to sexual position charts. 4.Correct. Dislodged pouch may further cause body image issues.

question

The pt presents with a complete blockage of the large intestine from a large tumor. Which HCP's order would the nurse question? 1. Obtain consent for a colonoscopy and biopsy. 2. Start an IV of 0.9% saline at 125 mL/hr. 3. Administer 3 liters of Go Lytely. 4. Give tap water enemas until it is clear.

answer

3. GoLytely would cause severe cramping and could cause an emergency. Tap water enema is the way to clean out the pt before diagnostic testing.

STUDY

Advise The Client Change The Dressing Cough And Deep Breathe End Stage Renal Failure Nursing Surgery

RENAL NCLEX QUESTIONS – Flashcards 45 terms

Mike Bryan

45 terms

Preview

RENAL NCLEX QUESTIONS – Flashcards

question

A client who has a renal mass asks the nurse why an ultrasound has been scheduled, as opposed to other diagnostic tests that may be ordered. The nurse formulates a response based on the understanding that: a) all other tests are more invasive than an ultrasound b) all other tests require more elaborate postprocedure care c) an ultrasound can differentiate a solid mass from a fluid-filled cyst d) an ultrasound is much more cost effective than other diagnostic tests

answer

c) an ultrasound can differentiate a solid mass from a fluid-filled cyst

question

A client has been admitted to the hospital with a diagnosis of acute glomerulonephritis. During history-taking the nurse first asks the client about a recent history of: a) bleeding ulcer b) deep vein thrombosis c) myocardial infarction d) streptococcal infection

answer

d) streptococcal infection

question

A nurse is assigned to care for a client with nephrotic syndrome. The nurse assesses which important parameter on a daily basis? a) weight b) albumin levels c) activity tolerance d) blood urea nitrogen (BUN) level

answer

a) weight

question

A client is being admitted to the hospital with a diagnosis of urolithiasis and ureteral colic. The nurse assesses the client for pain that is: a) dull and aching in the costovetebal area b) aching and camplike thoughout the abdomen c) sharp and radiating posteriorly to the spinal column d) excruciating, wavelike, and radiating toward the genitalia

answer

d) excruciating, wavelike, and radiating toward the genitalia

question

A client with renal failure is receiving epoetin alfa (Epogen) to support erythropoiesis. The nurse questions the client about compliance with taking which of the following medications that supports red blood cell (RBC) production? a) iron supplement b) zinc supplement c) calcium supplement d) magnesium supplement

answer

a) iron supplement

question

A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measures should the nurse implement to promote client safely? a) take blood pressures only on the right arm to ensure accuracy b) use the fistula for all venipunctures and intravenous infusions c) ensure that small clamps are attached to the AV fistula dressing d) assess the fistula for the presence of a bruit and thrill every 4 hours

answer

d) assess the fistula for the presence of a bruit and thrill every 4 hours

question

A nurse is assessing a client who is diagnosed with cystitis. Which assessment finding is inconsistent with the typical clinical manifestations noted in this disorder? a) hematuria b) low back pain c) urinary retention d) burning on urination

answer

c) urinary retention

question

The home care nurse is making follow-up visits to a client following renal transplant. The nurse assesses the client for which signs of acute graft rejection? a) hypotension, graft tenderness, and anemia b) hypertension, oliguria, thirst, and hypothermia c) fever, hypertension, graft tenderness, and malaise d) fever, vomiting, hypotension, and copious amounts of dilute urine

answer

c) fever, hypertension, graft tenderness, and malaise

question

A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. As an essential preprocedure component of the nursing assessment, the nurse plans to ask the client about a history of: a) familial renal disease b) frequent antibiotic use c) long-term diuretic therapy d) allergy to shellfish or iodine

answer

d) allergy to shellfish or iodine

question

The client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The priority nurse action would be to: a) check the shunt for the presence of bruit and thrill b) observe the site once as time permits during the shift c) check the results of the prothrombin time as they are determined d) ensure that small clamps are attached to the arteriovenous shunt dressing

answer

d) ensure that small clamps are attached to the arteriovenous shunt dressing - An arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours.

question

The nurse develops a post-procedure plan of care for a client who had a renal biopsy. The nurse avoids documenting which intervention in the plan? a) administering analgesics as needed b) encouraging fluids to at least 3L in the first 24 hours c) testing serial urine samples with dipstick for occult blood d) ambulating the client in the room and hall for short distances

answer

d) ambulating the client in the room and hall for short distances

question

The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of: a) pyelonephritis b) glomerulonephritis c) trauma to the bladder or abdomen d) renal cancer in the client's family

answer

c) trauma to the bladder or abdomen Use the process of elimination. Eliminate options A and B, knowing that any inflammatory disease or infection is accompanied by fever. Because this client is afebrile, these are not possible options. Use knowledge of anatomy and pain assessment to select option C. Pain from renal cancer is a later finding and is localized in the flank area.

question

The client who has a history of gout also is diagnosed with urolithisis and the stones are determined to be of uric acid type. The nurse gives the client instructions in which foods to limit, including: a) milk b) liver c) apples d) carrots

answer

b) liver

question

The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action? a) check the sodium level b) place the client on a cardiac monitor c) encourage increased vegetables in the diet d) allow an extra 500 ml of fluid intake to dilute the electrolyte concentration

answer

b) place the client on a cardiac monitor

question

The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: a) during dialysis b) just before dialysis c) the day after dialysis d) on return form dialysis

answer

d) on return form dialysis

question

The client with chronic renal failure has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. The nurse should immediately: a) change the dressing b) reinforce the dressing c) flush the peritoneal dialysis catheter d) scrub the catheter with povidine-iodine

answer

a) change the dressing - Clients with peritoneal dialysis catheters are at high risk for infection. A wet dressing is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.

question

The client hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism. The priority action for the nurse is to: a) discontinue dialysis and notify the physician b) monitor vital signs every 15 minutes for the next hour c) continue dialysis at a slower rate after checking the lines for air d) bolus the client with 500 ml of normal saline to break up the air embolus

answer

a) discontinue dialysis and notify the physician

question

The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the best understands the information if the client states to record daily the: a) amount of activity b) pulse and respiratory rate c) intake and output and weight d) blood urea nitrogen and creatinine levels

answer

c) intake and output and weight

question

Which of the following should be considered in the diet of the client with end-stage-renal-disease (ESRD)? a) limit fluid intake during anuric phase b) limit phosphorus and vitamin D-rich food c) limit calcium-rich food d) limit carbohydrates

answer

a) limit fluid intake during anuric phase during ESRD, fluid intake of the client should be limited during anuric phase to prevent fluid overload. Fluid overload increases renal workload, pulmonary edema, and congestive heart failure.

question

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to: a) 3 mg/dL b) 15 mg/dL c) 29 mg/dL d) 35 mg/dL

answer

b) 15 mg/dL the normal blood urea nitrogen level is 8 to 25 mg/dL

question

A adult client has had laboratory work done as part of a routine physical examination. The nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted? a) 0.2 mg/dlL b) 0.5 mg/dL c) 1.9 mg/dL d) 3.5 mg/dL

answer

c) 1.9 mg/dL the normal serum creatinine level foadults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slight elevated level. A creatinie level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creeatinie level of 3.5 mg/dL may be associated with acute or chronic renal failure.

question

The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? a) cream of wheat, blueberries, coffee b) sausage and eggs, banana, orange juice c) bacon, cantaloupe melon, tomato juice d) cured pork, strawberries, orange juice

answer

a) cream of wheat, blueberries, coffee - the diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Option B, C, and D are high in sodium, phosphorus, and potassium.

question

The client with continuous ambulatory peritoneal dialysis (CAPD) has cloudy dialysate. Which of the following is the best initial nursing action? a) send fluid to the laboratory for culture b) administer antibiotic c) do nothing, this is expected d) stop drainage of fluid

answer

a) send fluid to the laboratory for culture cloudy diasylate indicates infection (peritonitis). Culture of the fluid must be done to determine the microorganism present.

question

Which of the following may be included in the diet of the client with chronic renal failure? a) orange slices b) watermelon slices c) cantaloupe slices d) apple slices

answer

d) apple slices the client with renal failure should be given low potassium diet because of hyperkalemia. Apple contains very little potassium. So, it can be given to the client.

question

The client with chronic renal failure is on chronic hemodialysis. Which of the following indicate improvement of the client's condition due to hemodialysis? Select all that apply a) the client's BP is 130/90 b) the client's serum potassium is 4.8 mEq/L c) the client's hemoglobin level is 10 g/dL d) the client's serum calcium is 7.7 mg/dL e) the client's serum sodium is 140 mEg/L f) the client's serum magnesium is 4 mEq/L g) the client's weight has increased from 60 kg to 63 kg

answer

a) the client's BP is 130/90 b) the client's serum potassium is 4.8 mEq/L e) the client's serum sodium is 140 mEg/L

question

The client is in end-stage renal failure (ESRD). Which of the following foods may be allowed for the client? a) banana b) apple c) carrot cake d) cantaloupe

answer

b) apple APPLES ARE LOW IN POTASSIUM

question

The client has end-stage renal disease. He had undergone kidney transplant 5 days ago. Which of the following is the most important intervention for the client to prevent infection? a) observe asepsis b) increase fluid intake c) avoid clients with flu d) avoid crowded places

answer

a) observe asepsis

question

Which of the following should the nurse include in the nursing care plan of the client who is diagnosed to have renal failure, whose BUN is 32 mg/dl, serum creatinine is 4 mg/dl, hematocrit is 38%. He is complaining of fatigue and edema. a) low protein diet and fluid restriction b) high protein diet and fluid restriction c) low protein diet and increase in fiber d) high protein diet and potassium restriction

answer

a) low protein diet and fluid restriction

question

The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection? a) increased urinary output, BUN = 15 mg/dL b) HCT = 50%, Hgb = 17 g/dl c) decreased urinary output, sudden weight gain d) decreased urinary output, sudden weight loss

answer

c) decreased urinary output, sudden weight gain

question

Which of the following anti-hypertensive medications is contraindicated for clients with renal insufficiency? a) beta-adrenergic blockers b) calcium-channel blockers c) direct-acting vasodilators d) angiotensin-converting enzyme inhibitors

answer

d) angiotensin-converting enzyme inhibitors

question

The client has been diagnosed to have glomerulonephritis. What should the nurse observe in the urine? a) blood b) pus c) white blood cells d) glucose

answer

a) blood

question

A client has been diagnosed to have chronic renal failure. Sodium polysterene sulfonate (exchange resin kayexalate) is prescribed. The action of the medication is that it releases a) bicarbonate in exchange for primarily sodium ions b) sodium ions in exchange for primarily bicarbonate ions c) sodium ions in exchange for primarily potassium ions d) potassium ions in exchange for primarily sodium ions

answer

c) sodium ions in exchange for primarily potassium ions

question

Which of the following problems is expected in a client who is in end-stage renal failure? a) anemia b) thalassemia c) renal calculi d) hypotension

answer

a) anemia

question

Which of the following client responses shows a correct understanding of continuous ambulatory peritoneal dialysis (CAPD)? a) I am expected to perform the procedure at home b) the procedure lasts for one hour c) I have to sit and raise my legs during the procedure d) I have to go to the hospital for this procedure

answer

a) I am expected to perform the procedure at home

question

The client with chronic renal failure is undergoing peritoneal dialysis. He asks why the nurse monitors his blood glucose levels. Which of the following will be the most appropriate response by the nurse? a) I have to check if you have diabetes mellitus b) the dialysate contains glucose c) the procedure may lower your blood glucose levels d) it is a routine procedure for every client who undergoes the treatment

answer

b) the dialysate contains glucose

question

Which of the following is an expected finding in the client with chronic renal failure? a) anemia b) polyuria c) increased creatinine clearance d) increased serum calcium levels

answer

a) anemia

question

In the oliguric phase of renal failure, what is the most appropriate nursing diagnosis? a) fluid volume deficit b) activity intolerance c) ineffective breathing pattern d) fluid volume excess

answer

d) fluid volume excess

question

Which of the following complaints is common in a client with pyelonephritis? a) right upper quadrant pain b) left upper quadrant pain c) pain at the costovertebral region d) pain at the suprapubic region

answer

c) pain at the costovertebral region

question

The client had been diagnosed to have chronic renal failure. He had undergone hemodialysis for the first time. What signs and symptoms when experienced by the client suggest that he is experiencing disequilibrium syndrome? a) restlessness, hypotension, headache b) nausea and vomiting, hypertension, dizziness c) lethargy, hypotension, dizziness d) thachycardia, hypotension, headache

answer

b) nausea and vomiting, hypertension, dizziness disequilibrium syndrome is caused by more rapid removal of waste products from the blood from the brain. This is due to the presence of blood-brain barrier. This causes increased intracranial pressure.

question

Situation: Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome. The diagnosis of Idiopathic Nephrotic Syndrome has been confirmed. Which unexpected finding would the nurse report? a) proteinuria b) distended abdomen c) blood in the urine d) elevated serum lipid levels

answer

c) blood in the urine hematuria is rare in nephrotic syndrome but it is profuse is acute glomerulonephritis The manifestations of nephrotic syndrome are: Proteinuria - nephrosis is believed to be due to immunologic response that results in increased permeability of glomerular membrane to proteins resulting in massive protein losses in the urine -- proteinuria and albuminuria (+3 +4), the child losses 50-100 mg/kg weight/day from proteinuria. Hypoalbuminemia - loss of protein in blood results in hypoalbumenimia Edema - cardinal sign and appears first in the periorbital region followed by dependent edema and accompanied by pallor, fatigue and lethargy. Hypoalbuminemia leads to decreased oncotic pressure resulting in fluid shift from intravascular to interstitial causing generalized edema or anasarca.The child has lost appetite but gained weight -- puffiness of the eyes on awakening decreases during the day but appears on the legs and abdomen. Fluid shift causes decreased blood volume that leads to decreased blood supply to kidney. Decreased blood supply to kidney initiates release of aldosterone. Aldosterone causes sodium retention (in interstitial spaces so child will have hyponatremia) and water retention contributing to edema. Hypocholesteronemia and hyperlipidemia - triglycerides and fats are released by the liver in the blood to make up for the protein loss

question

Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome. Carlo's potential for impairment of skin integrity is related to: a) joint inflammation b) drug therapy c) edema d) generalized body rash

answer

c) edema - management: reduce protein excretion Prevention of Skin Breakdown from Edema frequent turning keep nails short to prevent scratching meticulous skin care to dependent and edematous areas - sacrum, scrotum, labia, abdomen, legs loose clothing Monitor Edema weigh daily and monitor I and O check for pulmonary edema manifested by crackles on auscultation ascites - measure abdominal girth Prevention of Infection - pulmonary edema predisposes to respiratory infection and generalized edema predisposes to skin breakdown. Avoid contact with persons who have infection. Diet - usually anorexic because of GI edema high protein diet sodium restriction if with severe edema fluid intake equal to output and insensible loss vitamin and iron supplements small feedings, give favorite foods

question

Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome Prednisone is prescribed for Carlo. The nurse evaluate its effectiveness by a) checking his BP every 4 hours b) checking his urine for protein c) weighing him each morning before breakfast d) observing him for behavioral changes

answer

b) checking his urine for protein Monitor side effect of prolonged steroid therapy Hyperglycemia - test urine monitor growth of child by checking height because steroid has growth suppressing effect by preventing calcium deposition in the bones Gastric Irritation - give milk or meals, test for occult blood, administer with antacids Avoid exposure to infection because child is immunosuppressed

question

Three year old Carlo has been admitted to the pediatric unit with a tentative diagnosis of nephrotic syndrome: At Carlo's last check-up when he was 2 1/2 years old, his BP was 95/60, PR was 110/min and weight was 15 kg. Which unexpected assessment today would the nurse report to help the diagnosis? a) BP: 95/60 b) weight: 20 kg c) PR: 110 d) temp: 37 C

answer

b) weight: 20 kg during the toddler period, the child gains 2.5 kg a year. Carlo has gained 5 kg in only 6 months. In nephrotic syndrome, this excessive weight gain is due to edema.

question

The physician orders a combination of Sulfamethoxazole and Phenazopyridine hydrochloride (Azogantrisol) for a patient. Which therapeutic effect should this combination drug have: a) plain relief and a decreased WBC count b) equal fluid intake and output c) polyuria with reddish stain d) increased complaints of bladder spasm after 20 minutes

answer

a) plain relief and a decreased WBC count

question

Diagnosis of acute pyelonephritis has been established your nursing intervention includes the following except: a) provide health teaching and discharge planning b) administer antibiotic c) measure I and O d) provide adequate comfort and rest

answer

c) measure I and O

STUDY

Change The Dressing Frontal And Temporal Lobes Geriatrics High Frequency Sounds Nursing

Ch. 40 NCLEX Questions – Flashcards 67 terms

William Hopper

67 terms

Preview

Ch. 40 NCLEX Questions – Flashcards

question

Which statement is true regarding falls in the elderly? A. Most falls occur in the garage B. Hip fractures resulting from falls are a leading cause of placement in long-term care facilities C. Fall risk decreases with addition of medications D. Sedatives reduce the risk of falls

answer

B. Hip fractures resulting from falls are a leading cause of placement in long-term care facilities

question

Appropriate nursing care for a patient with urinary incontinence is to: A. Insert an indwelling Foley catheter B. Order oxybutyin chloride (Ditropan) C. Encourage fluids to decrease the urine concentration so it is less irritating D. Recommend herbal approaches to reduce incontinence

answer

C. Encourage fluids to decrease the urine concentration so it is less irritating

question

A nursing intervention for a patient with constipation is to: A. Avoid the urge to defecate B. Limit fluid intake C. Give prune juice with a no carbonated drink D. Encourage bran cereal or whole grain breads

answer

D. Encourage bran cereal or whole grain breads

question

A patient with dysphagia is: A. Fed only for pleasure B. At low risk for nutritional deficits C. At higher risk for pneumonia D. Able to drink thin liquids

answer

C. At higher risk for pneumonia

question

Age-related eye changes may include: A. Increased visual accommodation B. Macular Degeneration C. Non-preventable blindness as a result of glaucoma D. Decrease ability of pupil to respond to light changes

answer

B. Macular Degeneration

question

Nurses' knowledge of sexuality in the older adult population should include: A. Chronic Illness may affect the ability to participate in sexual activity B. Sexual response time is unchanged C. Ability to achieve orgasm declines D. Dryness of vaginal walls is associated with pelvic inflammatory disease

answer

A. Chronic Illness may affect the ability to participate in sexual activity

question

What is the initial nursing intervention in preventing polypharmacy? A. Obtain a thorough medication history. B. Discontinue all herbal preparations C. Refer the patient to a geriatric practitioner D. Consult a pharmacist to review all medications

answer

A. Obtain a thorough medication history.

question

What should the nurse include in the teaching plan for self-medication practices of older adults? A. Eliminate unnecessary medications B. Substitute herbal preparations for certain prescribed medications C. Develop a drug reminder system and schedule D. Pharmacy shop for the cheapest medications

answer

C. Develop a drug reminder system and schedule

question

Which age-related changes predispose the elderly patient to drug toxicity and extended duration of action of drugs? (Select all that apply.) A. Decreased body water B. Increased ratio of muscle of fat C. Low serum albumin D. Reduce blood flow to liver

answer

C. Low serum albumin D. Reduce blood flow to liver

question

__________ is the use of multiple medications, often inappropriately and excessively, at the same time.

answer

Polypharmacy

question

The nurse takes into consideration that of all the physical changes that the elderly experience, the most common cause of most problems is that of: A. Visual disturbance B. Hearing deficit C. Loss of muscle mass D. Impaired mobility

answer

D. Impaired mobility

question

While discussing ways to increase exercise with an elderly patient with no musculoskeletal disorders, the nurse should encourage the patient to consider walking at a frequency of: A. 10-20 mins once or twice a week B. 10-20 mins 4x a week C. 20-30 mins once or twice a week D. 20-30 mins 3x a week

answer

D. 20-30 mins 3x a week

question

The home health nurse assesses all of the following relative to a resident in her own home: glasses with a missing eye piece, soft-soled floppy house shoes, walker with a wheels, a floor devoid a rugs. The item that is most likely to cause a fall would be the: A. Broken glasses B. Floppy house shoes C. Rolling walker D. No rug on floor

answer

B. Floppy house shoes

question

An elderly patient is too weak to walk independently after surgery. Based on the services available on the rehabilitation unit, the nurse should work collaboratively with an: A. Exercise physiologist B. Nutritionist C. Physical Therapist D. Occupational Therapist

answer

C. Physical Therapist

question

The nurse adds to the nursing care plan for a resident with presbycusis. To better communicate with the patient, the staff should use: A. Written notes B. A slower speed of speech C. A lower, deeper voice D. Hand signals

answer

C. A lower, deeper voice

question

The nurse strategy that may be most helpful in preventing falls in elderly patients on a skilled nursing unit would be to: A. Answer call bells promptly B. Use vest restraints as needed C. Keep lights dim for eye protection D. Always keep bed rails up

answer

A. Answer call bells promptly

question

The home health nurse assesses a hazard for a patient in the home setting. Which of the following assessments is considered a safety hazard? A. Throw rugs present in all rooms B. Stairways with handrails C. Grab bars in the bathroom D. Non-skid tape in the bathtub

answer

A. Throw rugs present in all rooms

question

A nurse is assisting an elderly neighbor to rearrange her kitchen to reduce fall risk. The nurse should encourage her to avoid unnecessary reaching by placing all objects that are needed below the level of the: A. Knees B. Waist C. Head D. Chest

answer

C. Head

question

An elderly patient in a skilled nursing facility tells the nurse that he has controlled his incontinence with the herbal remedies of: A. Black cohosh B. Pumpkin seeds C. Feverfew D. St. John's wort

answer

B. Pumpkin seeds

question

The nurse uses the behavioral technique of habit voiding with a confused elderly patient to reduce the frequency of urinary incontinence. This means the: A. Patient is assisted to the bathroom to use the toilet at regular intervals B. Patient is being taught to request assistance from nursing staff C. Staff are trying to lengthen the time between voiding for the patient D. Fluid intake of the patient is being reduce so that voiding so are less frequent

answer

A. Patient is assisted to the bathroom to use the toilet at regular intervals

question

The nurse reminds the staff that the most effective method in preventing skin breakdown from urinary incontinence is: A. Reducing fluid intake B. Turning frequently C. Ambulating frequently D. Using protective pads

answer

D. Using protective pads

question

An elderly patient on bed rest has been eating poorly. The patient is exhibiting abdominal distention and cramping and is passing small amounts of liquid stool. The nurse assesses these signs as an indication of: A. Constipation B. Fecal Impaction C. Diarrhea D. GI Tract infection

answer

B. Fecal Impaction

question

When performing a digital rectal examination to determine the presence of fecal impaction, the nurse must be alert for: A. Increasing blood pressure B. Increasing respiratory rate C. Reflex incontinence D. Decreasing heart rate

answer

D. Decreasing heart rate

question

The nurse, in reviewing with an elderly patient the nutritional changes that would be most beneficial would suggest: A. Reducing sugar intake B. Increasing fat intake C. Increasing intake of oils D. Decreasing intake of roughage

answer

A. Reducing sugar intake

question

The nurse stresses taking vitamins and minerals to elderly postmenopausal patients. To reduce the risk of osteoporosis, women should increase their intake of: A. Iron B. Magnesium C. Calcium D. Selenium

answer

C. Calcium

question

The nurse recognizes that of all the interventions to assist a dysphagic patient to eat safely, the most significant preventing aspiration is to: A. Sit the patient upright and remind the patient to tuck in the chin when swallowing B. Feed small bites of 1/2 inch square C. Thicken liquids D. Offer frequent sips of fluid

answer

A. Sit the patient upright and remind the patient to tuck in the chin when swallowing

question

The nurse is aware that the newly admitted resident has age-relate macular degeneration (AMD). The nurse will modify the care plan to accommodate the patient's: A. Loss of central vision B. Lack of ability to focus on near objects C. Inability to adjust from light to dark environments D. Increasing pressure in the eye with progressive blindness

answer

A. Loss of central vision

question

For a patient with visual impairment who wishes to continue to eat independently, the nurse's most helpful intervention would be to: A. Describe positions of foods on the plate by clock position B. Tell the patient to eat all foods that are firmest first C. Raise the over the bed table so that all food is within 3 inches of the eyes D. Have the patient use a spoon instead of a fork

answer

A. Describe positions of foods on the plate by clock position

question

A nurse who is assisting a blind patient to ambulated should: A. Hold the patient's arm fairly to gently push him in the proper direction B. Hold the patient by a strap around the patient's waist to prevent his falling C. Offer the patient an arm for guidance D. Acquire a cane for the patient

answer

C. Offer the patient an arm for guidance

question

An elderly patient with arthritis is having difficulty using a weekly pillbox as reminder to take daily medications. The nurse would suggest as the best alternative: A. A paper and pencil check off system B. A colorful calendar C. A homemade egg carton container D. Symbol- and color- coded medication bottles

answer

C. A homemade egg carton container

question

A nurse is caring for an 86 year old patient who still takes pride in the fact that he drives. The nurse suggests that his driving be limited to: A. Back roads B. Large shopping centers C. Going to church and the grocery store D. Daytime driving

answer

D. Daytime driving

question

An elderly Hispanic patient is brought to a clinic. She brings a bag full of medication with her. When the nurse is talking to the patient, a significant question to ask to get a full picture of the patient would be: A. "Do you live with your family?" B. "Tell me about your diet." C. "How many doctors prescribe drugs for you?" D. "Are you drinking herbal supplements?"

answer

D. "Are you drinking herbal supplements?"

question

The nurse takes into consideration that the resident in a nursing home has a hearing deficit related to a continuous ringing in his ears, which is a condition called _________________

answer

Tinnitus

question

The nurse documents the report of painful intercourse as ____________

answer

Dyspnea

question

The nurse lists the most common causes of polypharmacy as: (select all that apply): A. Use of mail order sources B. Being prescribe to by several physicians C. Sharing drugs with others D. Many drugs being prescribed under different names E. Availability of OTC medications

answer

A. Use of mail order sources B. Being prescribe to by several physicians D. Many drugs being prescribed under different names E. Availability of OTC medications

question

The elderly, especially women, are at high risk of decreased mobility. Which nutrients are critical for women to take to decrease this risk? (Select all that apply): A. Protein B. Fat C. Carbohydrates D. Calcium E. Vitamin D

answer

D. Calcium E. Vitamin D

question

A nurse reviewing the medication list for an elderly patient notices several drugs that would increase the risk of falls because of Orthostatic hypotension, which are: ( select all that apply) A. Anticoagulants B. Diuretics C. Stool softeners D. Anti hypertensive E. Antihistamine

answer

B. Diuretics D. Anti hypertensive E. Antihistamine

question

Regarding HIV, sexuality, and the older adult: A. Rates of HIV infection are decreasing in the older population B. Older women are less vulnerable than older men to acquiring a new HIV infection C. Health care providers are less likely to ask the older patients about their sex practices D. People living with HIV/AIDS typically do not live into their older adult years

answer

C. Health care providers are less likely to ask the older patients about their sex practices

question

Your neighbor asks your advice on nutrition for her aging parents. You consider your response based on the fact that: A. Older adults requires more protein for wound healing B. Decreasing fluid can reduce one's risk of urinary incontinence C. Increased amounts of high-fiber foods can lead to constipation D. In general, older adults require fewer calories

answer

D. In general, older adults require fewer calories

question

One of the most common reasons that elder adults are place in long term care facilities is: A. Behavioral problem B. Incontinence C. Cancer D. Delirium

answer

B. Incontinence

question

Which of the following is true regarding sensory deficits in the older adult? A. Cleaning excess cerulean can improve hearing B. Age-related macular degeneration can always be prevented C. Blindness is the leading cause of institutionalizations D. Low-frequency hearing loss occurs to some degree in all older adults

answer

A. Cleaning excess cerulean can improve hearing

question

Dietary recommit ions for the elderly include: A. Between 46 and 56 g/day of protein B. 2400to 2900 calories per day C. 40% of dietary calories as fast D. 75% of calories from complex carbohydrates

answer

A. Between 46 and 56 g/day of protein

question

The elder with a sensory impairment as a result of the aging process may: A. Experience an abrupt awareness of the sensory loss B. Be subject to safety problems C. Increase socialization patterns D. Easily adapt to new environments

answer

B. Be subject to safety problems

question

Measures to try to prevent age-related macular degeneration include: A. Sunglasses and a diet of antioxidant foods B. Sunglasses and a diet low in calcium oxidase C. Artificial tears and a low roughage diet D. Eye exercise and diet high in vitamin A

answer

A. Sunglasses and a diet of antioxidant foods

question

Drug toxicity occurs more easily in the elderly because of: (Select all that apply) A. Decreased kidney function B. Slower liver metabolism C. Others overdosing them D. Diet interaction with drugs

answer

A. Decreased kidney function B. Slower liver metabolism

question

Drug use assessment to identify concerns related to polypharmacy should include: A. Names of the pharmacies used B. Types of insurance coverage C. Usual diet consumes D. Type of drug reminder system used.

answer

A. Names of the pharmacies used

question

The condition most likely to cause a vision loss in the elderly

answer

Age-related macular degeneration

question

A 69-year-old male has fractured his left ankle and sustained a deep abrasion on the lower leg. As his home health nurse, you visit to change the dressing. During the visit, you perform other assessments. As the patient is mostly immobile because he needs to keep the right leg elevated and because he is taking pain medication, it is especially important to assess what? A. Mental Status B. Urinary Status C. Bowel Status D. Heart Status

answer

C. Bowel Status

question

When you asked the patient with a stasis ulcer if she is taking her antibiotics for the infection in her leg, the patient replies, "Yes, but I have so many pills, I'm not sure I'm taking them at the right times." What would be a good method to assist her take her pills correctly? A. Have a neighbor come in and give her the pills at different times during the day B. Set up a 7-day medicine planner for her that you can refill during your nursing visits. C. Have her daughter call and remind her when to take her pills D. Write out a list of the medications and the times that each is to be taken

answer

B. Set up a 7-day medicine planner for her that you can refill during your nursing visits.

question

When listing the patient's medications, you find that she has two very similar blood pressure medications prescribed by different doctors. To remedy the problem of polypharmacy, you would recommend that she does what? A. Give each doctor she sees a list of her medications B. Make certain that she knows exactly what each prescription is supposed to treat. C. Obtain her prescription medications from one pharmacy D. Ask her daughter to monitor her prescriptions for her

answer

C. Obtain her prescription medications from one pharmacy

question

A patient indicates she is not eating much because it is difficult for her to cook. Nursing interventions that might be appropriate in this care are what? (Select all that apply) A. Ask her best friend to prepare meals for her B. Ask her daughter to bring her several microwave meals C. Suggest using supplements such as Ensure to maintain her nutrition D. Ask the social worker to set up Meals on Wheels service for her

answer

B. Ask her daughter to bring her several microwave meals C. Suggest using supplements such as Ensure to maintain her nutrition D. Ask the social worker to set up Meals on Wheels service for her

question

Your patient has hypertension, asthma, hypothyroidism, and osteoarthritis, which are chronic conditions. As her osteoarthritis worsens, it may affect her ________________.

answer

Mobility

question

An alert, well-groomed, 82-year-old resident of a long-term care facility has been experiencing bladder incontinence since she had pneumonia. She seems quite depressed and you suspect that this development has seriously affected her what? A. Self- Esteem B. Attitude toward others C. Personality D. Mental acuity

answer

A. Self- Esteem

question

The first thing that should be done when beginning a bladder retraining program for a patient is what? A. Planning scheduled toileting time B. Decreasing her fluid intake C. Tracking when incontinence occurs D. Placing her in incontinence briefs

answer

C. Tracking when incontinence occurs

question

When considering a teaching session for a patient about the bladder retraining program, you would plan to do what? (Select all that apply) A. Eliminate outside noise and distractions B. Use printed materials along with explaining the process C. Quickly present the material to avoid causing fatigue D. Speak distinctly in a very loud voice

answer

A. Eliminate outside noise and distractions B. Use printed materials along with explaining the process

question

A patient has been having some difficulty with constipation from decreased appetite and antibiotic therapy. To assist her with this problem, you would encourage her to do what? (Select all that apply) A. Increase roughage with fresh fruits and vegetables B. Take a laxative each night at bedtime C. Attempt to evacuate the bowels at the same time each day D. Choose more breads and pastas at meals

answer

A. Increase roughage with fresh fruits and vegetables C. Attempt to evacuate the bowels at the same time each day

question

A patient has moderate macular degeneration. To decrease the possibility of falls at night, you would do what? A. Keep a very bright light burning in her room B. Ask her to call for assistance to the bathroom C. Keep her cane within reach of the bed D. Have an attendant stay with her at night

answer

B. Ask her to call for assistance to the bathroom

question

Your patient has been instructed by her physician to start taking Miacalcin nasal spray. Which statement by the nurse would be most helpful in assisting the patient to understand her new medication? A. This medication will help decrease the swelling in your nasal passages B. This medication will make you need to urinate frequently for the next few hrs C. This medication will help to strengthen your bones D. This medication may help to decrease the pressure in your eyes due to glaucoma

answer

C. This medication will help to strengthen your bones

question

A leading cause of hospitalization and placement in long-term care is? A. Cardiac Disease B. Diabetes C. Hip Fracture D. Pneumonia

answer

C. Hip Fracture

question

You patient is at risk for falls for a variety of reasons. Which of the following medications would cause you the most concern for this patient's fall risk? A. Furosemide B. Miacalcin C. Flonase D. Ampicillin

answer

A. Furosemide

question

Many common physical problems affect older adults. A common physical care problem in older people that has been reported to cost billions of dollars for nursing home care is ________________.

answer

Urinary Incontinence

question

Your patient is asking your advice on choosing an activity to promote better balance. Which of the following could be best answer you could provide to him? A. Tai Chi B. Meditation C. Gardening D. Swimming

answer

A. Tai Chi

question

A measure that is usually ordered before removing a fecal impaction is to administer what? A. Greatly increased fluids B. An oil retention enema C. A narcotic analgesic D. A diuretic

answer

B. An oil retention enema

question

Macular degeneration is a common eye disorder that is characterized by what? A. A clouding of the lens B. Inability to focus on near objects C. An accumulation of excess fluid inside the eye D. A gradual loss of central, acute, and color vision

answer

D. A gradual loss of central, acute, and color vision

question

Antioxidants that may help protect against macular degeneration include what? A. Calcium and Vitamin C B. Calcium and Vitamin D C. Vitamin C and Vitamin B D. Vitamin C and Vitamin E

answer

D. Vitamin C and Vitamin E

question

Presbycusis is characterized by the inability to hear what A. Low-Frequency sounds B. High-Frequency sounds C. Consonant sounds D. Vowel sounds

answer

B. High-Frequency sounds

question

Strategies to increase compliance in self-medication administration include what? (Select all that apply) A. Use of color-coded medication bottles B. Periodically counting the remaining pills C. An alarm clock D. Cueing with daily events

answer

A. Use of color-coded medication bottles C. An alarm clock D. Cueing with daily events

STUDY

Change The Dressing Nursing Surgery

NRSG 332 Kaplan Oncology – Flashcards 37 terms

Cindy Krause

37 terms

Preview

NRSG 332 Kaplan Oncology – Flashcards

question

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? a. increased calcium level b. increased WBCs c. decreased BUN level d. decreased number of plasma cells in the bone marrow

answer

a. increased calcium level

question

the nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? a. encourage fluids b. providing frequent oral care c. coughing and deep breathing d. monitoring the RBC count

answer

a. encourage fluids

question

the nurse is caring for a client with an internal radiation implant. When caring for the client, the nurrse should observe which principle? a. limit the time with the client to 1 hour per shift b. do not allow pregnant women into the clients room c. remove the dosimeter film badge when entering the client's room d. individuals younger than 16y/o may be allowed to go in the room as long as they are 6 feet away from the client

answer

b. do not allow pregnant women into the clients room

question

the client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial cation by the nurse is to: a. call the physician b. reinsert the implant into the vagina immediately c. pick up the implant with gloved hands and flush it down the toilet d. pick up the implant with long-handled forceps and place it in a lead container

answer

d. pick up the implant with long-handled forceps and place it in a lead container

question

The nurse is caring for a client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plans to: a. restrict all visitors b. restrict fluid intake c. teach the client and family about the need for hand hygeine d. insert an indwelling urinary catheter to prevent skin breakdown

answer

c. teach the client and family about the need for hand hygeine

question

the home health care nurse is caring for a client with cancer and the client is complaining of acute pain. The most appropriate nursing assessment of the client's pain would include which of the following? a. the clients pain rating b. nonverbal cues from the client c. the nurse's impression of the client's pain d. pain relief after appropriate nursing intervention

answer

a. the clients pain rating

question

The nurse is caring for a client who is postoperative following a pelvic exenteration and the physician changes the client's diet from NPO status to clear liquids. the nurse makes which priority assessment before administering the diet? a. bowel sounds b. ability to ambulate c. incision appearance d. urine specific gravity

answer

a. bowel sounds

question

the client is admitted to the hospital with a suspected diagnosis of hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? a. fatigue b. weakness c. weight gain d. enlarged lymph nodes

answer

d. enlarged lymph nodes

question

the nurse recognizes which of the following signs indicate cancer of the larynx? a. increased drooling b. blood-streaked sputum c. difficulty swallowing d. jaundice

answer

c. difficulty swallowing

question

a female pt diagnosed with acute myelogenous leukemia (AML) begins menstruating. Which of the following actions should the nurse take FIRST? a. instruct the pt to report any increased dizziness and weakness b. contact the physician c. weigh the pt's pads and tampons before and after use d. ask the pt if she had heavy periods in the past

answer

c. weigh the pt's pads and tampons before and after use

question

the nurse cares for a pt w/ stomatitis due to the chemotherapy. Which of the following actions is most important for the nurse to include in the pt's plan of care? a. examine the pt's mouth for blisters, sores, or drainage b. encourage the pt to use a commercially prepared mouthwash twice daily c. instruct the pt to use a soft-bristled toothbrush d. offer mouth care morning and night

answer

a. examine the pt's mouth for blisters, sores, or drainage

question

the nurse performs postoperative care for a pt after a Whipple procedure for tx of pancreatic cancer. the nurse is MOST concerned if which of the following is observed? a. there is a clear, colorless, bile-tinged drainage from the NG tube b. the NG tube is connected to a low continuous suction c. the pt is lying in a semi-fowlers position d. the nurse instills air to open the drainage lumen of the NG tube

answer

a. there is a clear, colorless, bile-tinged drainage from the NG tube

question

the nurse performs a home care visit for a client receiving chemotherapy for tx of cancer. The client's white blood cell count is 3,500mm^3. Which of the following observations; if made by the nurse, requires an intervention? a. the client cleans the toothbrush daily by washing it in the dishwater b. the client eats peeled fruits and cooked vegetables c. the client takes and records the oral temp each day d. the client pulls weeds in the garden every day

answer

d. the client pulls weeds in the garden every day

question

a young woman receiving chemotherapy for a brain tumor suddenly becomes angry and irritable with the staff. when the nurse tries to administer the pt's medications, the pt throws a tray across the room and curses. Which of the following actions by the nurse is most appropriate? a. ask another nurse to administer the medication b. leave the room, promising to return when the pt gains control c. remain with the pt and call for help d. restrain the pt and call for help

answer

c. remain with the pt and call for help

question

Ondansetron HCI (Zofran) 6mg PO q 6hr is ordered for a pt. The nurse knows that the most appropriate time to administer this medication is: a. 1hr after chemotherapy b. 30 min prior to start of chemotherapy c. 2hr after chemotherapy d. after the pt complains of nausea

answer

b. 30 min prior to start of chemotherapy

question

The nurse recognizes which of the following is an early symptom of gastric cancer? a. occult blood in stool b. vomiting c. iron deficiency anemia d. abdominal discomfort relieved w/ antacids

answer

d. abdominal discomfort relieved w/ antacids

question

the nurse instructs a group of pts about dietary habits to reduce the risk of cancer. which of the following statements, if made by a pt to the nurse, indicates further teaching is necessary? a. "eating polyunsaturated fats will decrease my chances of developing cancer" b. "I should increase my intake of foods high in fiber" c. "I should eat apricots, carrots, leafy vegetables, and citrus fruits" d. "i should eat turkey on my sandwich rather than bologna

answer

a. "eating polyunsaturated fats will decrease my chances of developing cancer"

question

Prior to insertion of a cervical radioactive implant, enemas are prescribed for the pt. The nurse understands enemas are prescribed for which of the following reasons? a. make more space for the implant b. decrease the chance of the implant becoming dislodged c. prevent constipation due to altered activity level during tx d. enhance tissue susceptibility to the effect of radiation

answer

b. decrease the chance of the implant becoming dislodged

question

the nurse makes a home visit to a client receiving chemotherapy for the tx of cancer. the nurse instructs the client about ways to avoid injury due to bone marrow suppression. The nurse should intervene if which of the following is observed? a. the client takes Alka-Seltzer for indigestion b. the client uses an electric razor to shave c. the client blows his nose gently d. after bumping his leg, the client applies ice for an hour

answer

a. the client takes Alka-Seltzer for indigestion

question

a patient is scheduled for a total laryngectomy. he tells the nurse, "I am worried about my operation. I just can't help it." Which of the following responses by the nurse is BEST? a. have you discussed your worries with your doctor? b. i hear your concerns about having the operation c. you have a really fine doctor so there seems to be little need to worry d. everyone worries about surgery, especially when it is a first-time experience

answer

b. i hear your concerns about having the operation

question

which of the following nursing interventions is MOST effective in promoting adequate nutrition for patients undergoing radiation and chemotherapy? a. include pts when making meal and snack selection b. ensure meals are served hot c. offer salty snacks every 2 hours d. serve additional portions of food at mealtime

answer

a. include pts when making meal and snack selection

question

the nurse knows which of the following is the MOST life-threatening side effect of chemotherapy? a. alopecia b. bone marrow suppression c. vomiting d. mucositis

answer

b. bone marrow suppression

question

the nurse instructs staff members about care of pt diagnosed with cancer of the cervix. the pt has internal radiation in place. the nurse should intervene if a staff member makes which of the following statements? a. i should allow the pt to bathe herself b. i should not stand at the foot of the bed c. i should place all linens in a special, lead-lined hamper d. i should wear a dosimeter while i am in the pt's room

answer

c. i should place all linens in a special, lead-lined hamper

question

on the evening before a scheduled lung biopsy, a pt says to the nurse, "Do you think i have cancer?" Which of the following responses by the nurse is MOST appropriate? a. it is not for me to say; you'll know after tomorrow b. you know that you have been taking a chance smoking cigarettes all these years c. several tests will have to be done to confirm that diagnosis d. you sound worried about what they might find tomorrow

answer

d. you sound worried about what they might find tomorrow

question

the nurse cares for a pt diagnosed with immunosuppression due to chemotherapy. the nurse determines care is appropriate if which of the following is observed? a. the nurse obtains the pt's vital signs q 8hrs b. the pt is placed in a room with a pt admitted with ulcerative colitis c. the nursing assistant washes hands prior to changing the pt's bed linens d. the staff brings in blood pressure equipment to be obtained the pt's blood pressure

answer

c. the nursing assistant washes hands prior to changing the pt's bed linens

question

after 2 weeks of chemotherapy txs, a pt's WBC count is 2,000/mm^3. The nurse knows that this finding is most likely due to which of the following? a. infection b. bone marrow depression c. weight loss d. polycythemia

answer

b. bone marrow depression

question

the nurse cares for a pt diagnosed with cancer receiving chemotherapy. the pt shares with the nurse how upset she is that she is losing her hair. which of the following statements by the nurse is BEST? a. im sure that your daughter will help you find a wig you like b. i would not want to lose my hair! c. your hair will grow back about one month after chemotherapy is complete d. there are many attractive hats and scarves that will look very good on you

answer

c. your hair will grow back about one month after chemotherapy is complete

question

a client experiences numbness and decreased sensation in both lower extremities during the course of tx with vinblastine (Velban). The nurse instructs the pt to take which of the following actions? a. soak both legs in hot water four times/day b. increase walking to three times a week for 30min c. ambulate carefully with broad-based gait d. elevate legs while sitting

answer

c. ambulate carefully with broad-based gait

question

the nurse performs discharge teaching for a pt after a right mastectomy. the nurse determines that teaching is effective if the pt makes which of the following statements? a. i should eat a full liquid diet for 3-4days b. i can take a shower as soon as i get home c. i should empty the drain reservoir twice a day d. i should eat with my left hand until the stitches are removed

answer

c. i should empty the drain reservoir twice a day

question

the nurse assesses a pt w/ a diagnosis of colorectal cancer. the nurse understands that eating which of the following foods may contribute to the pt developing colon cancer? a. broccoli and cabbage b. fried red meat c. water d. oranges and grapefruit

answer

b. fried red meat

question

the nurse understands which of the following is the MOST significant risk factor for developing cancer? a. advancing age b. smoking tobacco c. drinking alcohol d. family hx of cancer

answer

a. advancing age

question

the home care nurse monitors a client diagnosed with cancer of the lung. the client complains about awakening with a severe headache several mornings during the past week. the client also admits to becoming suddenly nauseated, has vomiting, and notices drooling. which of the following actions by the nurse is BEST? a. administer the prescribed antiemetic b. reassure the client that this is expected c. assess the status of the client's lungs d. contact the physician

answer

d. contact the physician

question

the nurse leads adult women in a wellness class. the nurse instructs the class about risk factors for developing breast cancer. the nurse should intervene if one of the women makes which of the following statements? a. women over the age of 40 have a greater chance of developing breast cancer b. women with a history of benign breast disease have a greater risk of developing breast cancer c. women who have a mother or sister with breast cancer are at a higher risk of developing breast cancer d. women who have never had children have a higher risk of developing breast cancer

answer

b. women with a history of benign breast disease have a greater risk of developing breast cancer

question

the nurse is leading a smoking cessation class. which of the following instructions should the nurse give FIRST? a. remove ashtrays and lighters from view b. go to places that tempt the client to smoke to test the resolve c. make a list of all of the reasons to quit smoking d. drink at least 8 glasses of water per day

answer

c. make a list of all of the reasons to quit smoking

question

the home care nurse visits a client undergoing ecternal radiation for tx of lung cancer. it is MOST important for the nurse to include which of the following intervenrions in the client's plan of care? a. use a washcloth to gently cleanse the irradiated area b. apply cream to the irradiated area daily c. apply sunscreen to the irradiated area if exposed to the sun d. use a patting motion to dry the irradiated area

answer

d. use a patting motion to dry the irradiated area

question

the nurse performs health screening on a group of people. the nurse identifies which of the following individuals is at GREATEST risk for developing skin cancer? a. a 15 y/o male with dark skin works as a lifeguard at the local pool b. a 30 y/o female w/ light skin works as a cashier at the local store c. 47y/o female w/ dark skin swims daily at a health club d. 62y/o male w light skin worked as a roofer for 40 years

answer

d. 62y/o male w light skin worked as a roofer for 40 years

question

the home nurse cares for a client diagnosed with acute myelogenous leukemia(AML). the clients temp is 101F. which of the following actions should the nurse take FIRST? a. notify the physician b. offer the client oral fluids c. administer an antipyretic d. encourage the client to cough and deep breathe

answer

a. notify the physician

STUDY

Change The Dressing Nursing

Nclex + Nclex Booklet+ Meds. IN – Flashcards 63 terms

Kenneth Wheeler

63 terms

Preview

Nclex + Nclex Booklet+ Meds. IN – Flashcards

question

Flumazenil (Romazicon) Naloxone hydrochloride (Narcan) Doxacuriun (Nuromax) Remifentanil (Ultiva)

answer

...

question

The nurse anticipates that a client who has received propofol (Diprivan) as the induction and maintenance agent for general anesthesia will most likely experience: 1. Minimal nausea and vomiting. 2. Hypotension. 3. Slow induction of anesthesia. 4. Small tremors of the skeletal muscle.

answer

1. Minimal nausea and vomiting. A nonbarbiturate anesthetic direct antiemetic action.

question

Myasthenia gravis

answer

Intermittent immune atk triggered by stress, idiopathic, etc . . . causes failure to contract and auto-atk. S/S muscle weakness, droppy eyes ("gravity bringing down eyes" ,main sign). ONLY ALS, nerves YOU control have an effect. Diagnosis: tenselon test. inject cholinergic agents to produce siliva etc, muscle tone, vagus nerves to slow down heart beat. Tx: thymus-ectomy 2/3 effective.

question

cystic fibrosis

answer

Salty sweat, pancreatitis dx: young, blood sample tx: heavy vitamins, avoid smoke, high fluids, exercise

question

5 months old 1. infant should have head lag 2. leg lag 3.

answer

infant head lag

question

Giving advice to mother of a 5 month old infant. 1. serve fruits/veg together 2. don't serive whole milk till after 1 year 3. Serve rice cereal 4.

answer

1. kinda true 2. typicalls no whole milk till 9 months- 12 months just to be safe. 3. about 4 months rice cereal is ok.

question

Support diagnosis of HIV 1. Rash on trunk with non-painful mucosa ulcer sore, fever 2. fatigue, harry "l. . . ", diarrhea, fever 3. swollen lymph

answer

swollen lymph, diarrhea, fever, night sweats, dry cough, rash, cold sores, tingling and weakness, irritating mentral.

question

Angry patient points figure at other patient 1. "ask other patient how it makes them feel." 2. "Calmly tell patient not to and go to room to control anger." 3. Call paitent out.

answer

...

question

peritoneal? something select all that applies 1. sitz bath. 2.non irritation cream. 3.

answer

... 1,

question

20 weeks patient gain 12 lbs. response should be? 1. 1/4 of planned weight. 2. consume more calories. 3. Ideal weight. 3. You consumed too much.

answer

3. Ideal weight.

question

abdominal distention? 1. legs straight and elevated? 2.

answer

upright position

question

Best breathing position for copd? 1. 45% 2.

answer

...

question

0-18 trust vs mistrust 2-3 autonomy vs shame & doubt 3-5 initiative vs guilt 6-12 industry vs inferiority 12-18 identity vs role confusion 19-40 intimacy vs isolation 40-65 generativity vs stagnation 65+ ego intregrity vs despair

answer

...

question

delegate to nursing assistant. 1. collect drainage amount. 2. clean wound area.

answer

...

question

prevent nosocomial infection. 1. remove gloves after leaving room. 2. wash hands with "chemical"

answer

...

question

client with infection wound @ homecare, teaching correct when. 1. client says to place wound dressing in sealed bag before disposing in regular trash can. 2.

answer

Must be properly separated from regular waste.

question

Near by bus accident. Which may need further investigation when a charge nurse says, . . . 1. you will be performing out of your normal scope of practice. 2. You may need to put yourself and risk the safety of your life to save others.

answer

...

question

When physician ask a patient who has been 8 hours into sedation to sign inform consent which is in violation. 1. unintentional tort 2. maleficent 3. justice 4. fidelity

answer

...justice

question

Epiglottitis 1. Do not give water? 2. 3.

answer

... life threating

question

Scabies 1. Wash cloth in cold water. 2.

answer

•If patient is hospitalized, practice good handwashing technique, or use gloves while performing nursing procedure. apply cream from neck down. avoid moisture.

question

Mother in 3rd stage of labor. 1. tell her to relax between contraction. 2. tell her not to push till full dilation. 3.

answer

2. tell her not to push till full dilation.=2nd 1. tell her to relax between contraction.= first stage 3rd stage complete delivery.

question

Mother with fetal decal during contraction only. 1. normal? 2. cord prolapse. 3. call physician immediately. 4. head compression

answer

Means its an early deceleration? Late deceleration is low FHR even after contraction. 2. cord prolapse is variable decel. 4. head compression is early decal.

question

The nurse is reviewing the chart of a 55 year old male client who is scheduled for lumbar laminectomy, The nurse should report which of the following to the surgeon? 1. Pimple on the lower back. 2. Abnormal electrocardiogram. 3. Hearing aid. 4. Allergy to iodine When completing the preoperative checklist on the nursing unit. the nurse discovers an allergy that the client has not reported. What should the nurse do first? 1. Administer the prescribed pre-anesthetic med. 2. Not this new allergy prominently at the front of the chart. 3. Contact the scrub nurse in the operating room. 4. Inform the nurse anesthetist.

answer

Ans: 1. infection risk 2. notify anethesist 3. 4. surgical team. Ans: 4. Inform the nurse anesthetist. Reason: The nurse anesthetist admin,s the agent and monitor the client;s phycial status throughout the sugery; the nurse anesthetist must have knowledge of all known allergies for the safety.

question

The client tells the preoperative nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? 1. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. 2. Tell the client that she will bring the hearing aid to the post anesthesia care unit so that she can have it as soon as she wakes up. 3.Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery nd wont need to hear, 4.Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.

answer

ANS: 4. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery. Previously I choose 2.

question

For which of the following preoperative clients should the nurse assess the glucose level? Select all that apply. 1. A client with a diabetes mellitus controlled by diet. 2. A client with a high stress response to surgery. 3. A client receving corticosteroids for the past 3 months. 4. A client with a family history of diabetes receving dex. 5% in lactated ringer's solution (D5LR) I.V. fluids. 5. A client whi consumes a high carbohydrate diet.

answer

1. A client with a diabetes mellitus controlled by diet. 2. A client with a high stress response to surgery. 3. A client receving corticosteroids for the past 3 months. Not 4. b/c hx: does not make the client actually have diabetes.

question

Surgical signs of client rubbing her eyes and wipe away nasal drainage is very early signs of allergy.

answer

immediate action of stopping infusion or removing catheter (latex)

question

The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority? 1. Reduction of risk potential. 2. Physiologic adaptation. 3. Psychosocial integrity. 4. Health promotion and maintenance.

answer

3. Psychosocial integrity.

question

Preadmission nurse usually responsible for discharge planning as well.

answer

...

question

A client will receive I.V. midazolam hydrochloride (Versed) during surgery. Which of the following should the nurse determine as a therapeutic effect? The nurse should also encourage? Deep and slow breathing. 1. Amnesia. Correctly picked. 2. Nausea. 3. Mild agitation. 4. Blurred vision.

answer

1. Amnesia. RN should also encourage slow and deep breathing. midazolam is also a respiratory depressant.

question

Metoclopramide (Reglan is ordered as a premedication for a client about to undergo a gastroduodenoscopy. The nurse expects which of the following as the primary therapeutic effect? 1. Inhibit gastric emptying. 2. Increase gastric pH. 3. Reduced anxiety. 4. Inhibited respiratory secretions.

answer

1. Inhibit gastric emptying. Metoclopramide is an antiemetic.

question

What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate (Robinul)? 1. Increased heart rate. 2. Increased respiratory rate. 3. Decreased secretions. 4. Decreased amnesia.

answer

Glycopy is an anticholinergic gicen for its ability to reduce oral and resp. secretions before general anesthesia. Increased heart rate and resp rate with be adverse effects of the drug. Amnesia should not be an effect of the drug.

question

Atropine sulfate (Atropine) is contraindicated in all BUT which one of the following clients? 1. A client with diabetes. 2. A client with glaucoma. 3. A client with urine retention. 4. A client with bowel obstruction.

answer

1. A client with diabetes. Just need to read question carefully.

question

After the nurse has administered droperidol (Inapsine). Care is taken to move the client slowly based on the knowledge of droperidol's effect on the: 1. Central nervous system. 2. Resp. System 3. Caridovascular system 4. Psychoneurologic system.

answer

3. Caridovascular system.Produces hypo but does not effect other system. Causes tachy and othostaic hypo. client should move slowly.

question

Predisone

answer

Notify anesthesis. immunosuppressant drug. suppresses corticosteroid in times of stress.

question

Which pediatric surgery client should not play with balloon? 1. A child having her 15th laser surgery for a meningioma.

answer

Repeated exposure increases sensitivity to latex.

question

The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included? 1. Ignore the urge to void. 2. Force fluids. 3. Ask for the bedpan. 4. Ring for assistance to the bathroom.

answer

2. Force fluids. Encourage to make fluid dilute. Scope into bladder. mucosal membrane is irritated and the client feels the need to void even though the bladder may not be full. Client should never avoid urge to void.

question

Hypothermia and hyperthermia are both common in surgery. Unless body is cooled. Use Dantrolene for skeletal muscle relaxant.

answer

...

question

Which explanation would be most appropriate for a child when teaching him about general anesthesia induction? 1. You will be given an injection before you go to surgery to make you sleep. 2. You will breathe in oxygen through a facial mask and receive IV med to make you sleepy. 3. You will receive IV med to make you sleepy. 4. You will breathe in med through a facial mask to make you sleepy.

answer

4. You will breathe in med through a facial mask to make you sleepy. For a child both is not given. IV not for starting off.

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A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium ( sodium Pentothal)because this drug causes: 1. Bradycardia 2. Complete muscle relaxation 3. Hypotension 4. Tachypnea

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3. Hypotension. short acting barbiturate. maybe a problem for people with impaired cardiac issues.

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A 250 lb male client recovering from general anesthesia has the following assessment findings:150bpm, 90/50 mm Hg, resp. rate, 28 breath/min, tympanic temperature, 99.8 F (37.7C) and rigid muscles. The nurse determines that the client is. 1. Exhibiting the effects of excessive blood loss experienced in the operating room and increases the rate of his IV infusion. 2. In the early stages of malignant hyperthermia and obtains emergency med. and notifies the anesthesiologist.

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2. In the early stages of malignant hyperthermia and obtains emergency med. and notifies the anesthesiologist. Reason: 150 bpm or greater and muscle rigidity are early signs of hyperthermia. Larger body frames are at risk. Late signs include rapid increase in temp.

question

The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? (S all that applies). 1. Administer the med as a 2-mg bolus. 2.Given the medication undiluted in incremental doses. 3.Be alert for shivering and hypotension. 4.Use only a free-slowing I.V. line in a large vein. 5.Monitor the client's level of consciousness.

answer

2,3,4,5.

question

An 80 year old clien has spinal anesthesia for a transurethral resection of the prostate and receieved 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care? 1. Empty the catheter drainage bag. 2. Cover the client with warm blankets. 3. Han new bags of irrigation. 4. Turn client.

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2. Cover the client with warm blankets. Reason: Elderly (80! will freeze), Spinal anesthesia (causes vasodilation= Heat loss). bladder irrigation all contributes to hypo.

question

naloxone (Narcan) to reverse the resp. depression. Monitor resp. freq. for 4 to 6 hrs. may need for repeated dose.

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The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)? 1. Dizziness. 2. Biliary colic. 3. Bleeding. 4. Urine retention.

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3. Bleeding., careful of b/p issues

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Postanesthesia monitor temp every 15mins.

answer

...

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Assess client, check doc, check nurse, Check to ascertain if nay discrepancy had been documented with accompanying reason/s last.

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...

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The nurse is planning to teach incisional care to a client before d/c. Which Intervention should be included? 1. Do nto touch your incision before our next appointment. 2. Clean your incision three times a day with hydrogen peroxide and water. 3. Do not be concerned about uneven lumps under the suture line. 4. If the staples don't come out by themselves. The surgeon will removed it by the next appointment.

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3. Do not be concerned about uneven lumps under the suture line. Reason: Normal due to collagen is under the incision line because new tissue at different rate. Eventually it will smooth out. Do not use hydrogen peroxide may dry out skin.

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4,500-10,000 normal WBC value. 1,500-7,500 Neutriphil lvl

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...

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The nurse is teaching a client who has had a laparoscopic cholecystectomy about postoperative pain management. Which has deficient knowledge? 1. My pain is related to the gas used to distend my abdominal cavity. 2. My diet should include eating bland foods until the gas clears up 3. "My pain is related to the large incision and manipulation." 4. My pain should be relieved by walking to eliminate the gas.

answer

3. "My pain is related to the large incision and manipulation."

question

The initial post operative assessment is completed on a client who had an arthroscopy of the knee. Assessment of which of the following parameters is not necessary every 15 minutes during the first postoperative hour? 1. vital signs including pulse oximeter. 2. Pain rating of the operative site. 3. Urine output. 4. Neurovascular check distal to the operative site.

answer

3. Urine output. Reason: all out vital signed checked for compartment syndrome. patient does not have a urinary catheter. Urine is measured but not check q 15mins.

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After surgery. a client was treated for postoperative nausea and vomiting and now is experiencing hypotension and tachycardia. Which of the following medications would be most likely associated with these findings? 1. ondansetron hydrochloride (Zofran). 2. droperidol (inapsine). 3. prochlorperazine (Compazine). 4. promethazine (phenergam).

answer

2. droperidol (inapsine). reason: hypotension and tachycardia are common adverse effects of droperidol and should be monitored closely by nurse. hypotensiona nd tachy are not common adverse effects of the other meds.

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When an epidural catheter is used for postoperative pain management, the nurse should: 1. assess but not disturb the epidural dressing. 2.change the epodiral dressing daily 3. change the epidural dressing daily only if it is wet. 4. use strict aseptic technique when handling the epidural catheter.

answer

1. assess but not disturb the epidural dressing. reason: The nurse should assess but not disturb the epidural dressing b/c the catheter can be easily dislodged and organism can easily be transmitted into the cns. the nurse should not have to change the dressing at all if a waterproof dressing is applied over the site. even with strict aseptic technique, a drain into a sterile cavity is a direct route for transmission of organisms and place a client at increased risk of infection.

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The nurse is caring for a client who is using a portable wound suction unit. 6 hours following surgery the drainage is full. Nurse should? 1. Remove the drain from the incision. 2. Notify the surgeon. 3. Empty drainage. 4. Record the amount in the unit as output on the client's chart.

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3. Empty drainage. Reason: surgeon will remove drainage. It is normal for drainage to be full after 6-8 hours and should be emptied. Emptied and measured but not jus measured. Must empty.

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When a client cannot read or write but is of sound mind and needs to fill out consent form/ 1. Have the clients next of kin sign. 2. have client put an "X" on the signature line. 3. havea court appoint a guardian for the client 4. have a hospital quality mamangement coordinator sign for the client.

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2. have client put an "X" on the signature line. reason: guardian will not be appointed for a sound mind client. kin does not sign for the client neither management coordinator.

question

Avoid wrong-site surgery by... 1. Ask the surgeon to preoperatively to mark with a permanent marker the correct knee. 2. Verbally ask the client to state his name, surgical site, and procedure. 3. Verify the correct client with the correct operative site by medical record and radiographic diagnostic reports. 4. call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. 5. show the client an anatomic model of the surgical site

answer

2,3,4. reason: client should mark the operative site in the preoperative period not the surgeon. show client the anatomical model will assist the client in understanding the location of the surgery but it will not prevent anyone from identifying the wrong site on the client.

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How often should the postoperative client's temperature be assessed during the first 24 hours after surgery? 1. q 2 hr 2. q 4 hr 3. q 6 hr 4. q 8 hr

answer

2. q 4 hr

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A nurse is assessing a surgical client's blood pressure 8 hrs after surgery. The client's blood pressure before surgery was 120/80 mm Hg and on admission to the postsurgical nursing unit, it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. What should the nurse do first? 1. Notify the health care provider. 2. Elevate the head of the bed. 3. Administer pain med. 4. Check the intake and output record.

answer

1. Notify the health care provider.

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A client has been positioned in the lithotomy position under general anesthesia for a pelvic procedure. In which anatomic area may the client expect to experience postoperative discomfort? 1. Shoulders. 2. Thighs. 3. Legs. 4. Feet.

answer

1. Shoulders. Reason: The client who has been positioned under general anesthesia may experience discomfort in the shoulders postoperatively because the client is placed in the trendlenburg position to expose the perineal area. The client's weight is then shifted towards the should and the client experiences muscle sorness postoperatively.

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The nurse is teaching the client about deep breathing technique. Which of the following client statements indicates the need for additional education? 1. will use my incentive spirometer every hr while im awake. 2. I should place my hands lightly over my lower ribs and upper abdomen 3. I should get into a comfortable position before doing my breathing exercise 4. I should take four deep breaths and then cough deeply from the lungs

answer

3. I should get into a comfortable position before doing my breathing exercise. Reason: must maintain upright position.

question

A client has had a nasogatric tube connected to low intermitted suction. The client is at risk for which of the following complications? 1. Confusion. 2. Muscle cramping. 3. Edema. 4. Tremors.

answer

2. Muscle cramping. Reason.

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Which of the following items of documentation is not required for the nurse to have on the chart before client is transported? operative consent, hus and physical information, laboratory test, anesthesia note.

answer

anesthesia note. Anesthesia notes are after (postoperative).

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A 15 year old client needs life saving emergency surgery but his relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? 1. Send the client to surgery without the consent? 2. Call the family for a consent over the telephone and have another nurse listen as a witness? 3. No action is necessary in this case because consent is not needed. 4. Have the family sign the consent form as soon as they arrive.

answer

2. Call the family for a consent over the telephone and have another nurse listen as a witness? Reason: If not family available and life threatening, no consent for need.

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The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next? 1. Bladder distention. 2.Heache. 3. Postoperative pain. 4. Ability to move the legs.

answer

1. Bladder distention. The last area to regain sensation is the perineal area, and the nurse should check the client for a distended bladder. The client has received a large volume of IV fluid since the epicural. All other assessments should be checked after bladder.

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