Resp
A patient has an SpO₂ of 84%, RR 30, and is using accessory muscles. What is the priority problem?
Impaired oxygenation/respiratory distress.
What two factors determine cardiac output?
Heart rate × stroke volume.
What term means painful or difficult urination?
Dysuria.
Which catheter remains in place to provide continuous urinary drainage?
Indwelling catheter/Foley.
When performing an abdominal assessment, which comes first: palpation or auscultation?
Auscultation.
Which oxygen device delivers approximately 1–6 L/min and about 24–44% FiO₂?
Nasal cannula.
A patient has BP 86/52, HR 124, cool clammy skin, and urine output of 15 mL/hr. What do these findings indicate?
Decreased cardiac output/poor tissue perfusion.
What term means decreased urine output?
Oliguria.
Where should a urine specimen be obtained from a patient with an indwelling catheter?
A. Drainage bag
B. Sampling port
C. End of catheter tubing
D. Bedpan
B. Sampling port.
A healthy new stoma should normally appear what color?
Moist, beefy red
A patient with COPD is restless, tachypneic, and increasingly short of breath. What should the nurse do first?
Assess the patient's respiratory status and oxygenation, position upright, and provide oxygen as ordered/protocol.
Which finding is most concerning for decreased cardiac output?
A. Warm skin
B. Increased urine output
C. New confusion
D. Bounding pulses
C. New confusion.
A postoperative patient has not voided for 6 hours and reports lower abdominal pressure. What should the nurse consider doing first?
Assess the patient and perform a bladder scan to evaluate for urinary retention.
For a clean-catch urine specimen, which portion of the urine is collected?
The midstream portion.
Which stoma finding requires immediate attention?
A. Slight edema
B. Pink and moist
C. Small amount of bleeding with cleaning
D. Dusky purple/black appearance
D. Dusky purple/black appearance.
Which finding is more strongly associated with CHF than COPD?
A. Barrel chest
B. Chronic cough
C. Pink, frothy sputum
D. Hyperinflation
C. Pink, frothy sputum.
The nurse notices a patient's urine output has dropped significantly. Why can this be an important sign of decreased cardiac output?
The kidneys may not be receiving adequate blood flow/perfusion.
A patient has a Foley catheter but there is no urine in the drainage bag. What should the nurse do first?
Assess the patient and catheter system—check for kinks, dependent loops, bag position, connections, and bladder distention.
When beginning a 24-hour urine collection at 0700, what should the patient do with the first urine?
Void and discard it, then record the start time.
What does a dark, dusky, purple, gray, or black stoma potentially indicate?
Compromised blood supply/ischemia and possible necrosis.
A patient with severe dyspnea has an SpO₂ of 82%, diffuse crackles, and pink frothy sputum. What is the priority problem?
Acute pulmonary edema causing severe impaired oxygenation.
A patient with suspected decreased cardiac output becomes increasingly confused, hypotensive, tachycardic, and has cool clammy skin. What is the nurse's priority?
Recognize worsening poor perfusion, assess the patient immediately, support ABCs, and notify/escalate appropriately.
A patient needs intermittent bladder drainage but does not need continuous catheterization. Which procedure is appropriate?
Straight/intermittent catheterization.
A patient accidentally forgets to save one urine specimen during a 24-hour collection. What should the nurse do?
Follow facility/laboratory policy; the collection may need to be restarted because an incomplete collection can make the result inaccurate.
A patient with a colostomy suddenly develops abdominal distention, vomiting, and absent bowel sounds. What is the priority concern?
Possible bowel obstruction or ileus requiring prompt assessment and intervention.