Urinary
A client with which history would be at highest risk for stress incontinence? A history of:
Six vaginal births
The client asks the nurse to recommend bulk-forming foods that may be included in the diet. Which of the following should be recommended by the nurse?
Whole Grains
A 76-year-old patient has been on bed rest for 10 days following surgery. The nurse notes that the patient has a poor appetite, abdominal distention, and has not had a bowel movement for 3 days. Which metabolic effect of immobility is the nurse most likely observing?
Decreased appetite and constipation
A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next?
Follow the plan for patient treatment.
Sign it and give it to the patient.
Individualize it to the specific client.
File it in the patient’s chart.
Individualize it to the specific client.
A nurse is going to insert an indwelling catheter for a female patient. Which action is most important to maintain sterility during the procedure?
Opening the catheter kit using sterile technique
The nurse is assessing a client’s colostomy and the stoma appears pale in color. The nurse should:
Notify the Physician
A hospital client’s health has declined sharply, and he is now rarely responsive to stimuli. To prevent complications of immobility, which nursing intervention is most important?
B- Reposition the patient at least every 2 hours
.......
Free points
What is Polyuria?
Excreting excessive amounts of urine
An 84-year-old male client is hospitalized with severe diarrhea. The nurse knows that the major problem associated with severe diarrhea is:
Electrolyte and Fluid loss
The nurse is preparing to help a patient who is weak after surgery transfer from the bed to a chair. Which nursing action demonstrates the use of evidence-based practice principles to maintain balance and prevent musculoskeletal strain?
Place feet shoulder-width apart with knees slightly flexed and use leg muscles when assisting the patient.
A nurse has just finished caring for his post-operative patient including the assessment and immediate post-operative orders. The best time for the nurse to document his findings is:
At the end of the shift when she has time to sit and think back to what all she performed.
Immediately after a task or procedure is performed.
On her lunch break when she knows she will not be interrupted.
After her shift ends so she is not taking time away from patient care.
Immediately after a task or procedure is performed.
The nurse is caring for a female client with stress urinary incontinence related to decreased pelvic muscle tone. A therapeutic nursing intervention based on this diagnosis is to:
Teach Kegel Exercises
A nurse is conducting an abdominal assessment. What is the rationale for performing palpation last in the sequence when conducting an abdominal assessment?
Palpation disturbs normal peristalsis and bowel motility
A nurse is caring for a patient who is ordered to be OOB in a chair for 1 hour twice a day. The nurse is concerned about the complication of orthostatic hypotension. What nursing action employed by the nurse will help to minimize the risk of orthostatic hypotension?
Dangle the patient in a sitting position on the side of the bed for 1-2 minutes before standing.
It is most acceptable for the nurse to accept a verbal order from the physician in which situation?
During a medical emergency
Upon admission of the client to the unit
Immediately prior to discharge
Prior to the client leaving the floor for therapy
During a medical emergency
A client’s urine is cloudy, she feels burning when she voids, and it has an unpleasant odor. Which problem may this information indicate that requires the nurse to perform a focused assessment?
Urinary Tract Infection
What information should the nurse include in the documentation associated with the changing of the client’s ostomy pouch? (Select all that apply)
All of the above
A 68-year-old patient is recovering from hip surgery and has been on bed rest for 5 days. The nurse is teaching the patient strategies to reduce the respiratory complications of immobility. Which nursing instruction is most important to include?
“Use the incentive spirometer every 1 to 2 hours while awake.”
The nurse is caring for an older adult resident in a long-term care facility. The client is crying and states, "I don't want to live anymore. I am a burden on everyone. I don't feel like doing anything at all. I don't even want to get up today." Which of the following should the nurse record in his charting? Select all that apply.
Client is crying.
Client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."
Client seems depressed
Client is suicidal
Client is in a bad mood
Client is crying.
Client states, "I don't want to live anymore. I am a burden of everyone. I don't feel like doing anything at all. I don't even want to get up today."