Urinary Elimination
The nurse is planning care for a renal patient who is prescribed a diuretic medication. In planning care, what is the most appropriate time of day to administer this medication?
1. In the morning
2. In the afternoon
3. In the evening before bedtime
4. After meals
1
1
Rationale: In planning care or teaching patients about diuretic medications, the nurse should administer and teach for these medications to be taken in the morning. Diuretics increase urine output and when taken at night can cause nocturia, leading to interrupted sleep. This is especially important for the elderly, as there may be associated safety risks with frequent arising for urination during the night.
The nurse assesses a patient’s abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggests which postoperative complication?
1.Paralytic ileus
2.Small bowel obstruction
3.Diarrhea
4.Constipation
1.
Rationale:
1.This is correct. Absent bowel sounds on the fourth postoperative day suggests paralytic ileus, a complication associated with abdominal surgery.
2.This is incorrect. Hyperactive bowel sounds occur with a small bowel obstruction.
3.This is incorrect. Diarrhea produces hyperactive bowel sounds.
4.This is incorrect. Constipation might be associated with hypoactive bowel sounds.
Which of the following best describes the function of type 1 alveolar cells?
1. They add moisture to the inhaled air in the lungs.
2. They open the airway during breathing to allow air to move.
3. They facilitate gas exchange in the lungs.
4. They produce surfactant to lubricate the lungs.
3.
Rationale:
1.This is incorrect. The airway adds moisture to the inhaled air.
2.This is incorrect. The epiglottis is a flap that prevents aspiration of foreign objects into the lungs and opens to allow air into the lungs.
3.This is correct. Type 1 alveolar cells within the lungs are the gas exchange cells.
4. This is incorrect. Type 2 alveolar cells produce surfactant, a lipoprotein that lowers the surface tension within alveoli to allow them to inflate during breathing.
The nurse is planning care for several surgical cases. The nurse is aware that knowing the type of surgery helps identify needs to plan client care. Which of the following surgeries poses the highest risk for infection?
1. Repair of a stab wound to the lower leg
2. Tonsillectomy of a preschool-age client
3. Cardiac catheterization via the femoral artery
4. Laparoscopic cholecystectomy
ANS: 1
Rationale
1.This is correct. The body system classification is useful for determining the postoperative risk of infection. For example, surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tract have a higher risk for infection than does surgery of other body systems. However, if an organ ruptures or surgery is required to repair a penetrating injury, the risk of infection is very high regardless of the body system involved.
2.This is incorrect. The body system classification is useful for determining the postoperative risk of infection. For example, surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tract have a higher risk for infection than does surgery of other body systems. Although this is a high risk for infection, the penetrating wound poses a higher risk.
3.This is incorrect. This is at a lower risk for infection than the penetrating wound. Diagnostic (exploratory) surgery is done to confirm or rule out a diagnosis. Examples include biopsy, fine-needle aspiration, or invasive testing, such as a cardiac catheterization.
4.This is incorrect. Ablative surgery involves removal of a diseased body part. For example, a cholecystectomy removes a diseased gallbladder and holds a lower risk of infection.
The nurse is caring for a patient who underwent a bowel resection 2 hours ago. The urine output for the past 2 hours totals 50 mL. Which action should the nurse take?
1.Do nothing; this is normal postoperative urine output.
2.Increase the infusion rate of the patient’s intravenous (IV) fluids.
3.Notify the provider about the patient’s oliguria.
4.Administer the patient’s routine diuretic dose early
3.Notify the provider about the patient’s oliguria.
Rationale: The amount of 50 mL in 2 hours is not normal output. The kidneys typically produce 60 mL of urine per hour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria).
A patient with cancer is started on morphine for excruciating pain. Which diagnosis should the nurse add to the patient’s care plan?
1.Risk for constipation
2.Constipation
3.Perceived constipation
4.Chronic constipation
1.
Rationale:
1 This is correct. Risk for constipation is an appropriate diagnosis to use for patients who are confined to bedrest, taking medications such as opioids, or having surgery. The nurse might use this diagnosis for a patient with a condition or taking medications known to decrease peristalsis, like morphine.
2 This is incorrect. Based upon the data in the scenario, at this time the patient does not have an actual problem of constipation.
3 This is incorrect. Perceived constipation is an appropriate diagnosis for a patient who makes a self-diagnosis of constipation and uses laxatives, suppositories, or enemas to ensure a daily bowel movement.
4 This is incorrect. At this point in time, the patient does not have chronic constipation—constipation that typically lasts 3 months or longer and may persist for years.
The nurse is caring for a client diagnosed with pneumonia, teaching them how to cough and deep-breathe. The client asks, “Why is drinking fluids so important?” What is the nurse’s best response?
1. “The doctor ordered increased fluid intake.”
2. “Fluids prevent pathogens from growing in your lungs.”
3. “Fluids help to flush infection away so it doesn’t grow in your lungs.”
4. “Fluids make secretions thin, making them easier to cough up.”
ANS: 4
1.This is incorrect. Although the doctor may have prescribed increased fluid intake, this does not explain why it is important.
2.This is incorrect. Fluids do not prevent the growth of pathogens.
3.This is incorrect. Fluids do not flush out the lungs because they do not, normally, enter the lungs.
4.This is correct. Fluids help to thin secretions and keep them from becoming thick and glue-like, which would be much harder to mobilize. Thin secretions will reduce the effort required by the client to cough mucus into the larger airways and expectorate it.
The nurse admits a client who is scheduled for surgery tomorrow morning. The nursing admission assessment indicates that the client is mildly anxious about the procedure, does not drink alcohol or smoke, is married with two children, and is allergic to kiwi, avocados, and penicillin. The nurse identifies the priority nursing diagnosis for this client as:
1. Fear.
2. Anxiety.
3. Risk for latex allergy response.
4. Ineffective airway clearance.
ANS: 3
1 This is incorrect. The client is only mildly anxious, and therefore fear would not be an appropriate diagnosis.
2 This is incorrect. Although the client does have mild anxiety, this is not the priority diagnosis for this client.
3 This is correct. Risk for latex allergy response is an appropriate diagnosis for clients who are allergic to bananas, avocados, kiwi, chestnuts, or poinsettia plants. This client has two of these allergies, so this is a priority diagnosis.
4 This is incorrect. There is no indication that this client will have ineffective airway clearance.
The nurse is caring for a patient who has had an indwelling urinary catheter inserted for the past 5 days. In reviewing and revising the plan of care, what is the most important nursing diagnosis for this patient?
1.Disturbed body image
2.Risk for infection
3.Risk for impaired skin integrity
4.Risk for decreased urine output
2
Rationale: 1-This is incorrect. Although the patient may be embarrassed about having a catheter, a body image diagnosis (disturbed body image) is rarely given priority over a basic need, such as remaining infection free. There are no data in the scenario to suggest an actual disturbed body image.
2-This is correct. Anyone who has an indwelling catheter is at risk for infection. The longer the catheter remains in place, the higher the risk for catheter-associated urinary tract infections.
3-This is incorrect. Although the catheter may be a risk factor for impaired skin integrity, that is less common and of a lower priority than risk for infection.
4-This is incorrect. The patient is not at risk for decreased urine output from a catheter. Decreased urine output is primarily a problem of fluid intake or kidney function, not from insertion of a catheter.
A day after abdominal surgery, a postoperative patient on the surgical unit says to the nurse, “I’m having a problem with a lot of gas. Maybe it’s the food I’m eating.” What is the appropriate response by the nurse? Select all that apply.
1.“If the problem continues after you go home, you’ll need to avoid gas-producing foods, such as beans.”
2.“Let’s get you out of bed and walking more. This can help with your gas.”
3.“When was your last bowel movement? You may be a bit constipated.”
“I understand. I’ll have to call the doctor for insertion of a rectal tube.”
4.“We may need to get you ready to go back to surgery to fix this problem.”
5.“We may need to get you ready to go back to surgery to fix this problem.”
1,2,3
Rationale:
1.This is correct. The patient is likely not eating gas-producing foods on postoperative day 1, but the nurse might want to teach the patient about this possibility. Some people develop flatulence after eating gas-producing foods, such as beans, cabbage, cauliflower, onion, or highly spiced foods. For others, flatulence occurs when fiber intake is increased.
2.This is correct. To help patients manage flatulence, the nurse should encourage patients who have had surgery to ambulate and perform bed exercises, as this helps to stimulate peristalsis and the passage of gas.
3.This is correct. The nurse should ask about bowel movements because constipation is often accompanied by flatulence due to digestive by-products undergoing prolonged fermentation in the colon.
4.This is incorrect. In severe cases, the nurse may need to obtain a prescription for a rectal tube. In this item, there is no indication that the patient’s flatulence is severe enough to indicate a rectal tube.
5.This is incorrect. Flatulence is not treated with surgery. There are other less invasive methods to decrease flatus.
The nurse is assessing an adult client diagnosed with chronic heart failure 10 years ago. Which finding would indicate poor perfusion to the tissues?
1. Blood pressure reading of 102/64 mm Hg
2. Absence of hair on the lower legs and feet
3. Pulse rate of 104 beats/min
4. Shortness of breath when supine
ANS: 2
1.This is incorrect. A blood pressure of 102/64 mm Hg is lower than the average range but may be normal for this client. It would not indicate poor perfusion to the tissues.
2.This is correct. Absence of hair on the lower extremities is an indicator of poor perfusion because hair growth requires adequate gas exchange.
3.This is incorrect. The client with heart failure is likely to have a slightly elevated heart rate if not taking medications that slow heart rate because the increased rate compensates for reduced cardiac output.
4.This is incorrect. Although shortness of breath may occur with heart failure, this is the result of poor pumping action of the heart, allowing fluid to accumulate in the lungs; it is not an indicator of peripheral circulation.
The nurse is caring for a client who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the client does which of the following? Select all that apply.
1. Describes signs associated with infection
2. Performs the dressing change as prescribed
3. Demonstrates absence of surgical incision pain
4. Completes the regimen of prescribed antibiotics
5. Completes bowel management regimen
ANS: 1, 2, 4
1. This is correct. The nurse would know that client teaching was effective if the client verbalizes signs and symptoms of infection.
2. This is correct. The nurse would know that client teaching was effective if the client can perform the ordered dressing change.
3. This is incorrect. Nurses cannot teach a client to be free of pain. Pain is subjective. The nurse can teach the client strategies to assist with pain, but they may not remove the pain completely.
4. This is correct. The nurse would know that client teaching was effective if the client completes the regimen of ordered antibiotics.
5. This is incorrect. Although the client should know a bowel regimen, it is not necessary for the client to complete a bowel regimen in order to verify adequate teaching/learning.
A client states that their friend told them to ask for Ativan (lorazepam) to help them sleep while hospitalized for a knee replacement surgery. The nurse knows that nonbenzodiazepines like Ambien (zolpidem) are preferred over benzodiazepines in this scenario because:
1. All benzodiazepines are long-acting and cause daytime drowsiness.
2. Nonbenzodiazepines have a long half-life and cause daytime sleepiness.
3. Nonbenzodiazepines cause sleep by depressing the central nervous system.
4. Nonbenzodiazepines are sedative-hypnotics with a short half-life.
ANS: 4
1 This is incorrect. Benzodiazepines are the first-line treatment for insomnia. They can be long- or short-acting. Nonbenzodiazepines are preferred in this scenario because they have a short half-life and do not cause daytime sleepiness.
2 This is incorrect. Nonbenzodiazepines have a short-half life and do not cause daytime sleepiness.
3 This is incorrect. Nonbenzodiazepines are selective, meaning that they target specific receptors instead of depressing the entire central nervous system.
4 This is correct. Nonbenzodiazepines in this scenario are preferred because they have a short half-life and do not cause daytime sleepiness. Also, they do not carry the risk for rebound insomnia, dependency, and tolerance that benzodiazepines do.
A client has just voided 50 mL and yet reports that the bladder still feels full. The nurse’s next actions should include which of the following? Select all that apply.
1.Palpating the bladder height
2.Obtaining a clean-catch urine specimen
3.Performing a bladder scan
4.Applying a heating pad to the lower abdomen
5.Inserting an incontinence pessary
ANS: 1, 3, 4
Feedback
1.This is correct. The nurse should palpate the bladder for distention to validate the client’s statement.
2.This is incorrect. Obtaining a clean-catch urine specimen is not necessary at this time.
3.This is correct. A bladder scan will yield a more accurate measurement of the postvoid residual urine, so it would be appropriate at this time.
4.This is correct. The nurse should apply a heating pad to the lower abdomen to relax the muscles near the bladder for a client with urinary retention.
5.This is incorrect. Inserting an incontinence pessary is for urinary incontinence, not urinary retention.
A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally every 12 hours. The patient reports that the last time they took this medication, they had frequent episodes of loose stools. Which recommendation should the nurse make to the patient?
1.Stop taking the drug immediately if diarrhea develops.
2.Take an antidiarrheal agent, such as diphenoxylate.
3.Consume yogurt daily while taking the antibiotic.
Increase intake of fiber until the diarrhea stops.
3.
1 This is incorrect. Diarrhea is a common adverse effect of antibiotics; therefore, stopping the drug is not necessary or advisable.
2 This is incorrect. The patient should not be encouraged to take an antidiarrheal agent at this time. Diphenoxylate slows peristalsis.
3 This is correct. Antibiotics given to combat infection decrease the normal flora in the colon. The result is often diarrhea. Bacterial populations can be maintained with daily consumption of yogurt.
4 This is incorrect. Increasing the intake of fiber combats constipation, not diarrhea.
The nurse is providing care to the client who is 3 days status post–cardiac bypass grafting. The client has incisions to their medial right leg from the graft harvest of the saphenous vein. The client complains of warmth and tenderness to their right calf. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the client has what kind of complication?
1. Deep vein thrombosis (DVT)
2. Dehiscence of the wound
3. Internal bleeding
4. Infection at the incisional site
ANS: 1
1.This is correct. DVT is formation of a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratt’s sign (squeezing calf to trigger pain) are not reliable in diagnosing DVT.
2.This is incorrect. Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture.
3.This is incorrect. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia.
4.This is incorrect. Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature).
The nurse is caring for a client who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the client does which of the following? Select all that apply.
1. Describes signs associated with infection
2. Performs the dressing change as prescribed
3. Demonstrates absence of surgical incision pain
4. Completes the regimen of prescribed antibiotics
5. Completes bowel management regimen
ANS: 1, 2, 4
1.This is correct. The nurse would know that client teaching was effective if the client verbalizes signs and symptoms of infection.
2.This is correct. The nurse would know that client teaching was effective if the client can perform the ordered dressing change.
3.This is incorrect. Nurses cannot teach a client to be free of pain. Pain is subjective. The nurse can teach the client strategies to assist with pain, but they may not remove the pain completely.
4.This is correct. The nurse would know that client teaching was effective if the client completes the regimen of ordered antibiotics.
The nurse would expect which signs and symptoms for a patient with a suspected urinary tract infection (UTI)? Select all that apply.
1. Urinary frequency
2. Dysuria
3. Polyuria
4. Upper abdominal pain
5. Foul-smelling urine
1,2,5
1.This is correct. Signs and symptoms of urinary tract infections include urinary frequency.
2.This is correct. Dysuria is present with a UTI.
3.This is incorrect. Polyuria is excessive urination and does not occur with a UTI. However, it may be caused by excessive hydration, diabetes mellitus, diabetes insipidus, or kidney disease.
4.This is incorrect. Patients do not usually complain of upper abdominal pain with UTI but could have pain in the lower abdomen. Pain, if present, is flank pain when the UTI advances to a kidney infection.
5.This is correct. Foul-smelling urine is a sign of a UTI.
In advising an older adult who takes laxatives regularly, the nurse would identify which of the following factors? Select all that apply.
1. Consistent use of laxatives is thought to cause, rather that cure, constipation.
2. Habitual use of laxatives may lead to the need for ever-increasing dosages until the intestine fails to work properly.
3. Chronic laxative use can lead to dependency on the medication.
4. Over-the-counter (OTC) laxatives are better than bulking agents.
5. Laxative use is recommended, if taken regularly.
1,2,3
Rationale:
1. This is correct. Laxatives are used to treat constipation; however, consistent use can, in fact, lead to constipation.
2. This is correct. Laxatives are frequently abused by people who self-medicate with OTC drugs, may become dependent on them, and require ever-increasing dosages until the intestine fails to work properly.
3. This is correct. Chronic laxative use can lead to dependency on the medication.
4. This is incorrect. Bulking agents are better than OTC laxatives.
5. This is incorrect. Laxatives are to be used infrequently, not regularly.
The nurse assesses a client diagnosed with pneumonia. Which data findings indicate that the client is not oxygenating adequately? Select all that apply.
1. Oxygen saturation 87%
2. Arterial blood gas pH 7.33
3. Respiratory rate 52 breaths/min
4. Fine rales in the left lower lobe
5. Cyanosis of the nail beds and lips
ANS: 1, 3, 5
1. This is correct. An oxygen saturation of 87% is below the accepted range and indicates inadequate oxygenation.
2. This is incorrect. A pH of 7.33 indicates acidosis, but further information is needed to determine whether the cause is respiratory or metabolic. A respiratory acidosis indicates poor gas exchange, but oxygenation may be adequate with inadequate carbon dioxide exchange.
3. This is correct. A respiratory rate of 52 breaths/min does not allow adequate time for gas exchange and would contribute to a finding of inadequate oxygenation.
4. This is incorrect. Fine rales indicate an altered airway, but this finding alone is not adequate for indicating lack of oxygenation.
5. This is correct. Cyanosis is caused by lack of oxygen to the tissues and is a good indicator of inadequate oxygenation.
The nurse is preparing the client for general anesthesia. The client asks, “What are the advantages of general anesthesia?” Select all that apply.
1. Risk reduction
2. Unconsciousness
3. Adjusted for age, condition, and length of procedure
4. Muscle relaxation and motionlessness
5. Reduced infection
ANS: 2, 3, 4
1. This is incorrect. The respiratory and circulatory muscles are depressed, predisposing the patient to pneumonia and thrombophlebitis in the postoperative period. General anesthesia carries the risk for death, heart attack, stroke, and malignant hyperthermia.
2. This is correct. Under general anesthesia, the client is unconscious and experiences no anxiety that might affect cardiac and respiratory function.
3. This is correct. Anesthesia can be adjusted to accommodate age, physical condition, and the length of the procedure. For example, an older adult may require less anesthetic than anticipated and the anesthesiologist can adjust the dose without interrupting the procedure.
4. This is correct. Under general anesthesia, the muscles are relaxed, so the patient remains completely motionless during the surgical procedure.
5. This is incorrect. There is no evidence that general anesthesia reduces infections.
For each of the following concepts, use critical thinking to describe how or why it is important to nursing, patient care.
Sleep vs Rest
Sleep
Sleep restores energy, allows the body to heal, improves learning, and strengthens the immune system. Both the nurse and the patient must have adequate sleep to function optimally and be able to think critically.
Rest
Rest allows a person to be calm, at ease, and relaxed free of anxiety and stress. Patients require rest for healing and growth; nurses need to be rested to function effectively in a full-spectrum role.
You also could talk about physiology
Theoretical knowledge about the physiology of sleep
Theoretical knowledge will help the nurse and patient to schedule routines around nonsleep periods and will underlie the nurse’s decision to avoid disturbing patients during the most
critical periods of sleep. It also increases the nurse’s understanding of the effect of sleep on disease states and the effects of disease states on sleep.
Circadian rhythm
Suggested response:
Circadian rhythm is important because people function better when they schedule their activities and sleep with consideration of their circadian rhythms. When people try to sleep at times when they are normally wakeful, they do not rest well. Again, this knowledge is helpful when planning interventions to support sleep.
Stages of sleep (e.g., REM sleep)
Suggested response:
This helps nurses and patients understand why they may not feel rested even though they have apparently been sleeping for an appropriate amount of time. It reinforces the understanding that “normal” sleep patterns must be achieved to promote repair of muscles, memory, and so on. Knowledge of the stages of sleep also improves the understanding and use of sleep medications.
Sleep apnea
Suggested response:
Sleep apnea causes fatigue and can be dangerous because the person suffers daytime fatigue and may fall asleep at inopportune times. Untreated sleep apnea is associated with
polycythemia, hypertension, angina, coronary artery disease, right-sided heart failure, stroke, impotence, depression, personality changes, and mood swings.
Sedatives
Suggested response:
Sedatives can be beneficial in helping clients who are experiencing temporary sleep problems. For example, they can help a patient to sleep on the night after a major surgery, so that they can recuperate more effectively. Sedatives can prevent the fatigue that occurs with sleep deprivation, and they may help to prevent chronic sleep deprivation. Note: This is why they are important. This does not address the problems of patients becoming dependent on them or of their becoming less effective over time.
Sleep log
Suggested response:
A sleep log is a good tool to use to monitor and assess the patient’s sleep patterns. The patient and the nurse can work together to encourage good sleep hygiene. Keeping a log or diary involves the person in planning care.