Module 7 Flashcards
An older adult female client tells the nurse, “Whenever I sneeze or cough, I urinate a little bit. It’s very embarrassing.” The nurse interprets the client’s statement as indicating which type of incontinence?
Stress
A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?
The client will have to wear an external appliance to collect urine
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?
intermittent urethral catheter
While providing care to a client admitted to the health care facility, the client states that she has “a burning sensation when urinating.” After further questioning, the nurse inspects the client’s perineal area. Which sign/symptom would the nurse document as an abnormal finding?
Reddened perineal skin
What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?
It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?
anuria
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?
cloudy, foul odor
The nurse is caring for a male client who has a urinary obstruction and is not a candidate for surgery. Which intervention will the nurse prepare the client for?
Insertion of a urologic stent
A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours?
functional incontinence
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?
Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.
The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?
“Let’s review the types of fluids that your child drinks in the morning.”
A woman is reporting bladder urgency. It is most important to assess:
caffeine intake.
The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?
“Void a small amount, stop, and discard it.”
The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?
Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.
A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client?
“How frequently do you urinate each day?”
The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?
The birth can cause perineal swelling
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?
The client has an enlarged prostate.
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?
Boys may take longer for daytime continence than girls.
The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:
pus
Which condition will have a great impact on the extracellular fluid for water conservation?
Burns
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
“Very little scar tissue will form.”
The nurse is preparing to measure the depth of a client’s tunneled wound. Which implement should the nurse use to measure the depth accurately?
a sterile, flexible applicator moistened with saline
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?
stage III
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?
stage III
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports “it feels numb.” What is the best action by the nurse at this time?
Discontinue the therapy and assess the client.
A client who had a knee replacement asks the nurse, “Why do I need this little bulb coming out of my knee?” What is the appropriate nursing response?
“The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound.”
A postoperative client is being transferred from the bed to a gurney and states, “I feel like something has just given away.” What should the nurse assess in the client?
Dehiscence of the wound
A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?
An infant’s skin and mucous membranes are easily injured and at risk for infection
For which client would the application of a hydrocolloid dressing be most appropriate?
A client who has a partial-thickness venous ulcer with moderate drainage
OR
A client who has just undergone a cholecystectomy (gallbladder removal)
A client who has a partial-thickness venous ulcer with moderate drainage
What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?
hydrocolloid
The nurse observes the presence of intestinal contents protruding from the client’s surgical wound after colon resection. What action will the nurse take?
Apply saline solution–moistened gauze over the protruding area.
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?
Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?
Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?
The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?
Diffuse dermatitis accompanied by pruritus
A medical-surgical nurse is assisting a wound care nurse with the debridement of a client’s coccyx wound. What is the primary goal of this action?
removing dead or infected tissue to promote wound healing
A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?
use pillows to maintain a side-lying position as needed
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?
“Dehiscence is when a wound has partial or total separation of the wound layers.”
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
Clean the wound from the top to the bottom and from the center to outside.
A full-thickness or third-degree burn develops a leathery covering called a(an):
eschar
The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma?
Use water and mild soap
The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?
Stop the administration of the enema momentarily.
A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?
cleansing enema
A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?
Begin by measuring from the tip of the client’s nose to the earlobe to the xiphoid process
The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?
The NG tube is in the client’s airway.
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?
Disconnect the nasogastric tube from suction during the assessment of bowel sounds.
When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate?
briefly clamping the tubing while the client breathes deeply
The nurse assesses the stool of clients admitted to the hospital with abdominal distress. Which statements accurately describe the normal characteristics of stool and special considerations for observation? Select all that apply.
The rapid rate of peristalsis in the breastfed infant causes the stool to be yellow.
Antacids in the diet cause the stool to be whitish.
A gastrointestinal obstruction may result in a narrow, pencil-shaped stool.
A nurse is caring for a client whose primary care provider has written an order for “enemas until clear.” Which explanation to the client about this procedure is correct?
“I will administer enemas until the enema return is without stool.”
The health care provider has prescribed a hypertonic sodium solution for a client who requires immediate colonic emptying. Which client factor should the nurse notify the provider about that will prevent administration of this type of enema? Select all that apply.
The client has a history of chronic renal failure.
The client has an elevated glucose level.
The client has an elevated phosphorus level. The client is lactose intolerant. The client has a history of left sided heart failure.
The client has a history of chronic renal failure.
The client has an elevated phosphorus level.
The client has a history of left sided heart failure.
The nurse provides teaching to a client experiencing constipation. Which food choice on the client’s breakfast tray indicates effective teaching?
Grapefruit
Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?
Digital removal of stool may cause parasympathetic stimulation
A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?
If within 2 hours after NG tube removal, the client’s abdomen is showing signs of distention, notify the health care provider.
The student nurse is caring for a client with a colostomy. When changing the ostomy appliance, the nurse manager would intervene if which action by the student is observed?
Starts at the bottom of the appliance, holds abdominal skin taut and gently removes the faceplate
While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?
Stop the procedure, monitor heart rate and blood pressure.
A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?
“This test detects heme, an iron compound in blood within the stool.”
The nurse is selecting antidiarrheal medications for clients with diarrhea. Which statements accurately describe the action of specific antidiarrheal medications? Select all that apply.
Loperamide is a nonaddictive antidiarrheal medication that has a longer duration of action than diphenoxylate/atropine.
Bismuth subsalicylate contains salicylates; a physician should be consulted before giving it to children or clients taking aspirin.
Paregoric contains morphine and may be addictive.
The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?
fecal occult blood test, barium studies, endoscopic examination
Which medication causes constipation?
Magnesium antacids
Bisacodyl
Aspirin Iron supplements
Iron supplements
Which factor is related to developmental changes in bowel habits for older adult clients?
Weakened pelvic muscles lead to constipation
The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?
Right lateral
OR
Left lateral
Left lateral
What is first intention wound healing?
wound that is closed surgically with sutures or staples as close as possible
What is second intention wound healing?
A wound that is clean and left alone to close on it’s own
What is third-intention wound healing?
wound left open for a period of time to ensure no infection, then closed at a later time with sutures or staples
What stage pressure injury is occuring when the skin is non-blanchable persistent red skin?
Stage I
What stage pressure injury presents with partial thickness loss of dermis?
Stage II- presents as shallow open ulcer with red/ pink wound bed without slough.
This pressure injury stage may also present as an intact or open/ruptured serum-filled blister
Stage II
What stage pressure injury presents with full thickness tissue loss that may have subcutaneous fat visible but NOT bone, tendon, or muscles exposed?
Stage III- slough may be present but does not obscure the depth of the tissue loss
This stage pressure injury MAY include undermining and tunneling
Stage III
Which stage pressure injury presents with full thickness loss with exposed tendon or muscle?
Stage IV
This pressure injury stage may present with slough or eschar on some parts of the wound bed and often includes undermining and tunneling
Stage IV
A Braden Score of 15-18 is:
At risk
A Braden Score of 13-14 is:
moderate risk
A Braden Score of 10-12 is:
high risk
A Braden Score of < 9 is:
very high risk
What is oliguria?
abnormally small amounts of urine that could indicate a problem with ADH
When would a urine specific gravity level be high?
High d/t dehydration
What do casts in a urinalysis indicate?
infection- it is the sloughing of epithelial cells in the tubules
BUN and Creatinine are high in the urine when:
Kidney function is impaired b/c its not being taken out by kidneys indicating impaired functioning
When is a 3 way catheter used?
Used when there is recent surgery in the bladder and saline is used to irrigate for bleeding so it does not clot and block the hole
What pt would get a coude tip catheter?
pt w/ prostate issues
Indwelling catheters are used:
acute urinary retention or bladder outlet obstruction
The bristol stool chart Type 7 is:
entirely liquid with no solid pieces
The bristol stool chart Type 1 is:
Separate hard lumpy stool that is hard to pass
This type is considered normal on the Bristol Stool Chart:
Type 4: like a sausage or snake, smooth and soft
