Test #1 Flashcards
Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection.
Prodromal
What best motivates a patient to participate in an exercise program?
Providing information to the patient when the patient is ready to change behavior
Which group of patients is at most risk for severe injuries related to falls?
older adults
You are transferring a patient who weighs 320 lb (145.5 kg) from his bed to a chair. The patient has an order for partial weight bearing as a result of bilateral reconstructive knee surgery. What is the best technique for transfer?
ceiling mount lift
Which is the correct gait when a patient is ascending stairs on crutches?
A modified four-point gait. Both legs advance between the crutches to the stairs.
A patient recovering from bilateral knee replacements is prescribed bilateral partial weight bearing. You reinforce crutch walking knowing that which of the following crutch gaits is most appropriate for this patient?
Two-point gait
A patient on week-long bed rest is now performing isometric exercises. Which nursing diagnosis best addresses the safety of this patient?
Risk for activity intolerance
What is the priority concern when providing oral hygiene for a patient who is unconscious?
Preventing aspiration
You are helping a female patient bathe. As you are about to perform perineal care, the patient says, “I can finish my bath.” The patient has discomfort and burning in the perineal area. What action do you need to take initially?
Explain to the patient that, because of her symptoms, you need to observe the perineal area
The nurse recognizes that her older-adult patient needs additional teaching about skin care when the older adult says, “I should:
Use hot water for bathing.
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is:
Cystitis
A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void?
Suggest he stand at the bedside
An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to:
Initiate Kegel exercises.
Since removal of the patient’s Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first?
Check for bladder distention
To minimize the patient experiencing nocturia, the nurse would teach him or her to:
Limit fluids before bedtime
The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by:
1700
If 4 hours after Foley removal have elapsed without voiding, it may be necessary to reinsert the Foley
The postoperative patient has difficulty voiding after surgery and is feeling “uncomfortable” in the lower abdomen. Which action should the nurse implement first?
Turn on the bathroom faucet as he tries to void
What is an Intravenous pyelogram?
a special x-ray examination of the kidneys, bladder, and ureters. The dye used in the procedure is iodine based. Assessing for history of any allergies can predict allergy to the dye used. Fluid intake dilutes and flushes the dye from the patient.
The nurse notes that the patient’s Foley catheter bag has been empty for 4 hours. The priority action would be to:
Check for kinks in the tubing
A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is:
750-1000 mL
The nurse is caring for a patient with a colostomy. Which intervention is most important?
Selecting a bag with an appropriate-size stoma opening
The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to:
Prevent gastric mucosal damage.
Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to
Ask the patient to void
The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient?
When was the last time you moved your bowels?
The nurse recognizes which patient needs to use a fracture pan for a bowel movement?
A patient recovering from hip surgery
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, “It hurts when I try to breathe, and I can’t catch my breath.” Your first action is to:
Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher?
The patient received an injection of morphine 30 minutes ago for pain.
Which is an outcome for a patient diagnosed with osteoporosis?
Maintain independence with activities of daily living (ADLs)
