Exam 1 Practice - Fundamentals of Nursing Part 3

Nutrition – Chp. 36 a. b. c. d. 1. A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient’s height is 5′6″ and his current weight is 325 lb. What would the nurse document as his BMI? 50.5 52.4 54.5 55.2 a. b. c. d. e. f. 2. A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply. Absence of nausea, vomiting Weight gain Bowel sounds within normal range Large amount of gastric residue Absence of diarrhea and constipation Slight abdominal pain and distention 3. A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process? a. Stroke the underside of the patient’s chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime. a. b. c. d. 4. A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient? Administering pain medication after meals. Encouraging food from home when possible. Scheduling his respiratory therapy before each meal. Reinforcing the importance of his eating exactly what is delivered to him. a. b. c. d. 5. A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? Feed the patient solids first and then liquids last. Place the head of the bed at a 30-degree angle during feeding. Puree all foods to a liquid consistency. Provide a 30-minute rest period prior to mealtime. a. b. c. d. e. f. 6. A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. A patient with irritable bowel syndrome who has intractable diarrhea A patient with celiac disease not absorbing nutrients from the GI tract A patient who is underweight and needs short-term nutritional support A patient who is comatose and needs long-term nutritional support A patient who has anorexia and refuses to take foods via the oral route A patient with burns who has not been able to eat adequately for 5 days a. b. c. d. 7. A nurse is feeding a patient who states that she is feeling nauseated and can’t eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? Remove the tray from the room. Administer an antiemetic and encourage the patient to take small amounts. Explore with the patient why she does not want to eat her food. Offer high-calorie snacks such as pudding and ice cream. a. b. c. d. 8. A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? Vitamin B malnutrition Obesity Dehydration Vitamin C deficiency a. b. c. d. 9. A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. The nurse wets a washcloth and washes the area around the tube with soap and water. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. The nurse tapes a gauze dressing over the site after cleansing it. 10. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient’s diet should not be advanced? a. b. c. d. The patient consumed 75% of the liquids on her breakfast tray. The patient tells you she is hungry. The patient’s abdomen is soft, nondistended, with bowel sounds. The patient reports fullness and diarrhea after breakfast. a. b. c. d. 11. A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? Auscultate the bowel sounds. Measure the gastric aspirate pH. Measure the amount of residual in the tube. Obtain an order for a radiographic examination of the tube. a. b. c. d. 12. Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18? Risk for Imbalanced Nutrition: More Than Body Requirements Imbalanced Nutrition: More Than Body Requirements Readiness for Enhanced Nutrition Imbalanced Nutrition: Less Than Body Requirements a. b. c. d. 13. A nurse nutritionist is collecting assessment data for a patient who complains of “tiredness” and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm? Malabsorption Anemia Protein depletion Reduction in total muscle mass a. b. c. d. 14. A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse’s next action following this assessment? Use warm water or air and gentle pressure to remove the clog. Use a stylet to unclog the tubes. Administer cola to remove the clog. Replace the tube with a new one. a. b. c. d. 15. A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? A 19-year-old patient who is a vegan An older adult patient who takes daily nutritional drinks A 43-year-old patient who takes ginkgo biloba and an aspirin daily An infant who is breastfeeding ANSWERS WITH RATIONALES 1. b. 2. a, c, e. Criteria to consider when evaluating patient feeding tolerance include: absence of nausea, vomiting, minimal or no gastric residual, absence of diarrhea and constipation, absence of abdominal pain and distention, presence of bowel sounds within normal limits. 3. a. To feed a patient with dementia, the nurse should stroke the underside of the patient’s chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands. 4. b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply. 5. d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency. 6. a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract; and when oral intake has been or is expected to be inadequate over a 7- to 14-day period. PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will. 7. a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect. 8. a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract. 9. a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry. 10. d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray. 11. d. Although a radiographic examination exposes the patient to radiation and is costly, it is still the most accurate method to check correct tube placement. Other methods that can be used are aspiration of gastric contents and measurement of the pH of the aspirate. The recommended method for checking placement, other than a radiograph, is measuring the pH of the aspirate. Visual assessment of aspirated gastric contents is also suggested as a tool to check placement. In addition, the length of the exposed tube is measured after insertion and documented. Tube length should be checked and compared with this initial measurement, in conjunction with the previous two methods for checking tube placement. The auscultatory method is considered inaccurate and unreliable. Measurement of residual amount does not confirm placement. 12.d. A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate. The patient is not at risk for imbalanced nutrition because it is already a problem and certainly is not experiencing nutrition that is more than body requirements. Readiness for Enhanced Nutrition is appropriate when there is a healthy pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened and enhanced. 13.b. Test results for hemoglobin (normal = 12 to 18 g/dL): if decreased it indicates anemia; results for hematocrit (normal = 40% to 50%): if decreased indicates anemia, if increased indicates dehydration. Serum albumin tests for malnutrition and malabsorption. Protein depletion and malnutrition are diagnosed with serum albumin, prealbumin, transferrin, and blood urea nitrogen tests. The creatinine test may indicate dehydration, reduction in total muscle mass, and severe malnutrition. 14.a. In order to remove a clog in a feeding tube, the nurse should try using warm water or air and gentle pressure to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced. 15.c. A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties. Being a vegan should not affect surgery unless the patient has serious nutritional deficiencies. Drinking nutritional drinks and breastfeeding do not adversely affect the outcomes of surgery. Activity – Chp. 33 a. b. c. d. e. f. 1. A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. Instruct the patient to avoid sudden position changes that may cause dizziness. Recommend that the patient restrict fluid until after exercising is finished. Instruct the patient to push a little further beyond fatigue each session. Instruct the patient to avoid exercising in very cold or very hot temperatures. Encourage the patient to modify exercise if weak or ill. Recommend that the patient consume a high-carb, low-protein diet. 2. A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is “too tired to go on.” What would be priority nursing actions for this patient? Select all that apply. a. Stop performing the exercises. b. Decrease the number of repetitions performed. c. Reevaluate the nursing care plan. d. e. f. Move to the patient’s other side to perform exercises. Encourage the patient to finish the exercises and then rest. Assess the patient for other symptoms. a. b. c. d. e. f. 3. A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: Grasp the gait belt. Stay with the patient and call for help. Place feet wide apart with one foot in front. Gently slide patient down to the floor, protecting her head. Pull the weight of the patient backward against your body. Rock your pelvis out on the side of the patient. a. b. c. d. 4. A nurse caring for patients in a pediatrician’s office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? A 4-month-old infant who is unable to roll over A 6-month-old infant who is unable to hold his head up himself An 11-month-old infant who cannot walk unassisted An 18-month-old toddler who cannot jump a. b. c. d. 5. A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? Have the patient extend his arms outward and cross his legs on top of a pillow. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. Have the patient cross his arms on his chest and place a pillow between his knees. Place a cervical collar on the patient’s neck and gently roll him to the other side of the bed. a. b. c. d. 6. A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? Improved renal blood supply to the kidneys Urinary stasis Decreased urinary calcium Acidic urine formation a. b. c. d. 7. A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? Dorsal recumbent position Lateral position Fowler’s position Sims’ position 8. A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. a. Do full-body pushups in bed six to eight times daily. b. Breathe in and out smoothly during quadriceps drills. c. d. e. f. Place the bed in the lowest position or use a footstool for dangling. Dangle on the side of the bed for 30 to 60 minutes. Allow the nurse to bathe the patient completely to prevent fatigue. Perform quadriceps two to three times per hour, four to six times a day. a. b. c. d. 9. A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient’s feet to prevent footdrop? Supination Dorsiflexion Hyperextension Abduction a. b. c. d. 10. A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? Support weight on stronger leg and cane and advance weaker foot forward. Hold the cane in the same hand of the leg with the most severe deficit. Stand with as much weight distributed on the cane as possible. Do not use the cane to rise from a sitting position, as this is unsafe. a. b. c. d. 11. A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? Use the axillae to bear body weight. Keep elbows close to the sides of the body. When rising, extend the uninjured leg to prevent weight bearing. To climb stairs, place weight on affected leg first. a. b. c. d. 12. A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? Carefully assessing the patient care environment Using two nurses to lift a patient who cannot assist Wearing a back belt to perform routine duties Properly documenting the patient lift a. b. c. d. 13. A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient’s and she tells the nurse she feels faint. What is the appropriate nursing action? Wait a few minutes and then continue the move to the chair. Call for assistance and continue the move with the help of another nurse. Lower the f pivot her back into bed. Have the patient sit down on the bed and dangle her feet before moving. a. b. c. d. 14. A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? Side-lying Fowler’s Sims’ Prone 15. A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: “Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient a. b. c. d. needs help moving from bed to chair. Patient follows directions and can feed self.” Based on this data, which score would the patient receive on the Katz index? 2 4 5 6 ANSWERS WITH RATIONALES 1. a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D–enriched diet. 2. a, c, f. When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day. 3. c, f, a, e, d, b. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help. 4. b. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump. 5. c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses. 6. b. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively. 7. c. Fowler’s position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims’ position would not facilitate respiration and would be difficult for the patient to maintain. 8. b, c, f. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs. 9. b. For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop. 10.a. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position. 11.b. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs. 12.a. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention. 13.c. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient’s vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position. 14.d. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine. 15.b. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding. Urinary Elimination – Chp. 37 1. A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. a. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. b. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. c. d. e. f. The nurse collects a sterile urine specimen from the collection receptacle of a patient’s indwelling catheter. The nurse collects about 3 mL of urine from a patient’s indwelling catheter to send for a urine culture. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient. a. b. c. d. e. f. 2. A nurse caring for patients in an extended-care facility performs regular assessments of the patients’ urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. A 78-year-old male patient diagnosed with an enlarged prostate An 83-year-old female patient who is on bedrest A 75-year-old female patient who is diagnosed with vaginal prolapse An 89-year-old male patient who has dementia A 73-year-old female patient who is taking antihistamines to treat allergies A 90-year-old male patient who has difficulty walking to the bathroom a. b. c. d. e. f. 3. A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply. Wear underwear with a synthetic crotch Take baths rather than showers Drink 8 to 10 8-oz glasses of water per day Drink a glass of water before and after intercourse and void afterward Dry the perineal area after urination or defecation from the front to the back Observe the urine for color, amount, odor, and frequency a. b. c. d. 4. A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient’s urine output? Decreased and highly concentrated Decreased and highly dilute Increased and concentrated Increased and dilute a. b. c. d. 5. The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? The male urethra is more vulnerable to injury during insertion. In the hospital, a clean technique is used for catheter insertion. The catheter is inserted 2 to 3 in into the meatus. Since it uses a closed system, the risk for UTI is absent. a. b. c. d. 6. A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? Irrigation of long-term urinary catheters is a routine order. Irrigation is recommended to prevent the introduction of pathogens into the bladder. A blood clot threatens to block the catheter. It is preferred to irrigate the catheter rather than increase fluid intake by the patient. 7. A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. a. Measure the patient’s fluid intake and output. b. c. d. e. f. Keep the skin around the stoma moist. Empty the appliance frequently. Report any mucus in the urine to the primary care provider. Encourage the patient to look away when changing the appliance. Monitor the return of intestinal function and peristalsis. a. b. c. d. 8. A nurse is changing the stoma appliance on a patient’s ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? The stoma is hard and dry. The stoma is a pale pink color. The stoma is swollen. The stoma is a purple-blue color. a. b. c. d. 9. After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? Pouring warm water over the patient’s fingers. Having the patient ignore the urge to void until her bladder is full. Using a warm bedpan when the patient feels the urge to void. Stroking the patient’s leg or thigh. a. b. c. d. 10. A nurse caring for a patient’s hemodialysis access documents the following: “5/10/20 0930 AV fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted.” Which documented finding would the nurse report to the primary care provider? Positive bruit noted. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive thrill noted. a. b. c. d. 11. A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? Teach the patient that incontinence is a normal occurrence with aging. Ask the patient’s family to purchase incontinence pads for the patient. Teach the patient to perform PFMT exercises at regular intervals daily. Insert an indwelling catheter to prevent skin breakdown. a. b. c. d. 12. A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic). The patient questions the nurse: “My urine was bright orangish red today; is there something wrong with me?” What would be the nurse’s best response? “This is a normal finding when taking phenazopyridine.” “This may be a sign of blood in the urine.” “This may be the result of an injury to your bladder.” “This is a sign that you are allergic to the medication and must stop it.” a. b. c. d. 13. A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What action would be a priority when caring for this patient? Preventing the tubing from kinking to maintain free urinary drainage Not removing the sheath for any reason Fastening the sheath tightly to prevent the possibility of leakage Maintaining bedrest at all times to prevent the sheath from slipping off 14. A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow? a. b. c. d. a. b. c. d. The nurse would use different equipment for catheterization of male versus female patients. The nurse should use the smallest appropriate indwelling urinary catheter. The nurse should always sterilize the equipment prior to insertion. The nurse should choose a 12F, 5-mL or 10-mL balloon, unless ordered otherwise. 15. Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least important for the evaluation process? The incontinence pattern State of physical mobility Medications being taken Age of the patient ANSWERS WITH RATIONALES 1. d, e, f. A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. 2. a, c, e. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence. 3. c, e, f. It is recommended that a healthy adult drink 8 to 10 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse. 4. a. Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount. 5. a. Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6 to 8 in. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI. 6. c. The flushing of a tube, canal, or area with solution is called irrigation. Natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction. However, intermittent irrigation is sometimes prescribed to restore or maintain the patency of the drainage system. Sediment or debris, as well as blood clots, might block the catheter, preventing the flow of urine out of the catheter. 7. a, c, f. When caring for a patient with a urinary diversion, the nurse should measure the patient’s fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma. 8. d. A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should subside with time. A normal stoma should be moist and dark pink to red in color. 9. b. Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding. 10. b. The nurse would report a site that is warm and edematous as this could be a sign of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein. If these are not present, the access may be cutting off. No report of pain is a normal finding. 11. c. Kegel exercises may help a patient regain control of the micturition process. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. An indwelling catheter is the last choice of treatment. Bowel Elimination – Chp. 38 a. b. c. d. 1. A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses. a. b. c. d. 2. A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? Elevate the head of the bed 30 degrees and reposition the rectal tube. Place the patient in a supine position and modify the amount of solution. Lower the solution container and check the temperature and flow rate. Remove the rectal tube and notify the primary care provider. a. b. c. d. e. f. 3. A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. A patient diagnosed with peritonitis A patient who is on prolonged bedrest A patient who has diarrhea A patient who has gastroenteritis A patient who has an early bowel obstruction A patient who has paralytic ileus caused by surgery 4. A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a. b. c. d. e. f. A patient who is taking narcotics for pain A patient who is taking metformin for type 2 diabetes mellitus A patient who is taking diuretics A patient who is dehydrated A patient who is taking amoxicillin for an infection A patient taking over-the-counter antacids a. b. c. d. 5. A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient? The nurse administers a large volume of solution (500 to 1,000 mL) The nurse mixes milk and molasses in equal parts for an enema The nurse instructs the patient to retain the enema for at least 30 minutes The nurse administers the enema while the patient is sitting on the toilet a. b. c. d. e. f. 6. A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. “When you inspect the stoma, it should be dark purple-blue.” “The size of the stoma will stabilize within 2 weeks.” “Keep the skin around the stoma site clean and moist.” “The stool from an ileostomy is normally liquid.” “You should eat dark-green vegetables to control the odor of the stool.” “You may have a tendency to develop food blockages.” a. b. c. d. 7. A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? Have the patient follow a low-fiber diet several days before the test. Have the patient take bisacodyl and ingest a gallon of bowel cleaner on day 1. Prepare the patient for the use of general anesthesia during the test. Explain that barium contrast mixture will be given to drink before the test. d. 8. A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should be the nurse’s next action? Reassure the patient that this is a normal reaction to the procedure. Stop the procedure, prepare to administer CPR, and notify the primary care provider. Stop the procedure, assess vital signs, and notify the primary care provider. Stop the procedure, wait 5 minutes, and then resume the procedure. a. b. c. d. 9. A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? c, b, d, a d, c, a, b a, b, d, c b, a, d, c a. b. c. d. 10. A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply. Draw up 30 mL of saline solution into the syringe. Unclamp the suction tubing near the connection site to instill solution. Place the tip of the syringe in the tube to gently insert saline solution. Place the syringe in the blue air vent of a Salem sump or double-lumen tube. a. b. c. e. f. After instilling irrigant, hold the end of the NG tube over an irrigation tray. Observe for return flow of NG drainage into an available container. a. b. c. d. 11. A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention? Using a diet that is low in bulk Decreasing fluid intake to 1,000 mL Administering an enema once a day to stimulate peristalsis Monitoring bowel movements a. b. c. d. 12. A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient? Incontinence Constipation Electrolyte imbalances Infection a. b. c. d. 13. For which patient would a nurse expect the primary care provider to order colostomy irrigation? A patient with IBS A patient with a left-sided end colostomy in the sigmoid colon A patient with post-radiation damage to the bowel A patient with Crohn’s disease a. b. c. d. 14. A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse’s first action in this situation? Reassure the patient that this is a normal finding with a new ostomy. Notify the primary care provider that the stoma is prolapsed. Have the patient rest for 30 minutes to see if the prolapse resolves. Remove the appliance and redo the procedure using a larger appliance. a. b. c. d. 15. A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? A saline osmotic laxative A bulk-forming laxative Methylcellulose A stool softener ANSWERS WITH RATIONALES 1. a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals. 2. c. If the patient reports severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. The head of the bed may be elevated 30 degrees for the patient’s comfort if the patient needs to be placed on a bedpan in the supine position while receiving the enema. 3. a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes —signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged 4. 5. 6. 7. immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction. b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation. c. The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer’s instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort. d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark-green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry. a. If possible, a low-residue diet (low fiber) should be followed several days before the procedure. Most will maintain the low-residue diet; others may have full liquid diet the day before the procedure. There are multiple types of bowel preps for this procedure. The provider performing the procedure will decide which is best for the individual patient. The prep is usually given as a split dose, with half being given the night before and rest the morning of the procedure. It is recommended the second dose be given at least 5 hours and completed at least 2 hours before the study. There are some who may receive the prep the same day as the procedure, especially if the procedure is scheduled for later in the day. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and small-bowel series of tests. 8. c. When a patient reports dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the health care provider. The vagus nerve may have been stimulated. 9. d. A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them. 10.a, c, e, f. The nurse irrigating an NG tube connected to suction should draw up 30 mL of saline solution (or the amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container. 11.d. For a bowel-training program to be effective, the nurse should monitor bowel movements including frequency, consistency, shape, volume and color, as appropriate, monitor bowel sounds, teach patient about specific foods that are assistive in promoting bowel regularity, ensure privacy, and encourage adequate fluid intake. 12.a. The outcomes for this IPAA surgery are not always ideal, and many patients experience decreased quality of life due to frequent defecation and fecal seepage and incontinence. 13.b. Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, post-radiation damage to the bowel, diverticulitis, and Crohn’s disease. 14.c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma. 15.a. Certain saline osmotic laxatives can lead to fluid and electrolyte imbalances and should not be used in older adults or those with kidney or cardiac disease.