Unit 4 Comprehensive Review

Unit 4 Comprehensive Review

Multiple Choice

When assessing the patient who has a lower urinary tract infection (UTI), the nurse will initially ask about

• a. flank pain.

• b. pain with urination.

• c. poor urine output.

• d. nausea.

B

Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

Multiple Choice

Trimethoprim and sulfamethoxazole (Bactrim) BID for 7 days is ordered for a patient who has a recurrent relapse of an Escherichia coli UTI. The nurse instructs the patient to:

• a. take the antibiotic for the full 7 days, even if symptoms improve in a few days.

• b. return to the clinic in 3 days so that a urine culture can be done to evaluate the effectiveness of the drug.

• c. increase the effectiveness of the drug by taking it with cranberry juice to acidify the urine.

• d. take two of the pills a day for 5 days, and reserve the rest of the pills to take if the symptoms reappear.

A

Although an initial infection may be treated with a shorter course of antibiotics, the patient with a recurrent infection should take the antibiotic for 7 days. Success of treatment is evaluated by resolution of symptoms rather than by a repeat culture. Acidifying the urine when a patient is taking sulfa antibiotics may lead to stone formation. The patient is instructed to take all the antibiotics.

Multiple Choice

The nurse determines that instruction regarding prevention of future UTIs for a patient with cystitis has been effective when the patient states,

• a. "I will empty my bladder every 3 to 4 hours during the day."

• b. "I can use vaginal sprays to reduce bacteria."

• c. "I will wash with soap and water before sexual intercourse."

• d. "I will drink a quart of water or other fluids every day."

A

Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

Multiple Choice

To relieve the symptoms of a lower UTI for which the patient is taking prescribed antibiotics, the nurse suggests that the patient use the OTC urinary analgesic phenazopyridine (Pyridium) but cautions the patient that this preparation:

• a. contains methylene blue, which turns the urine blue or green.

• b. should be taken on an empty stomach for maximum effect.

• c. causes the urine to turn reddish orange and can stain underclothing.

• d. frequently causes allergic reactions and should be stopped if a rash occurs.

C

Patients should be taught that Pyridium will color the urine deep orange and stain underclothing. Urised may turn the urine blue or green. The medication can cause gastrointestinal distress and should be taken with food. Although an allergic reaction may occur, this is not common.

Multiple Choice

A 72-year-old patient with benign prostatic hyperplasia and a history of frequent UTIs is admitted to the hospital with chills, fever, and nausea and vomiting. To determine whether the patient has an upper UTI, the nurse will assess for:

• a. suprapubic pain.

• b. foul-smelling urine.

• c. bladder distension.

• d. costovertebral angle (CVA) tenderness.

D

CVA tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.

Multiple Choice

A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

• a. Draw blood for blood urea nitrogen (BUN) and creatinine.

• b. Administer lorazepam (Ativan) 0.5 mg.

• c. Insert 16 French retention catheter.

• d. Schedule for IVP.

C

The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently.

Multiple Choice

A patient with a history of renal calculi is hospitalized with gross hematuria and severe colicky left flank pain that radiates to his left testicle. In planning care for the patient, the nurse gives the highest priority to the nursing diagnosis of:

• a. acute pain related to irritation by the stone.

• b. deficient fluid volume related to inadequate intake.

• c. risk for infection related to urinary system damage.

• d. risk for nausea related to pain and renal colic.

A

Although all the diagnoses are appropriate, the initial nursing actions should focus on relief of the acute pain.

Multiple Choice

The nurse instructs a patient seen in the outpatient clinic with symptoms of renal calculi to strain all urine and to

• a. report the pain level when the stone passed.

• b. collect the stone and bring it to the clinic.

• c. record the time that the stone passed.

• d. save a urine specimen to check for blood.

B

The patient should save the stone for analysis of the stone composition, which will help in determining treatment. Reporting the pain level and recording the time the stone passed are not essential. Hematuria is common with urinary calculi, so it is not necessary to test the urine for blood.

Multiple Choice

A patient with a confirmed urinary stone in the proximal left ureter undergoes extracorporeal shock-wave lithotripsy. Which information is most important for the nurse to collect after lithotripsy?

• a. Urine output

• b. Pain level

• c. Appearance of the site

• d. Patient temperature

A

Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to monitor the urine output. The patient may have pain as the stones pass and bruising at the site, but these are not unexpected. Extracorporeal shock wave lithotripsy (ESWL) is not associated with a risk for infection.

Multiple Choice

The composition of a patient's renal calculus is identified as uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid:

• a. spinach, chocolate, and tomatoes.

• b. organ meats and fish with fine bones.

• c. milk and dairy products.

• d. legumes and dried fruits.

B

Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

Multiple Choice

A 78-year-old patient is admitted to the hospital with dehydration and electrolyte imbalance. The patient is confused and incontinent of urine on admission. In developing a plan of care for the patient, an appropriate nursing intervention for the patient's incontinence is to:

• a. insert an indwelling catheter.

• b. apply absorbent incontinent pads.

• c. assist the patient to the bathroom q2hr.

• d. restrict fluids after the evening meal.

C

In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for UTI. Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

Multiple Choice

After her bath, a 62-year-old patient asks the nurse for a perineal pad, saying that she uses them because sometimes she leaks urine when she laughs or coughs. Which intervention is most appropriate to include in the care plan for the patient?

• a. Teach the patient how to perform Kegel exercises.

• b. Demonstrate how to perform Credé's maneuver.

• c. Place commode at the patient's bedside.

• d. Assist the patient to the bathroom q3hr.

A

Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé maneuver is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.

Multiple Choice

A pt in the hospital has a history of urinary incontinence. Which nursing action will be included in the plan of care?

• a. Place a bedside commode near the patient's bed.

• b. Use an ultrasound scanner to check urine residual after the patient voids.

• c. Demonstrate the use of the Credé maneuver to the patient.

• d. Teach the use of Kegel exercises to strengthen the pelvic floor.

A

Environmental changes can make it easier for the patient to avoid incontinence for patients with urinary incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.

Multiple Choice

After the home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying, which patient statement indicates that the teaching has been effective?

• a. "I will need to buy seven new catheters weekly and use a new one every day."

• b. "I will use a sterile catheter and gloves for each time I self-catheterize."

• c. "I will need to take prophylactic antibiotics to prevent any urinary tract infections."

• d. "I will wash the catheter with soap and water before and after each catheterization."

D

Patients who are at home can use a clean technique for intermittent self-catheterization and change the catheter every 7 days. There is no need to use a new catheter every day, to use sterile catheters, or to take prophylactic antibiotics.

Multiple Choice

The nurse observes a nursing assistant (NA) doing all of the following when caring for a patient with a retention catheter. Which action requires that the nurse intervene?

• a. The NA uses an alcohol-based hand cleaner before performing catheter care.

• b. The NA disconnects the catheter from the drainage tube to obtain a specimen.

• c. The NA uses soap and water when cleaning around the urinary meatus.

• d. The NA tapes the catheter to the skin on the patient's upper inner thigh.

B

The catheter should not be disconnected from the drainage tube because this increases the risk for UTI. The other actions are appropriate and do not require any intervention.

Multiple Choice

Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider?

• a. Dysuria

• b. Temperature 100.1°F

• c. Left-sided flank pain

• d. Hematuria

C

Flank pain indicates that the patient may have developed pyelonephritis as a complication of the bladder infection. The other clinical manifestations are consistent with a lower UTI.

Multiple Choice

The Patient hx indicates the the patient was taking ondanserton at home before admission. The nurse inquires as to the effectiveness of this medication in treating which symptom?

• a. Pain

• b. Nausea

• c. Headache

• d. Leg Cramps

B

Ondanserton (Zofran) is an antiemetic. The nurse would inquire as to its effectiveness in reducing the pt's nausea. Ondanserton will not treat headaches, pain, or leg cramps.

Multiple Choice

Following the administration of a dose of metoclopramide to the pt, the nurse determines that the medication has been effective when what is noted?

• a. Decreased BP

• b. Absence of muscle tremors

• c. Relief of nausea and vomiting

• d. No further episodes of diarrhea

C

Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the pt's nausea and vomiting should resolve. Metoclopramide does not affect BP, muscle tremors, or diarrhea.

Multiple Choice

The nurse is assisting a patient who has been admitted with severe abdominal pain. Suddenly, the pt vomits a large amount of emesis that looks similar to coffee grounds. Which action by the nurse is a priority?

• a. Ask the pt about the timing of the last meal

• b. Offer the pt sips of water to prevent dehydration

• c. Monitor the pt for any further episodes of nausea and vomiting

• d. Notify the primary health care provider about the pt's condition

D

 Vomitus with a "coffee ground" appearance is related to gastric bleeding, in which blood changes to dark brown as a result of its interaction with hydrochloric acid. The primary health care provider needs to be notified immediately about this change in the pt's condition. Asking the pt about the timing of the last meal and monitoring the pt are appropriate, but not priority. The nurse should not offer water just in case the pt may have a diagnostic study that requires NPO status.

Multiple Choice

The postop pt state that he or she has never taken pantoprazole in the past. The pt asks why he or she is getting this medication if the pt has never had heartburn. What is thee best response by the nurse?

• a. "This will prevent gas pains from the excess air in your small intestine."

• b. "This will prevent the heartburn that occurs as a side effect of your diabetes."

• c. "The stress of surgery is likely to cause stomach bleeding if you don't receive it."

• d. "This will reduce the amount of acid in your stomach until you can eat a regular diet again."

D

Pantoprazole is a proton pump inhibitor that decreases acid production in the stomach. It minimizes damage to the gastric mucosa while the pt is on bed rest and hospitalized after surgery. Pantoprazole will not prevent gas pains and will not prevent stomach bleeding from surgery. Heartburn is not a side effects of diabetes.

Multiple Choice

The nurse plans to give a scheduled dose of metoclopramide at what most beneficial time?

• a. 0200

• b. 0500

• c. 1130

• d. 1345

C

Metoclopramide is an antiemetic and an upper-GI stimulant. For this reason, it should be given 30 minutes before meals to promote gastric emptying. It also is used as an antiemetic. The hours 0200, 0500, and 1345 are not close to meal times.

Multiple Select

A patient has had a persistent nausea and vomiting for the last five days. Which immediate nursing interventions available are appropriate for this patient? SELECT ALL THAT APPLY

• a. Monitor vital signs continuously

• b. Encourage pt to do physical activity

• c. Administer opioid drugs to sedate pt

• d. Administer IV fluids and electrolytes

• e. Insert a nasogastric tube connected to suction

A, D, E

The vital signs should be monitored continuously to determine the physiologic state of the patient. Patients with persistent vomiting should immediately be put on NOP status and should be given IV fluids to BP recent dehydration. A nasogastric tube should be placed for aspiration of stomach contents. Opioids induce vomiting and hence should not be administered. Persistent vomiting would induce fatigue, and physical activity would worsen the condition of the pt.

Multiple Choice

The pt has received a dose of aluminum hydroxide with magnesium and simethicone 30 mL PO. The nurse would evaluate its effectiveness by questioning the pt as to whether which symptom resolved?

• a. Flatus

• b. Diarrhea

• c. Indigestion

• d. Constipation

C

Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of GI distress, like heartburn and GERD. Mylanta will not have an effect on diarrhea, constipation, or flatus

Multiple Choice

A nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement from the client indicates teaching by the nurse is effective?

• a. "After meals I will take a 10-minute walk."

• b. "After meals I will drink 8 oz (240 mL) of water."

• c. "After meals I will rest in a sitting position for one hour."

• d. "After meals I will lie down in bed for at least 20 minutes."

C

Gravity (sitting up after meals) facilitates digestion and prevents reflux of stomach contents into the esophagus. Exercise immediately after eating may prolong the digestive process. Water should not be taken with or immediately after meals because it overdistends the stomach. Lying down in bed for at least 20 minutes is not an appropriate action because it promotes the reflux of gastric contents into the esophagus.

Multiple Choice

A client is evaluated at a clinic, and the healthcare provider suspects that the client has anemia and a peptic ulcer. To determine if the client has a peptic ulcer, the nurse expects that what diagnostic test will be performed?

• a. Barium enema

• b. Gastric biopsy

• c. Gastric culture

• d. Stool examination

C

A gastric culture enables the healthcare provider to identify the presence of Helicobacter pylori. Two thirds of individuals with gastric or duodenal ulcers are infected with this organism. A barium enema outlines structural changes in the lower gastrointestinal tract; it will not outline the stomach or duodenum. A gastric biopsy is done to identify the presence of malignant cells. A stool examination may identify melena or parasites, but it is not definitive for peptic ulcers.

Multiple Choice

Which is the priority intervention for the dependent client with peptic ulcer disease (PUD) who is vomiting bright red blood?

• a. Apply oxygen

• b. Place the client in a side-lying position

• c. Prepare to administer packed red blood cells

• d. Assess the client's pulse and blood pressure

B

Recall ABCs of priority care. The client who needs assistance to manage self-care (dependent) should be placed in the side-lying position when vomiting to prevent aspiration. The use of supplemental oxygen may support oxygen saturation in the client with decreased hemoglobin because of gastrointestinal bleeding. However, in the dependent client who is vomiting, applying oxygen is of lower priority than placing the client in a side-lying position. Restoring circulation, is of lower priority than protecting the airway in a dependent client whose airway is at risk. Assessing for adequate circulation doesn’t take priority over protecting the airway.

Multiple Choice

A nurse is performing the initial history and physical examination of a client with a diagnosis of duodenal ulcer. Which type of pain does the nurse expect the client to describe?

• a. Pain that is relieved with eating

• b. Pain that is worse with antacids

• c. Pain that is relieved with sleep

• d. Pain that is worse one hour after eating

A

Duodenal ulcer pain is relieved with food and antacids and often awakens the client at night when sleeping. Gastric ulcer pain is worse with eating or one hour after eating.

Multiple Choice

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor?

• a. "My blood type is A positive."

• b. "I smoke one pack of cigarettes a day."

• c. "I have been overweight most of my life."

• d. "My blood pressure has been high lately."

B

Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

Multiple Choice

After an acute episode of upper GI bleeding, a client vomits undigested medications and reports severe epigastric and abdominal pain. The client has absent bowel sounds, rigid abdomen, a pulse rate of 134, and shallow respirations of 32 per minute. The primary healthcare provider has been contacted. What should be the nurse's next priority?

• a. Keep the client nothing by mouth (NPO)

• b. Teach the client coughing and deep breathing

• c. Inquire whether any red or black stools have been noted

• d. Place the client in the supine position with the legs elevated

A

The assessment findings are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Keeping the client NPO is priority. Teaching coughing and deep breathing is not appropriate at this time, even though the client will have surgery. Keeping the client NPO in preparation for surgery is more important than asking about the presence of black, tarry stools or red stools. Although this question should be asked, knowing whether any red or black stools have been noted will not change the medical or nursing care of the client at this time. Drawing up the knees is more comfortable for the client.

Multiple Choice

An obese client with a hiatal hernia asks the nurse how to prevent GERD. Which is the nurse's best response?

• a. "Lie down after eating."

• b. "Eat less food at each meal."

• c. "Increase your intake of fat."

• d. "Drink more fluid with each meal."

B

Eating less food not only relieves intraabdominal pressure, but it promotes weight loss, which helps to decrease the tendency of gastric contents to reflux into the esophagus. The response "Lie down after eating" increases pressure against the diaphragmatic hernia, thereby increasing symptoms. Fats decrease emptying of the stomach and promote gas, extending the period during which reflux can occur; fats should be decreased. The response "Drink more fluid with each meal" will increase intraabdominal pressure; fluid should be discouraged with meals.

Multiple Choice

What nursing diagnostic statement would be assigned the highest priority in the plan of care for a pt who has Ulcerative Colitis?

• a. Activity intolerance

• b. Deficient fluid volume

• c. Impaired tissue integrity

• d. Risk for impaired skin integrity

B

In ulcerative colitis, fluid is not absorbed from the distal large intestine because of ulceration, bleeding, and, later, scarring and narrowing of the lumen of the bowel. Fluid and electrolytes are also lost in the stool; therefore, deficient fluid volume is the priority nursing diagnostic statement. Activity intolerance, impaired tissue integrity, and risk for impaired skin integrity are all possibilities related to ulcerative colitis, but they are not as high of a risk as deficient fluid volume.

Multiple Choice

A patient has a newly formed ileostomy and asks the nurse, "When can I start training my ostomy to only produce stool at certain times?" What is the nurse's appropriate response?

• a. "We will start training when the stoma heals."

• b. "When your stools transition from liquid to semisolid."

• c. "Because you have an ileostomy and not a colostomy, we can start any time."

• d. "We will not be able to train your ileostomy because of the frequent drainage from the site."

D

Drainage from the ileostomy is frequent, of liquid consistency, and irritating to the skin, preventing regularity from being established. Not all colostomies can be trained. A colostomy formed in the sigmoid or descending colon produces semi-formed or formed stools and can be regulated by the irrigation method.

Multiple Choice

The nurse is caring for a patient after a sigmoid colostomy. What type of stool does the nurse anticipate when assessing the patient?

• a. Liquid

• b. Formed

• c. Semiliquid

• d. Semiformed

B

Formed stool is observed in a patient after a sigmoid colostomy. Liquid stool is observed in a patient after an ileostomy. Semiliquid stool is observed after an ascending colostomy. Semiformed stool is observed after a transverse colostomy.

Multiple Choice

The nurse is educating a patient about dietary fiber and the ways to incorporate it into the daily diet. What information should the nurse include while teaching this patient about fiber intake?

• a. Drink at least 2 liters of water daily

• b. Avoid having prunes and prune juice

• c. Check flatulence formation in the case of dietary fiber intake

• d. Check for milk and milk products that are high in dietary fiber

A

Drink at least 2 liters of water daily. Dietary fiber absorbs water. Therefore, when adding dietary fiber to a diet, it is important to maintain a good fluid intake. Prunes and prune juices are high in dietary fiber and should be included in this diet. Initially, fiber may increase the production of gas but that effect decreases with time. Milk and milk products do not have a high-fiber content.

Multiple Choice

The nurse provides postoperative care one day after a patient undergoes colostomy surgery. The patient's stoma is moist and dark pink, with no obvious drainage. Which action should the nurse take?

• a. Document the normal findings

• b. Consult the enterostomal therapist

• c. Irrigate the ostomy with normal saline

• d. Palpate the abdomen around the stoma

A

A colostomy stoma that is moist and dark pink without any drainage on the first postoperative day is normal. These findings should be documented in the patient's medical record. Consulting the enterostomal therapist, irrigating the ostomy, and palpating the abdomen are not necessary because the colostomy stoma is normal.

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Multiple Choice

A 72-year-old patient with benign prostatic hyperplasia and a history of frequent UTIs is admitted to the hospital with chills, fever, and nausea and vomiting. To determine whether the patient has an upper UTI, the nurse will assess for:

• a. suprapubic pain.

• b. foul-smelling urine.

• c. bladder distension.

• d. costovertebral angle (CVA) tenderness.

D

CVA tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.