Chapters 33 & 38

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.

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 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 find would the nurse expect in this patient?

• Improved renal blood supply to the kidneys

• Urinary stasis

• Decreased urinary calcium

• Acidic urine formation

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

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 side of the body.

• When rising, extend the uninjured leg to prevent weight bearing.

• To climb stairs, place weight on affected leg first.

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse firs 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 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 provider.

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."

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."

The nurse is planning a bowel training program for a patient with frequent constipation. What is the 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.