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What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear. - CORRECT ANSWER-2. Initiate bowel or habit training program to promote continence. The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance - CORRECT ANSWER-4. Lactose intolerance
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What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment?
During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first?
When obtaining subjective data from a patient during assessment of the endocrine system, the nurse asks specifically about a. energy level. b. intake of vitamin C. c. employment history. d. frequency of sexual intercourse. - CORRECT ANSWER-a. energy level. An appropriate technique to use during physical assessment of the thyroid gland is a. asking the patient to hyperextend the neck during palpation. b. percussing the neck for dullness to define the size of the thyroid. c. having the patient swallow water during inspection and palpation of the gland. d. using deep palpation to determine the extent of a visibly enlarged thyroid gland. - CORRECT ANSWER-c. having the patient swallow water during inspection and palpation of the gland. Endocrine disorders often go unrecognized in the older adult because a. symptoms are often attributed to aging. b. older adults rarely have identifiable symptoms. c. endocrine disorders are relatively rare in the older adult. d. older adults usually have subclinical endocrine disorders that minimize symptoms. - CORRECT ANSWER-a. symptoms are often attributed to aging. Abnormal findings during an endocrine assessment include (select all that apply) a. excess facial hair on a woman. b. blood pressure of 100/70 mm Hg. c. soft, formed stool every other day. d. 3-lb weight gain over last 6 months. e. hyperpigmented coloration in lower legs. - CORRECT ANSWER-a. excess facial hair on a woman. e. hyperpigmented coloration in lower legs. A patient has a total serum calcium level of 3 mg/dL (1.5 mEq/L). If this finding reflects hypoparathyroidism, the nurse would expect further diagnostic testing to reveal a. decreased serum PTH. b. increased serum ACTH. c. increased serum glucose. d. decreased serum cortisol levels. - CORRECT ANSWER-a. decreased serum PTH. An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.)
tries to kick you away from his bed with a purposeful aim. - CORRECT ANSWER- Behavioral The nurse is inserting a Foley catheter for an elderly client with benign prostatic hypertrophy (BPH). The technique for this procedure is classified as ...? - CORRECT ANSWER-Sterile technique Procedures that are classified as aseptic techniques. - CORRECT ANSWER- Handwashing Emptying a full foley drainage bag Cleaning the ports of IV tubing prior to giving medications Wiping the bedside table prior to preparing a sterile field Match:
A. Use the patient's dominant arm B. Check for contraindications for using the extremity C. Select a vein with minimal curvature D. Avoid areas of flexion E. Choose a vein that feels rigid to touch F. Start proximally and move distally - CORRECT ANSWER- A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? SELECT ALL THAT APPLY a Use the patient's dominant arm b Check for contraindications for the site/extremity c Select a vein with minimal curvature d Avoid areas of flexion if possible e Choose a vein that feels rigid to touch — means they've used it a lot and there's scarring F Start proximally and move distally — opposite - CORRECT ANSWER-b Check for contraindications for the site/extremity c Select a vein with minimal curvature d Avoid areas of flexion if possible You're assigned to an 88yr. old female patient who needs a peripheral IV initiated. Her weight is 56kg and a height 5'2". Her skin is dry, fragile and her veins are visible. Which steps are necessary when inserting a peripheral IV line? SELECT ALL THAT APPLY a Apply tourniquet over her sleeve 10 to 15 cm (4 to 6 inches) above the intended insertion site. b. Clean skin using an approved antiseptic agent such as 70% isopropyl alcohol and allow to dry thoroughly. c Stabilize the vein by placing the thumb proximal to the insertion site while stretching the skin in the direction of insertion. d Use the smallest-gauge and shortest catheter available and insert with the bevel up at a 10- to 15-degree angle. e Observe for blood in the flashback chamber of the catheter and advance the catheter off the needle into the vein. f Release the tourniquet once the catheter has been secured and the dressing has been applied - CORRECT ANSWER-a Apply tourniquet over her sleeve 10 to 15 cm (4 to 6 inches) above the intended insertion site. b. Clean skin using an approved antiseptic agent such as 70% isopropyl alcohol and allow to dry thoroughly. d Use the smallest-gauge and shortest catheter available and insert with the bevel up at a 10- to 15-degree angle. e Observe for blood in the flashback chamber of the catheter and advance the catheter off the needle into the vein.
b Phlebitis c Hematoma d Infiltration e Pump malfunction - CORRECT ANSWER-d Infiltration The nurse goes in to provide discharge instructions for another client who has had surgery. The client has this finding at a previous IV site. The nurse concludes that which of the following complications has occurred? a Infection b Hematoma or bruising c Infiltration d Thrombophlebitis - CORRECT ANSWER-b Hematoma or bruising The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order.
The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching?
e. use a Y-type infusion set to initiate 0.9% normal saline - CORRECT ANSWER-a. obtain the client's vital signs d. determine typing and crossmatching of blood e. use a Y-type infusion set to initiate 0.9% normal saline which type of asepsis is the nurse using when he or she washes his or her hands before changing a client's postoperative dressing? a. wound asepsis b. medical asepsis c. surgical asepsis d. concurrent asepsis - CORRECT ANSWER-b. medical asepsis the nurse is preparing to change a client's dressing. for which reason would the nurse use surgical asepsis? a. keeps the area free of microorganisms b. confines microorganisms to the surgical site c. protects self from microorganisms in the wound d. reduces the risk for growing opportunistic microorganisms - CORRECT ANSWER-a. keeps the area free of microorganisms which nursing action would be performed first in a client who reports chills and flank pain ten minutes after the initiation of a blood transfusion? a. stop the transfusion b. obtain the vital signs c. notify the health care provider d. maintain the flow with normal saline - CORRECT ANSWER-a. stop the transfusion acute hemolytic reaction which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? a. stop the blood transfusion and infuse saline b. administer the prescribed antipyretic c. obtain a prescription for an antihistamine d. notify the blood bank about the symptoms - CORRECT ANSWER-a. stop the blood transfusion and infuse saline acute hemolytic reaction which action should the nurse take to maintain sterility when performing a dressing change?
a. put the unopened sterile glove package carefully on the sterile field b. remove the sterile drape from its package by lifting it by the corners c. don sterile gloves before opening the package containing the field drape d. pour irrigation liquid from a height of at least 3 inches (2.5 cm) above the sterile container - CORRECT ANSWER-b. remove the sterile drape from its package by lifting it by the corners which technique would the nurse use to maintain surgical asepsis? a. change the sterile field after sterile water is spilled on it b. put a sterile gloves before opening a container of sterile saline c. place a sterile dressing no more than half an inch from the edge of the sterile field d. clean the surgical area with a circular motion, moving from the outer edge toward the center - CORRECT ANSWER-a. change the sterile field after sterile water is spilled on it which action by the fmaily member during a return demonstration indicates the need for additional tecahing after a home health nurse teaches a fmaily member to cleanse a client's wound and apply a sterile dressing? a. placing the old dressing in a plastic bag b. changing the dressing without wearing a mask c. donning non-sterile gloves for removing the old dressing d. using a back and forth motion with the same gauze while cleaning the wound - CORRECT ANSWER-d. using a back and forth motion with the same gauze while cleaning the wound why are the faucet handles on the sink in a client's room considered contaminated? a. they are not in sterile area b. they are touched by dirty hands when turning the water on c. large number of people use them each day d. water encourage bacterial growth - CORRECT ANSWER-b. they are touched by dirty hands when turning the water on which basic principles of surgical asepsis must the nurse consider when changing the dressing of a child with severe burns? a. a paper field must remain dry to be considered sterile b. sterile items held below the waist are considered sterile c. a 1-inch (2.5cm) border around a sterile field is considered contaminated d. sterile objects in contact with clean objects are considered contaminated e. a fenestrated drape is not considered sterile - CORRECT ANSWER-a. a paper field must remain dry to be considered sterile c. a 1-inch (2.5cm) border around a sterile field is considered contaminated d. sterile objects in contact with clean objects are considered contaminated