Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
A range of nursing interventions and assessments related to various medical conditions, including urinary tract infections, acute kidney injury, septic shock, transplant rejection, chemotherapy side effects, and fracture management. Insights into the nurse's role in monitoring patient status, administering appropriate treatments, and educating patients on self-care strategies. It covers topics such as medication management, fluid and electrolyte balance, respiratory support, and prevention of complications. The information presented can be valuable for nursing students and professionals in understanding the nursing process and evidence-based practices for managing these common medical scenarios.
Typology: Exams
1 / 125
A patient treated with antihypertensive medication is planning to start using meditation to promote relaxation and reduced anxiety. The nurse cautions the patient that A. meditation can be used successfully only if the patient is responsive to suggestion B. the blood pressure should be monitored frequently because the medication might need to be adjusted C. frequent appointments, practice times, and goal setting are necessary for effective use of medication D. meditation can be a good complementary therapy, but medications will always be needed B. the blood pressure should be monitored frequently because the medication might need to be adjusted The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? A. a client requiring a colostomy irrigation B. a client receiving continuous tube feedings C. a client who requires urine specimen collection D. a client with difficulty swallowing food and fluids C. A client who requires urine specimen collection
The nurse teaches the female patient with frequent UTIs that she should A. take tub baths with bubble bath B. urinate before and after sexual intercourse C. take prophylactic sulfonamides for the rest of her life D. restrict fluid intake to prevent the need for frequent voiding B. urinate before and after sexual intercourse A 46-year-old woman returns to clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take? A. teach the patient to take the prescribed medications for 3 days B. remind the patient about the need to drink 1 liter of fluids a day C. obtain a midstream urine specimen for culture and sensitivity testing D. suggest that the patient use acetaminophen to treat the symptoms C. obtain a midstream urine specimen for culture and sensitivity testing Which finding by the nurse will be most helpful in determining whether a 67-year-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)? a. Bladder distention b. Foul-smelling urine
c. Suprapubic discomfort d. Costovertebral tenderness d. costovertebral tenderness We have an expert-written solution to this problem! The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. choosing diuretic fluids such as coffee. d. drinking 2000 to 3000 mL of fluid a day. d. drinking 2000 to 3000 mL of fluid a day. An older male patient visits his primary care provider because of burning on urination and production of urine that he describes as "foul smelling". The health care provider should assess the patient for what factor that may put him at risk for a urinary tract infection (UTI)? A. benign prostatic hyperplasia B. sedentary lifestyle C. recent use of broad-spectrum ABX D. high purine diet A. benign prostatic hyperplasia
Eight months after the delivery of her first child, a 31 yo woman has sought care because of occasional incontinence that she experiences when sneezing or laughing. Which measure should the nurse first recommend in an attempt to resolve the woman's incontinence? A. Kegel exercises B. Use of adult incontinence pads C. Intermittent self-catheterization D. Dietary changes including fluid restriction A. Kegel exercises The nurse is caring for a 73 year-old male with a history of benign prostatic hyperplasia and symptoms fo a possible urinary tract infection. Which diagnostic finding would support this diagnosis? A. Glucose, protein, and ketones are present in the urine B. Nitrites and leukocyte esterase are present in the urine C. WBC count is 7500 cells/microL D. Antistreptolexin-O (ASO) titer is 106 Todd units/mL B. Nitrites and leukocyte esterase are present in the urine The nurse is caring for a 62 year-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? A. Restrict fluids to prevent incontinence B. Prostate exams are not needed after surgery
C. Sexual functioning will not be affected D. Avoid straining during defecation D. Avoid straining during defecation Which nursing diagnosis is a priority in the care of a patient with renal calculi? A. Risk for constipation B. Risk for powerlessness C. Acute pain D. Deficient fluid volume C. Acute pain We have an expert-written solution to this problem! Which factors place a patient at risk for experiencing urinary stasis? Select all that apply. Constipation Urinary Retention Diabetes Mellitus Renal Impairment Urinary Tract Calculi Urinary Retention Renal Impairment Urinary Tract Calculi
Which diagnostic test would the nurse anticipate scheduling for the patient experiencing recurrent infections from a suspected urinary tract obstruction? A. sensitivity testing B. dipstick urinalysis C. clean-catch urine sample D. CT scan D. CT scan Which of the following are used to determine staging in AKI based on RIFLE classification? A. serum creatinine and BUN B. serum creatinine and urine output C. GFR and BUN D. GFR and cystatin C B. serum creatinine and urine output (the third is GFR. BUN is not a determinant) Which of the following is a risk factor for developing AKI in a patient about to receive intravenous dye contrast? A. dehydration B. hypertension C. female gender D. adolescence A. dehydration
If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? A. hyperkalemia and hyponatremia B. hyperkalemia and hypernatremia C. hypokalemia and hyponatremia D. hypokalemia and hypernatremia C. hypokalemia and hyponatremia Which classification of UTI is described as an infection of the renal parenchyma, renal pelvis, and ureters? A. Upper UTI B. Lower UTI C. Complicated UTI D. Uncomplicated UTI A. Upper UTI While caring for a 77 year old woman who has a urinary catheter, the nurse monitors the patient for the development of a UTI. What clinical manifestations is the patient likely to experience? A. Cloudy urine and fever B. Urethral burning and bloody urine C. Vague abdominal discomfort and disorientation D. Suprapubic pain and slight decline in body temperature C. Vague abdominal discomfort and disorientation
The patient has recently experienced a myocardial infarction. Which action by the nurse would help prevent cardiogenic shock? A. Monitor the patient's telemetry B. Turn the patient every two hurs C. Administer oxygen via nasal cannula D. Place the patient in the Trendelenburg position C. Administer oxygen via nasal cannula The EMTs deliver a patient to the ER who was in an automobile accident. The patient presents with a heart rate of 45 bpm and a temp of 93. During the assessment, the nurse notices the patient doesn't have sensation below T3. What type of shock is the patient experiencing? Neurogenic shock The nurse is caring for a patient who just returned from the recovery room after undergoing abdominal surgery. The nurse monitors the client for which early sign of hypovolemic shock? A. Lethargy B. Increased pulse rate C. Increased depth of respiration D. Decreased deep tendon reflexes B. Increased pulse rate Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
A. The patient slows the inflow rate when experiencing pain B. The patient leaves the catheter exist site without a dressing C. The patient plans 30 to 60 minutes for a dialysate exchange D. The patient cleans the catheter while taking a bath every day D. The patient cleans the catheter while taking a bath every day The nurse counsels a 64-year-old man on dietary restrictions to prevent recurrent uric acid renal calculi. Which foods should the nurse teach the patient to avoid? A. venison, crab, and liver B. spinach, cabbage, and tea C. milk, yogurt, and dried fruit D. asparagus, lentils, and chocolate A. venison, crab, and liver The nurse should know that which diagnostic study will be most indicative of chronic kidney disease (CKD) in this patient? A. Serum creatinine B. Serum potassium C. Microalbuminuria D. Calculated glomerular filtration rate (GFR) D. Calculated glomerular filtration rate (GFR) During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply): A. hypotension B. ECG changes
C. hypernatremia D. pulmonary edema E. urine with high specific gravity b. ECG changes d. pulmonary edema A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation of 88. The patient is increasingly lethargic. Which intervention will the nurse anticipate? A. Administration of 100% O2 by non rebreather mask B. Endotracheal intubation and positive pressure ventilation C. Insertion of a mini-tracheostomy with frequent suctioning D. Initiation of continuous positive pressure ventilation (CPAP) B. Endotracheal intubation and positive pressure ventilation When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness. a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
A. A patient with cystic fibrosis who has thick, green-colored sputum B. A patient with pneumonia who has crackles bilaterally in the lung bases C. A patient with emphysema who has an oxygen saturation of 90 to 92 D. A patient with septicemia who has intercostal and suprasternal retractions D. A patient with septicemia who has intercostal and suprasternal retractions This patient's symptoms suggests the onset of ARDS The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? A. The patient's PaO2 is 45 mmHg B. The patient's PaCO2 is 35 mmHg C. The patient's respirations are shallow D. The patient's respiratory rate is 32 breaths/min A. The patient's PaO2 is 45 mmHg indicates severe hypoxemia and respiratory failure Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the RN delegate to an experienced LPN in the intensive care
unit? A. assess breath sounds every hour B. monitor CVPs C. place patient in the prone position D. insert an indwelling urinary catheter D. insert an indwelling urinary catheter repositioning is typically able to be delegated but for an intubated patient who requires proning, it's a multiple person job During change-of-shift report on a medical unit, the nurse learns that a patient with respiratory distress has become increasingly agitated. Which action should the nurse take first? A. Give the prescribed PRN sedative drug B. Offer reassurance and reorient the patient C. Use pulse oximetry to check the patient's oxygen saturation D. Notify the healthcare provider about the patient's status C. Use pulse oximetry to check the patient's oxygen saturation Agitation may be an early indicator of hypoxemia A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure and pulmonary artery wedge pressure. Urine output has been 30 mL/hr for the past 3 hours. Which order by the HCP should the nurse question? A. Administer furosemide
B. Increase normal saline infusion C. Give hydrocortisone D. Titrate norepinephrine to keep SBP above 90 mmHg A. Administer furosemide The pt has low pressures, patients in septic shock require large amounts of fluid resuscitation A nurse is caring for a patient whose hemodynamic monitoring indicates a blood pressure of 92/54 mmHg, a pulse of 64 BPM, and an elevated pulmonary artery wedge pressure (indicative of cardiogenic shock). Which intervention ordered by the HCP should the nurse question? A. Elevate HOB to 30 degrees B. Infuse normal saline at 250 mL/hr C. Hold nitroprusside if SBP is less than 90 mmHg D. Titrate dobutamine to keep SBP greater than 90 mmHg B. Infuse normal saline at 250 mL/hr Do not want to give large amounts of fluid in cardiogenic shock A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? A. Inspiratory crackles B. Heart rate 45 bpm
C. Cool, clammy extremities D. Temperature 101. B. Heart rate 45 bpm Neuogenic shock is characterized by hypotension and bradycardia The ED receives a report that a seriously injured patient involved in a motor vehicle crash is being transported to the facility with an estimated arrival in 5 minutes. In preparation with the patient's arrival, the nurse will obtain A. a dopamine infusion B. a hypothermia blanket C. lactated Ringer's solution D. two 16-gauge IV catheters D. two 16-gauge IV catheters Which is the best indicator that fluid resuscitation for a 90 kg patient with hypovolemic shock has been effective? A. hemoglobin is within normal limits B. urine output is 65 mL over the past hour C. CVP is normal D. MAP is 72 B. urine output is 65 mL over the past hour this is an indicator of end organ perfusion
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? A. check temperature every 2 hours B. monitor breath sounds frequently C. maintain patient in supine position D. assess skin for flushing and itching B. monitor breath sounds frequently We have an expert-written solution to this problem! What finding indicates nitroprusside has been effective in treating cardiogenic shock? Warm, pink, and dry skin Indicates perfusion to tissues is improved Which assessment finding is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective? A. Heart rate B. Orientation C. Blood pressure D. Oxygen saturation D. Oxygen saturation
We have an expert-written solution to this problem! Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? A. The patient's serum creatinine level is elevated B. The patient complains of intermittent chest pressure C. The patient's extremities are cool and pulses are weak D. The patient has bilateral crackles throughout the lung fields A. The patient's serum creatinine level is elevated We have an expert-written solution to this problem! A patient with septic shock has a BP of 70/46 mmHg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104, and blood glucose of 246. Which intervention ordered by the healthcare provider should the nurse implement first? A. Give normal saline IV B. Give acetaminophen C. Start insulin drip D. Start norepinephrine
A. Give normal saline IV Fluids are first line. Other actions are appropriate and should be initiated quickly as well When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining a cool room temperature for the patient with neurogenic shock d. Maintaining a cool room temperature for the patient with neurogenic shock Pts with neurogenic shock have poikilothermia so the temperature should be kept warm to avoid hypothermia We have an expert-written solution to this problem!
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the HCP? A. Skin cool and clammy B. HR of 118 C. BP of 92/ D. O2 sat of 93 A. Skin cool and clammy This indicates progression of shock/deterioration of patient status because in the early stages of septic shock skin is still warm and dry A patient is admitted to the ED for shock of unknown etiology. The first action by the nurse should be A. obtain the blood pressure B. check the level of orientation C. administer supplemental oxygen D. obtain a 12 lead ECG C. administer supplemental oxygen During the change of shift report a nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the HCP? A. New onset confusion B. Decreased bowel sounds
D. Pale, cool, and dry extremities A. New onset confusion Indicate patient is in progressive stage of shock and rapid intervention is needed to prevent further deterioration. Other info is consistent with compensatory shock. A 68 year old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care? A. Restrict fluids between meals and after the evening meal B. Insert an indwelling catheter until the symptoms have been resolved C. Assist the patient to the bathroom every 2 hours during the day D. Apply absorbent adult incontinence diapers and pads over the bed linens C. Assist the patient to the bathroom every 2 hours during the day Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate? a. Monitor the patient's intake and output over night. b. Have the patient drink small amounts of fluid frequently. c. Use an ultrasound scanner to check the postvoiding residual
volume. d. Reassure the patient that this is normal after rectal surgery because of anesthesia. c. Use an ultrasound scanner to check the postvoiding residual volume. Symptoms indicate overflow incontinence 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 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 clean the catheter carefully before and after each catheterization D. I will take prophylactic antibiotics to prevent UTIs C. I will clean the catheter carefully before and after each catheterization We have an expert-written solution to this problem!
A 76 year old with benign prostatic hyperplasia is agitated and confused, with a markedly distended bladder. Which interventions prescribed by the HCP should the nurse implement first? A. Insert a urinary catheter B. Draw blood for a serum creatinine level C. Schedule an IV pyelogram D. Administer lorazepam (ativan) A. Insert a urinary catheter The nurse observes UAP taking the following actions when caring for a patient with a urethral catheter. Which action requires that the nurse intervene? A. Taping the catheter to the skin on the patient's upper inner thigh B. Cleaning around the patient's urinary meatus with soap and water C. Disconnecting the catheter from the drainage tube to obtain a specimen D. Using an alcohol-based gel hand cleanser before performing catheter care C. Disconnecting the catheter from the drainage tube to obtain a specimen A patient is admitted to the emergency department with possible renal trauma after an automobile accident. Which prescribed intervention will the nurse implement first?
A. Check BP and HR B. Administer morphine C. Transport to radiology for an intravenous pyelogram D. Insert a urethral catheter and obtain a urine specimen A. Check BP and HR After the insertion of an arteriovenous graft (AVG) in the right forearm, a 54-year-old patient complains of pain and coldness of the right fingers. Which action should the nurse take? a. Teach the patient about normal AVG function. b. Remind the patient to take a daily low-dose aspirin tablet. c. Report the patient's symptoms to the health care provider. d. Elevate the patient's arm on pillows to above the heart level. c. Report the patient's symptoms to the health care provider. We have an expert-written solution to this problem! When a patient with acute kidney injury (AKI) has an arterial blood pH of 7.30, the nurse will expect an assessment finding of a. persistent skin tenting b. rapid, deep respirations. c. bounding peripheral pulses. d. hot, flushed face and neck.
b. rapid, deep respirations. patient has metabolic acidosis - Kussmaul respirations to try to compensate We have an expert-written solution to this problem! Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease? A. Blood pressure B. Phosphate level C. Neurologic status D. Creatinine clearance B. Phosphate level We have an expert-written solution to this problem! Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the A. Bowel sounds B. Blood glucose
A. Bowel sounds Kayexalate should not be given to a patient with a paralytic ileus because bowel necrosis can occur Which menu choice by the patient who is receiving hemodialysis indicates that the nurse's teaching has been successful? a. Split-pea soup, English muffin, and nonfat milk b. Oatmeal with cream, half a banana, and herbal tea c. Poached eggs, whole-wheat toast, and apple juice d. Cheese sandwich, tomato soup, and cranberry juice c. Poached eggs, whole-wheat toast, and apple juice When caring for a patient with a left arm arteriovenous fistula, which action will the nurse include in the plan of care to maintain the patency of the fistula? A. Auscultate for a bruit at the fistula site B. Assess the quality of the left radial pulse C. Compare blood pressures in the left and right arms D. Irrigate the fistula site with saline every 8 to 12 hours A. Auscultate for a bruit at the fistula site We have an expert-written solution to this problem!
The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo) b. Magnesium hydroxide A 55-yr-old patient with end-stage kidney disease (ESKD) is scheduled to receive a prescribed dose of epoetin alfa. Which information should the nurse report to the healthcare provider before giving the medication? A. Creatinine 1.6 B. Oxygen sat 89 C. Hemoglobin 13 D. BP 98/56 C. Hemoglobin 13 A 62 year old female patient has been hospitalized for 4 days with AKI caused by dehydration. Which information will be most important for the nurse to report to the HCP? A. The creatinine level is 3 B. Urine output over an 8 hour period is 2500 mL