Nursing Practice Test #3

Questions and Answers

Which factor is most likely the cause of Cheng's UTI?

A high urine glucose level

The indwelling urinary catheter (correct)

The close proximity of the male genitalia to the rectum

Decreased immunity

Which term denotes a patient's inability to void even though the kidneys are producing urine?

Retention (correct)

Urgency

Dysuria

Oliguria

What should the nurse be aware of for Mrs. D'Ambrosia who voids frequently?

One of every 10 nursing home residents is incontinent.

Incontinence is to be expected in a woman Mrs. D'Ambrosia's age.

Kegel exercises performed at regular intervals throughout the day may be helpful. (correct)

An indwelling catheter should be inserted as soon as possible.

What is the priority treatment option for Mrs. D'Ambrosia?

Behavioral techniques Signup and view all the answers

A patient taking phenazopyridine should be cautioned that her urine may change to which color?

Orange-red Signup and view all the answers

Which part of the plan could create stress for Mr. Bales and possibly increase his inability to urinate?

Staying with him while voiding Signup and view all the answers

What is a nursing priority when caring for a male patient with a condom catheter?

Preventing the tubing from kinking to maintain free urinary drainage Signup and view all the answers

A patient with a nursing diagnosis of Impaired Urinary Elimination related to maturational enuresis is likely which of the following?

A child older than 4 years of age who has involuntary urination Signup and view all the answers

Which information is least important for the evaluation process when planning to reduce urinary incontinence?

Age of the patient Signup and view all the answers

If a patient was instructed to avoid foods that may have a laxative effect, which food should they avoid?

Alcohol Signup and view all the answers

Which is a true statement about the effects of medication on bowel elimination?

Diarrhea commonly occurs with amoxicillin clavulanate use. Signup and view all the answers

When administering an oil-retention enema for fecal impaction, what should the nurse instruct?

Instruct the patient to retain the enema for at least 30 minutes Signup and view all the answers

What can the nurse expect regarding a newly created ileostomy?

Fecal drainage will be liquid Signup and view all the answers

Which class of laxative acts by causing the stool to absorb water and swell?

Bulk-forming Signup and view all the answers

A colonoscopy allows for which examination?

Visual examination of the large intestine Signup and view all the answers

A bowel training program includes which of the following?

Allowing ample time for evacuation Signup and view all the answers

Which food, if eaten regularly, would you identify as possibly responsible for excessive flatulence?

Cauliflower Signup and view all the answers

Why should a barium enema be done before an upper gastrointestinal series?

Retained barium may cloud the colon. Signup and view all the answers

Why should nurses recommend avoiding habitual use of laxatives?

They will cause chronic constipation. Signup and view all the answers

When explaining the action of a hypertonic solution enema, what is the basis for its action?

Osmosis of water into colon Signup and view all the answers

Which guidelines for documentation are correct?

Enter information in a complete, accurate, concise, factual, and organized manner. Signup and view all the answers

Which documentation guidelines are correct?

Document nursing interventions as closely as possible to the time of their execution. Signup and view all the answers

According to the HIPAA, patients have the right to which of the following?

To choose how to receive health information Signup and view all the answers

In which case is an authorization needed to release a patient's health information for purposes other than treatment?

The patient is a public figure and the local news media are preparing a news report. Signup and view all the answers

What is the best response to a friend asking for information about a patient?

Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks. Signup and view all the answers

What is the correct abbreviation for 'as needed'?

PRN Signup and view all the answers

If you were looking for trends in a patient's vital signs, what form should you consult first?

Graphic sheet Signup and view all the answers

This method of documentation uses the categories data, action, and response (DAR) to facilitate charting.

Focus charting Signup and view all the answers

What should the resident do regarding the verbal order for pain medication?

I am sorry but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly. Signup and view all the answers

What may cause fever?

tissue injury Signup and view all the answers

What term would the nurse use to report a temperature of 38.5°C (101.3°F)?

Fever Signup and view all the answers

The nurse would plan to use the oral route to assess temperature for which patient?

15-year-old healthy adolescent Signup and view all the answers

When assessing a temperature rectally, what should the nurse prevent?

A decrease in heart rate Signup and view all the answers

What should the nurse do if she finds an adult patient's pulse to be 140 beats/min?

Report the rate. Signup and view all the answers

What would the nurse not be surprised to find when assessing a patient with severe abdominal pain?

An increase in pulse rate Signup and view all the answers

What equipment does the nurse take to take an apical pulse?

Stethoscope Signup and view all the answers

How would the nurse document a difference of 8 beats per minute when taking an apical-radial pulse?

Pulse deficit Signup and view all the answers

Which adult respiration rate is considered normal?

12 to 20 breaths/min Signup and view all the answers

What should the nurse do first for a patient having dyspnea?

Elevate the head of the bed Signup and view all the answers

What does the blood pressure measure?

Force of blood against arterial walls Signup and view all the answers

How does aging affect blood pressure?

Decreased elasticity in arterial walls Signup and view all the answers

What should the nurse recommend for a patient with a blood pressure reading of 130/90 mm Hg?

Follow-up measurements of blood pressure Signup and view all the answers

What does the nurse interpret the 120 in a blood pressure reading of 120/80 mm Hg to represent?

Systolic pressure Signup and view all the answers

What can result from using an improperly sized blood pressure cuff?

An incorrect reading Signup and view all the answers

What should the nurse do when taking blood pressure for a patient with intravenous fluids in the right arm?

Take the blood pressure in the left arm Signup and view all the answers

What would the nurse assess for a patient's body temperature in the late afternoon at 37.2ºC (99ºF)?

Result of a normal circadian rhythm Signup and view all the answers

Which tool records muscle tone?

Electromyograph (EMG) Signup and view all the answers

In which stage of sleep is a patient most likely to experience involuntary muscle jerking?

Stage I NREM sleep Signup and view all the answers

What is expected in a patient's vital signs while sleeping at night?

It would be most difficult to awaken him at this time. Signup and view all the answers

How many cycles of sleep does a person typically go through each night?

4 or 5 Signup and view all the answers

What significant change with age affects REM sleep?

The amount of REM sleep decreases with age. Signup and view all the answers

What disorder should the nurse suspect if a patient falls asleep during a conversation?

Narcolepsy Signup and view all the answers

What is true about the diagnostic tool called a sleep diary?

It includes a record of daily physical activity Signup and view all the answers

What can help a patient get to sleep?

Follow his usual bedtime routine if possible Signup and view all the answers

What is the most common complaint of patients visiting sleep disorder clinics?

Chronic insomnia Signup and view all the answers

What may result from a prolonged pattern of REM deprivation?

Symptoms of psychosis Signup and view all the answers

During which stage of sleep does active dreaming occur?

REM sleep Signup and view all the answers

Which statement about illness as a stressor influencing sleep is true?

Hypothyroidism can result in a decrease in the amount of certain stages of NREM sleep. Signup and view all the answers

When should caffeine intake be avoided?

Avoided at least 4 to 5 hours before bedtime Signup and view all the answers

What should the nurse be aware of regarding sedative-hypnotics?

They usually become ineffective after several weeks. Signup and view all the answers

What type of pain does a patient complain about if it's difficult to localize?

Visceral Signup and view all the answers

What type of pain occurs in a different site from where it originates?

Referred pain Signup and view all the answers

What response is the patient demonstrating if he cradles his injured wrist?

Behavioral Signup and view all the answers

What describes Ann's technique of concentrating on a favorite vacation setting to relieve pain?

Imagery Signup and view all the answers

What best describes intractable pain?

Resistant to treatment Signup and view all the answers

What nursing intervention is effective for lower back pain based on gate control theory?

Applying a moist heating pad to the area at prescribed intervals Signup and view all the answers

What physiological response is expected during moderate pain?

Pupil dilation Signup and view all the answers

What is most effective for managing breakthrough pain in a terminal cancer patient?

Supplementing with doses of a short-acting opioid Signup and view all the answers

What concern should the nurse have regarding inadequate pain relief in children?

Inadequate or inconsistent relief of pain is widespread. Signup and view all the answers

What should be a priority nursing diagnosis for a patient recovering from abdominal surgery who refuses pain medication?

Acute Pain related to fear of taking prescribed postoperative medications Signup and view all the answers

What should the nurse remember when planning pain control strategies for older patients?

Denial of pain may occur. Signup and view all the answers

How should analgesics be administered for chronic pain management?

Around the clock (ATC) Signup and view all the answers

What is true about using a placebo for pain control without the patient's consent?

Deceptive Signup and view all the answers

What should the nurse monitor vigilantly when a patient receives epidural analgesia?

Respiratory depression Signup and view all the answers

What indicates to the nurse that a patient on a continuous opioid infusion needs to notify the physician?

A sedation level of 4 Signup and view all the answers

What should the nurse keep in mind when collecting a urine specimen for routine urinalysis?

Results may be altered if a sample is left standing at room temperature for a long time. Signup and view all the answers

What should be included in teaching to promote healthy urinary functioning?

Caffeine-containing beverages should be monitored to prevent excess intake. Signup and view all the answers

How would the urine output be described for a person with fever or diaphoresis?

Decreased and highly concentrated Signup and view all the answers

What should the nurse be aware of when inserting an indwelling catheter in a male patient?

The male urethra is more vulnerable to injury during insertion. Signup and view all the answers

What nursing care includes for a patient with an indwelling catheter?

Encouraging a generous fluid intake if not contraindicated by the patient's condition. Signup and view all the answers

What nursing action could lead to increased difficulty voiding after surgery?

Having Ms.Young ignore the urge to void until her bladder is full Signup and view all the answers

Study Notes

Vital Signs and Temperature Assessment

Fever can result from tissue injury, including cardiac events, pulmonary issues, cancer, trauma, and surgical procedures.
A temperature of 38.5°C (101.3°F) is classified as a fever.
The oral route for temperature assessment is appropriate for a healthy 15-year-old but not suitable for infants, oxygen-dependent patients, or unconscious individuals.
Care is needed with rectal temperature assessment to avoid bradycardia (decrease in heart rate).
A pulse rate of 140 beats/min should be reported immediately if found during assessment.
Increased pulse rate can be expected with acute abdominal pain.
To assess an apical pulse, use a stethoscope.
A difference of 8 beats per minute between apical and radial pulse rates is documented as a pulse deficit.

Respiratory and Blood Pressure Assessment

Normal respiratory rate for adults is 12 to 20 breaths/min.
For a patient experiencing dyspnea, the initial action is to elevate the head of the bed.
Blood pressure measures the force of blood against arterial walls; it tends to be higher in older adults due to decreased arterial elasticity.
A reading of 130/90 mm Hg should lead to recommendations for follow-up measurements.
Systolic pressure is represented by the first number in blood pressure readings.
Accurate blood pressure measurement requires the correct cuff size to avoid erroneous readings.
If a patient has IV fluids in one arm, blood pressure should be taken in the opposite arm.

Sleep and Pain Management

Body temperature can vary based on the time of day, with a late afternoon reading of 37.2ºC (99ºF) typically indicating a normal circadian rhythm.
The electromyograph (EMG) records muscle tone.
Sleep disturbances can lead to involuntary muscle jerking, particularly during Stage I NREM sleep.
A typical night of sleep includes about 4 to 5 cycles.
REM sleep is characterized by active dreaming; prolonged REM deprivation may lead to symptoms of psychosis.
Chronic insomnia is the most common complaint among patients in sleep disorder clinics.
Caffeine intake should be avoided 4 to 5 hours before bedtime to promote better sleep quality.
A sleep diary tracks daily physical activity and sleep habits; it assists in diagnosing sleep issues.

Pain Characteristics and Management

Visceral pain is difficult to localize, while referred pain occurs in a different site than its origin.
Behavioral responses to pain can include protective actions like cradling the injured area.
Imagery techniques can help distract from pain by focusing on pleasant thoughts or settings.
Pain that cannot be effectively managed is termed intractable pain; it is often resistant to treatment.
Pupil dilation is a physiological response expected with moderate pain.
Breakthrough pain in cancer patients can be effectively managed with supplemental short-acting opioids.
Chronic pain management is most effective with around-the-clock (ATC) analgesics.

Urinary Function Assessment and Care

Urine output can decrease and become highly concentrated during fever or diaphoresis.
Indwelling catheters pose a risk for urinary tract infections, particularly in patients with compromised immunity.
Urinary retention is characterized by the inability to void, despite urine production.
Kegel exercises can aid older patients in managing urinary incontinence.
Behavioral techniques are prioritized in treating urinary issues in elderly patients.
Urine may turn orange-red due to the intake of phenazopyridine (Pyridium).

Monitoring and Complications

Vigilant monitoring is vital for patients receiving epidural analgesia to prevent respiratory depression.
A sedation level of 4 in patients on continuous opioid infusion warrants immediate physician notification.
Results from routine urinalysis may be affected if urine is not processed quickly, highlighting the importance of prompt handling.
Encouraging adequate fluid intake is essential for patients with indwelling catheters unless contraindicated.
Ignoring the urge to void can exacerbate difficulty in urination.### Nursing Care Priorities
Providing privacy for patients during voiding is essential for dignity and comfort.
Regularly scheduled urinal offers help manage urinary needs effectively.
For male patients using condom catheters, preventing tubing from kinking ensures free drainage.

Nursing Diagnoses and Patient Conditions

Impaired urinary elimination in a child is defined as involuntary urination beyond the age of 4.
For older adults with urinary incontinence, critical evaluation data includes incontinence patterns, physical mobility, and medications, but age is less relevant.

Dietary Considerations

Alcohol should be avoided when instructed to steer clear of laxative-effect foods.
Excessive flatulence may be linked to regular consumption of cauliflower.

Enemas and Bowel Management

An oil-retention enema requires the patient to retain the solution for at least 30 minutes.
Fecal drainage from an ileostomy consists of liquid, and irrigation is not needed for regulation.
A hypertonic solution in enemas utilizes osmosis to help soften fecal contents.

Documentation and Health Information Privacy

The nursing plan should include accurate and timely documentation, avoiding vague terms.
Patients have rights under HIPAA, including access and the ability to request changes to their health records.
Disclosures of patient information, especially for public figures, require special authorization.

Verbal Orders and Charting Procedures

Verbal orders are only acceptable in emergencies and must be documented appropriately afterward.
Focus charting uses the DAR (data, action, response) method to streamline nursing documentation.

General Nursing Actions

Assisting patients in a normal position is crucial to promote regular bowel habits.
Regularly assessing and managing bowel habits includes allowing sufficient time for evacuation.

Medical Test Explanations

A colonoscopy provides a visual examination of the large intestine, while a barium enema is conducted prior to upper GI studies to prevent clouding the colon.

Risk Management

Avoiding habitual laxative use is critical as it can lead to chronic constipation, demonstrating the need for proper patient education.

Patient Advocacy

Nurses must maintain patient confidentiality, refusing requests for information from friends or family without patient consent.

Special Notes on Patient Experience

Bradycardia may occur during fecal impaction removal due to vagal stimulation, highlighting the need for careful monitoring in such procedures.

This information encapsulates various nursing responsibilities, patient care protocols, and the significance of documentation while ensuring patient privacy and rights are upheld.

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Description

This practice test focuses on key nursing concepts, including the assessment of fever and tissue injury. Improve your understanding of vital signs and their implications in patient care through flashcard-style questions. Perfect for nursing students preparing for exams.