Nursing Quiz: Patient Positions & Catheterization

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Questions and Answers

Which precaution should be taken to ensure effective range of motion (ROM) exercises?

Repeat each movement 10 times during a session

Perform exercises using head-to-toe sequence (correct)

Perform exercises quickly for effectiveness

Carry out movements slowly and smoothly (correct)

What priority nursing action aligns with The Joint Commission's standards for safe administration of enteral feeding via nasoenteric tube?

Identifying the patient using two identifiers (correct)

Checking the expiration date on the patient's formula

Performing hand hygiene after touching the patient

Explaining the procedure to the patient after starting the feeding

Which statement accurately describes a component of medication prescriptions?

Route of administration (correct)

Chemical name of medication

Administering nurse's name

Generic name of medication (correct)

Which act is violated by keeping a visible patient names listing at the front desk?

Health Insurance Portability and Accountability Act (HIPAA) Signup and view all the answers

What is the most appropriate nursing action to prevent pressure injuries in a patient with urinary incontinence?

Managing moisture around the area Signup and view all the answers

Which patient position should be avoided to reduce the risk of aspiration in a patient with dysphagia?

Supine Signup and view all the answers

Which factor does NOT influence bowel elimination?

Gender Signup and view all the answers

What are potential complications of dysphagia that the nurse should monitor for?

Aspiration pneumonia Signup and view all the answers

Which statement indicates a nursing student may need further education regarding the evaluation phase of urinary catheterization?

The nurse discusses the importance of the catheter with the patient. Signup and view all the answers

What is the primary use for double-lumen catheters?

Indwelling catheterization Signup and view all the answers

What is the normal pH range for urine?

4.6 to 8 Signup and view all the answers

What are recommended measures to prevent urinary tract infections in females?

Proper handwashing Signup and view all the answers

Which of the following suggestions would NOT help a patient prevent urinary tract infections?

Take frequent baths Signup and view all the answers

Which type of laxative works by causing stool to absorb water and swell?

Bulk-forming Signup and view all the answers

What component's presence in urine suggests glomerular injury?

Large proteins Signup and view all the answers

Which condition is likely caused by frequent straining during defecation?

Hemorrhoids Signup and view all the answers

What is considered a short-term solution to constipation?

Cathartics Signup and view all the answers

Which condition has the highest risk for constipation?

Patient receiving opioid analgesics Signup and view all the answers

What defines a stage 2 pressure injury during wound assessment?

Reddish-pink wound bed without slough Signup and view all the answers

Which right regarding medication administration does a patient not possess?

The right to prescribe their own medication Signup and view all the answers

What should a nurse do first upon discovering a medication error?

Assess the patient's condition Signup and view all the answers

Which sign indicates early pressure that resolves without tissue loss?

Blanchable erythema Signup and view all the answers

What statement regarding nutrition is correct?

Nutrition is essential for organ function. Signup and view all the answers

Which rights of medication administration are NOT recognized?

Right color Signup and view all the answers

What is a recommended way to prevent medication errors?

Read labels at least 3 times before administration Signup and view all the answers

Which preliminary assessment should the nurse perform to minimize the risk of aspiration while administering oral medications?

Ability to swallow Signup and view all the answers

Which patient condition is safe for administering oral medication?

Patient with skin abrasions Signup and view all the answers

Which dietary recommendations should the nurse include to help prevent obesity?

Controlling sodium intake Signup and view all the answers

Which chronic disease accounts for the highest healthcare costs?

Diabetes Signup and view all the answers

What statement is an example of a nonmodifiable risk factor for heart disease?

My family has a history of heart disease. Signup and view all the answers

Which law mandates that healthcare agencies provide emergency care before transferring patients to other hospitals?

Emergency Medical Treatment and Active Labor Act (EMTALA) Signup and view all the answers

Which condition is older adults more likely to experience due to proprioceptive changes?

Increased difficulty with balance Signup and view all the answers

What is an effective communication strategy for a patient with expressive aphasia?

Offering pictures or a communication board Signup and view all the answers

What factors contribute to wound healing?

Protein and Vitamins A & C Signup and view all the answers

Which organization is responsible for enforcing medication laws to ensure safety and efficacy of medications?

Food and Drug Administration (FDA) Signup and view all the answers

Which statement about medication trough level is correct?

Trough indicates minimum serum concentration before the next dose. Signup and view all the answers

Which patient condition may result from reduced tactile sensation due to being confined to bed?

Skin breakdown Signup and view all the answers

Loosening the tubing of a patient's nasal cannula aims to prevent which complication?

Skin irritation Signup and view all the answers

Which actions can help a nurse avoid malpractice and professional negligence?

Regularly updating nursing knowledge Signup and view all the answers

What is essential to perform for a patient with hemiparesis to support musculoskeletal health?

Passive range-of-motion (ROM) exercises Signup and view all the answers

Study Notes

Patient Positions and Aspiration Risk

Avoid the supine position when feeding patients with dysphagia to minimize aspiration risk.
The high-Fowler position is better suited for feeding patients with swallowing difficulties.

Bowel Elimination Factors

Factors influencing bowel elimination include age, pain, and position, but gender is not a factor.

Dysphagia Complications

Dysphagia can lead to weight loss, aspiration pneumonia, decreased nutritional status, and dehydration.

Urinary Catheterization Evaluation

During the evaluation phase of urinary catheterization, the nurse reassesses urination patterns and asks patients about their experiences and if their expectations have been met regarding the catheterization. Nurses should also inquire about if there have been any permanent changes in elimination patterns.
Explaining the procedure and importance is part of the initial phase, not the evaluation phase.

Catheter Types

Double-lumen catheters are used for indwelling catheterization, not intermittent catheterization or irrigations.

Normal Urine pH

Normal urine pH ranges from 4.6 to 8.

Preventing Urinary Tract Infections (UTIs) in Females

Proper hand hygiene, wiping from front to back, adequate fluid intake, and avoiding indwelling catheters are important preventative measures.
Frequent sexual intercourse is not a factor for UTI prevention.

Preventing UTIs

Adequate fluid intake to produce pale yellow urine is crucial for preventing UTIs.

Glomerular Injury Indicators

The presence of large proteins in urine suggests potential glomerular injury.

Short-Term Constipation Solutions

Cathartics, laxatives, and enemas are short-term solutions for constipation.
Diet change and altered defecation schedules provide long-term solutions.

Bowel Elimination Factors (Further Teaching Needed)

A recommended daily fluid intake of 1.5 liters for women is crucial for normal bowel function; however, other factors such as position, emotional stress, and muscle tone are also important.

Types of Laxatives

Bulk-forming laxatives work by absorbing water and swelling the stool.

Frequent straining during defecation can lead to hemorrhoids.

Medications for Defecation

Laxatives are used to promote defecation.

Constipation Risk Factors

Patients taking opioid analgesics have a higher risk of constipation.

Nutrition Importance

Adequate nutrition supports organ function, growth, development, and maintenance of body tissues.

MyPlate Program

The MyPlate program recommends grains to make up half the plate, not all. To maintain a healthy diet avoid excess fat and cholesterol and choose lean protein sources. Include a variety in color and type of vegetables and fruits for a varied diet.

Pressure Injury Characteristics

Stage 2 pressure injuries show a reddish-pink wound bed without slough.

Braden Scale and Pressure Injuries

A Braden Scale score of 11 indicates a high risk for pressure injuries.

Early Signs of Pressure

Blanchable erythema is an early indicator of pressure that resolves without tissue loss if the pressure is eliminated.

Medication Error Management

Immediately assess and examine the patient's condition after discovering a medication error.

Patient Rights Regarding Medications

Patients have the right to know the name and purpose of medications and to refuse them.

Antidotes and Medication Toxicity

Keeping medication antidotes at the patient's bedside is vital for treating medication toxicity.

Medication Administration Rights

The "right nurse," "right medication," "right patient," "right dose," "right time," "right reason," "right route," and "right documentation" are crucial parts of safe medication administration. The "right color" should not be part of consideration.

Preventing Medication Errors

Carefully reviewing medication labels at least three times before administration.

Medication Action Intervals

Medication intervals are not defined in the provided questions.

Aspiration Risk Assessment

Assessing a patient's ability to cough, swallow, and have an intact gag reflex is crucial to prevent aspiration.

Oral Medication Administration

Patients with skin abrasions, but without swallowing problems, can safely be administered oral medications. Be sure to check for ability to swallow.

Dietary Recommendations for Obesity Prevention

Controlling alcohol and sodium intake, choosing low-fat dairy, and eating fruits and vegetables are beneficial dietary choices for preventing obesity. Avoiding grains is not a healthy option.

Costliest Chronic Disease

Diabetes is the most costly chronic disease in terms of healthcare.

Nonmodifiable Heart Disease Risk Factor

Family history of heart disease is a nonmodifiable risk factor.

Emergency Medical Treatment and Active Labor Act (EMTALA)

EMTALA makes it mandatory for healthcare agencies to provide emergency care to patients before transferring them to other hospitals.

Proprioception in Older Adults

Older adults often experience increased difficulty with balance due to proprioceptive changes.

Communicating with Patients with Expressive Aphasia

Offering communication aids, such as pictures or a communication board, is essential when communicating with patients with expressive aphasia.

Pressure Injury Staging

Stage 1 pressure injuries are characterized by non-blanchable erythema.
Stage 2 involves partial-thickness skin loss with exposed dermis.
Stage 3 exhibits full-thickness skin loss, with visible fat.
Stage 4 involves full-thickness tissue loss, with exposed bone, muscle, or tendon.
Unstageable pressure injuries have obscured necrotic tissue and may be difficult to stage.
Deep tissue injuries have a darker appearance than stage 1-4 injuries.

Wound Healing and Nutrition

Protein, vitamins A & C, zinc, and copper are crucial for wound healing. Adequate hydration and calorie intake also play valuable roles.

Medication Safety and Regulations

The Food and Drug Administration (FDA) ensures medication safety and efficacy.

Medication Blood Levels

Trough is the minimum blood serum concentration of a medication, not the maximum.

Pressure Injury Risk and Reduced Tactile Sensation

Patients with reduced tactile sensation are at greater risk of skin breakdown.

Nasal Cannula Safety

Loosening a nasal cannula's tubing prevents skin irritation.

Nurse's Responsibilities and Roles

Nurses are caregivers, educators, advocates, and managers.

Medication Interactions

When one medication modifies the action of another, a medication interaction occurs. Synergistic effects result in a combined action greater than the individual effects.

Pressure Injury Staging (Heel Wound)

A heel wound with partial-thickness skin loss has exposed dermis. This is a Stage 2 pressure injury.

Medication Absorption Rates

Intravenous (IV) administration is the fastest way to absorb medications.

Avoiding Malpractice and Negligence

Proper documentation, maintaining current knowledge, adhering to standards of care, thoroughness and timely completion of documentation are critical to avoiding malpractice and professional negligence.

Passive Range-of-Motion (ROM) Exercises for Patients with Hemiparesis

A head-to-toe approach, avoiding forced movements, slow and smooth movements, and awareness of potential discomfort are crucial for passive ROM exercises for patients with hemiparesis.

Enteral Feeding Safety

Identifying the patient using two identifiers is crucial for ensuring patient safety when administering enteral feedings.

Medication Prescription Components

Medication prescriptions include generic name, route, dose, frequency, and instructions, but not the chemical name (unless in a specific circumstance) or the administering nurse's name. This is usually a physician.

HIPAA Violation

Listing patient names at the front desk for easy access constitutes a HIPAA violation.

Urinary Incontinence and Pressure Injury Prevention

Managing moisture is crucial for preventing pressure injuries in patients with urinary incontinence.

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Description

Test your knowledge on the best practices for patient positioning during feeding, the implications of dysphagia, and the evaluation of urinary catheterization. This quiz covers essential nursing considerations to minimize risks and ensure patient comfort and safety.