Vsims questions EXAM 2 Graded A(latest update)

Document Content and Description Below

Vsims question EXAM 2 The nurse has an order to check a patient’s post-void residual urine. How would the nurse carry out this order? Measure the amount of urine in the bladder using a bladder sca... nner Calculate the difference between the patient’s intake and output Palpate the bladder for distention and record findings in the chart Insert a straight catheter and measure the urinary output in two hours the nurse is caring for a patient who is unable to urinate voluntarily since a gunshot injury. Patient data associated with which intervention will provide information regarding the patients kidney function? Daily serum creatinine levels Results of preauthorization bladder scans Number of times the patient requests oxybutynin over a 24-hour period Urinary output over eight hours Which information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure? (Select all that apply) the scanner is moved over the skin of the patients lower abdomen The procedure is necessary when a patient experiences difficulty voiding the scan typically does not cause the patient any pain The scan produces an image of the pt.’s bladder and the amount of urine it contains the patient’s body is draped to promote modesty The nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. What questions would the nurse include when assessing the patient? (Select al that apply) have you noticed any change in your usual voiding pattern? Is there anything that you do that helps you urinate? When was your last menstrual period do you ever leak urine? how often do you urinate? The nurse is caring for a patient experiencing the effects of paraplegia. What urinary condition is associated with this diagnosis? Oliguria Neurogenic bladder Chronic cystitis Stress incontinence While inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. What is the appropriate action by the nurse? Carefully remove the catheter & reinsert it into the urethra Leave the catheter in the vag as a landmark & begin the procedure again w/ new supplies Allow the pt a period of rest and attempt the procedure at a later time Remove the catheter & re-start the procedure using a new sterile kit The nurse is preparing to catheterize a female patient and is positioning the patient. Which position(s) would be appropriate for this procedure? (Select all that apply) Dorsal recumbent Supine Side lying Lithotomy Semi-fowler The nurse is providing discharge education on complications associated with intermittent self-catheterization. Which possible complications should the nurse include in the teaching session? (SATA) Urinary tract infections Nephrotic syndrome urethral strictures bladder spasms bladder perforation The nurse is recording fluid intake for Ms. Johnson. Which items on the dinner tray should the nurse include when completing this documentation? Tomato soup iced tea Apple sauce Creamed corn ice cream The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse? Call for a coworker to help hold the patients legs in position Notify the provider that the procedure could not be completed because the patient is paralyzed Ask a family member to assist you with the cauterization Instruct the pt. to turn on her side The nurse has created a sterile field and is preparing to catheterize a patient. While using sterile balls to clean the patient prior to the procedure, the nurse corps a contaminated cotton ball in the middle of the sterol field. What is the correct action of the nurse at this time? Obtain a new catheter kit and restart the process Remove the contaminated cotton ball from the field with the non-dominant hand Ask a co-worker to remove the contaminated cotton ball from the field Continue with the procedure while avoiding the contaminated cotton ball The nurse has received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patients specimen? pH Clarity  odor sediment color After completing an intermittent catheterization what information concerning the procedure will the nurse include in Ms. John sons medical record? Characteristics of the urine obtained Time procedure was performed Size of catheter used Description of the patient's tolerance for the procedure Description of the cleansing process preceding the procedure The nurse is providing Ms. Johnson discharge education about intermittent self-catheterization. What statement if made by the patient would indicate the need for further instruction? It is important that I self-catheterize at regular intervals I should maintain sterile technique throughout the procedure There are risks associated with self-catheterization, such as bleeding and infection If I do not catheterize myself, I may develop urinary problems The nurse is completing documentation following the insertion of an intermittent urinary catheter. What should be included in the documentation? Size of the catheter Patient's tolerance of the procedures The length of time for completion of the procedure Date the procedure was performed Time the procedure was performed Ms. Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session? You may experience excessive saliva production while taking this medication This medication helps reduce bladder spasms Your urine may appear reddish-orange You may have to urinate more frequently while taking this medication Ms. Johnson asks: why do I need to self-Cath at regular interval? What would be the appropriate response by the nurse? This helps prevent your bladder from becoming over distended You will only need to self-catheterize once daily Self-catheterization helps reduce your risk of infection this allows you to accurately measure your urine The nurse is providing patient education on self-cath. what statement indicates need for further teaching? I can use either an indwelling or intermittent catheter I may be eligible for free catheters through Medicare .I should report signs and symptoms of potential complications to the provider immediately I should store my reusable catheters in a clean, dry container Marvin Hayes Which statement by the nurse indicates a thorough understanding of the purpose of postoperative nursing care? The goal is to ensure uneventful recovery from surgery. The goal is well-managed post-op pain The goal is to prevent infection. The goal is frequent assessment of the surgical incision site. Which nursing interventions are implemented primarily to prevent respiratory complication in a patient after abdominal surgery? (Select all that apply.) Prompting to cough Assisting in early ambulation encouraging deep breathing Providing pain medication as required Education on incentive spirometer use Which intervention takes priority when the nurse determines that a postoperative patient has hypoactive bowel sounds? Assess the abdomen for signs of distention Notify the surgeon of this assessment finding Advance the patient's diet to soft, solid food assess the patient for indications of hypotension Which statement made by the patient indicates an understanding of diet progression after surgery? I know it is important to get my strength back, so I will ask for a milkshake after surgery I'll start drinking water as soon this nausea subsides I love coffee, so I'll have some as soon as I get back from surgery I can't tolerate a soft diet, so I'll simply go back to drinking clear liquids Which diagnostic test is used as a screening tool for the possible diagnosis of colon cancer? Stool pinworms Occult blood timed stool specimen Stool culture The need for a sigmoid colostomy is generally a result of cancer at what point in the intestinal tract? .Anywhere in the descending colon anywhere in the transverse colon near the rectum near the ileocecal valve What information will the nurse include when providing education for a patient scheduled for a colostomy as treatment for rectal cancer? The surgeon will determine whether the ostomy can be temporary once surgery has begun Permanency will depend on how much colon function has been affected by the surgery the ostomy will be permanent because of the nature of the illness once the inflammation in the colon subsides, the ostomy will be reversed What information will the nurse include when providing education for a patient who is scheduled for a sigmoid colostomy? (Select all that apply.) When an ostomy is needed, intestinal mucosa is brought through the abdominal wall the fecal matter that will pass through the stoma will be liquid in form a healthy stoma is bright red, moist, and rounded A stoma is the portion of the intestinal mucosa that is secured to the skin of the abdomen the term ostomy refers to an opening from the inside of an organ to the outside of the body. Which statements will guide the nurse when preparing to educate a patient whose condition requires a permanent colostomy? (Select all that apply.) Help the patient get accustomed to looking at the ostomy Encourage the patient to take part in the care process Assess the patient for signs of depression If the patient is accepting, include family members in the teaching  Schedule the teaching two to three days after the surgery The nurse is preparing discharge education for a patient with a permanent colostomy. What information concerning diet and nutrition will the nurse include? (Select all that apply).  .Avoid foods that previously caused diarrhea gradually add new foods into the diet Drink at least two quarts of water daily Avoid high fiber foods for eight weeks after the surgery be aware that colostomies are prone to develop food blockages Which patients have an increased risk for developing colorectal cancer? (Select all that apply.) A 30 y.o. with a 13- year history of Crohn's disease A 50 y.o. whose diet includes red meat daily A 63 y.o. who is healthy A 70 y.o. who has been diagnosed as obese A 40 y.o. with a history of lupus A postoperative patient is receiving enoxaparin sodium therapy. Which assessment data would the nurse report immediately to the patient's health care provider? A platelet reading of 260,000 per mcL Small amount of gum bleeding after completing oral hygiene Patient has reported self-medicating with aspirin three times since surgery Patient reports no bowel movement for two days What assessment data will the nurse expect to find to support the assumption that Mr. Hayes’s surgical incision is in the inflammatory phase of wound healing? (Select all that apply.) Increased white blood cell count Incision is slightly edematous Incisional site pain Redness surrounding the incision Signs of scabbing are noted at the incision site A patient is placed on omeprazole 20 mg daily. When will the nurse administer the medication? At bedtime One hour after any meal One hour before breakfast with breakfast When should the nurse caring for a patient with a new colostomy plan to change the pouching system? After any meal  before breakfast Right before bed before the patient showers Which interventions will the nurse implement to help minimize a postoperative patient's risk for surgical site complications? (Select all that apply.) Following strict aseptic techniques when changing surgical dressing Monitoring for elevation in body temperature Providing sufficient fluids to maintain hydration Advancing diet as appropriate to provide adequate nutrition Encouraging deep, sustained breathing and supported coughing What instruction should the nurse provide to a patient concerning how often the colostomy pouch should be emptied?  Whenever the pouch is one-third full of fecal drainage when the pouch isn't well attached to the skin After each meal At least four to five times daily What information should the nurse include in the documentation associated with the changing of a patient's colostomy pouch? (Select all that apply.) Condition of the skin around the stoma  how often the process will be done Description of the stoma Characteristics of the fecal matter Patient's response to the process Which statements best support the nurse's evaluation that a patient who recently experienced a sigmoid colostomy has begun to accept the body change? (Select all that apply.) I'm anxious to get a bathing suit that accommodates my colostomy My stoma continues to be red and moist My ostomy nurse always has helpful suggestions about daily care routine Having a colostomy is a small price to pay for being healthy I really hope no one else I know has to ever deal with a colostomy Which statements indicate that a patient who recently required a colostomy has achieved the outcomes set for regular bowel elimination? (Select all that apply.) Getting a short nap each afternoon makes me feel so much better I've learned to implement the techniques I learned in stress management I've gotten accustomed to drinking at least two quarts of water a day My routine includes about 30 minutes of exercise daily I know that what I eat has a large impact on my bowel function [Show More]

Last updated: 1 year ago

Preview 1 out of 4 pages