Week 3 Flashcards
1
Q
A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination?
A
Water retention
2
Q
Which constituent found in urine indicates the presence of an abnormality?
A
Protein
3
Q
A client’s urinalysis is reported as being normal. What were the client’s results?
A
pH 6 and no glucose present
4
Q
The nurse is caring for patients with a variety of wounds. Which type of wounds heals by primary intention?
A
Surgical incision
5
Q
The nurse documents that a client’s postoperative wound is purosanguinous. What did the nurse assess in this client’s wound?
A
Purulent drainage and red blood cells.
6
Q
The nurse is assessing a client’s pressure ulcer. To determine the depth of the ulcer, the nurse should:
A
Insert a sterile swab into the deepest part of the wound.
7
Q
The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client’s skin?
A
Use a transfer device when moving the client in bed.
8
Q
The nurse assesses an open area over a greater trochanter of a client that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy.The edges of the wound cup in toward the center. Which additional findings would indicate to the nurse that this is a stage IV pressure injury?
A
The joint capsule of the hip is visible
9
Q
Which cues support the hypothesis of Constipation for a patient?
A
Limited mobility
Receives narcotic pain medication
Decreased fluid intake
10
Q
Which cues would prompt the nurse to develop a hypothesis of Dehydration for a patient?
A
Numerous semiliquid stools
Output more than intake
Dry mouth
11
Q
Which hypothesis would the nurse address first for a patient having continuous seepage of liquid stool?
A
Fecal Impaction
12
Q
Which solution would the nurse consider for a patient with constipation who is on bed rest?
A
Patient education
13
Q
Which outcome would the nurse include for a patient with a hypothesis of reluctant to care for stoma?
A
Patient will assist with ileostomy care daily.
14
Q
Which cue would prompt the nurse to select a hypothesis of Bowel Incontinence for a patient?
A
Intermittent soiling from soft feces
15
Q
Which hypothesis would the nurse develop for a patient who states, “I can’t stand to look at the stoma or this colostomy bag”?
A
Disturbed body image
16
Q
Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Diarrhea?
A
Quick transit time reducing water absorption
17
Q
The nurse would consider which pathophysiologic factor when caring for a patient with dementia whose bed linens are soiled several times a day?
A
Impaired neurologic status
18
Q
Which hypothesis would the nurse select for a patient who has hyperactive bowel sounds, abdominal cramping, and liquid stools?
A
Diarrhea
18
Q
Which hypothesis would the nurse select for a patient who has hyperactive bowel sounds, abdominal cramping, and liquid stools?
A
Diarrhea
19
Q
The nurse would develop a hypothesis of Risk for Impaired Skin Integrity for which patient?
A
A patient with an ostomy created from the ileum
20
Q
Which patient situation would the nurse prioritize as the most critical?
A
Choking on food, closing airway
21
Q
The nurse recognizes that the outcome of “Patient will pass soft stools daily during rehabilitation” directly applies to which hypothesis?
A
Constipation
22
Q
The nurse recognizes that the outcome of “Patient will pass soft stools daily during rehabilitation” directly applies to which hypothesis?
A
Constipation
23
Q
Which member of the multidisciplinary team would the nurse include in caring for a patient who has impaired manual dexterity for toileting?
A
Physical therapist
24
Which solution would the nurse consider for a patient with flatulence who is in traction?
Avoidance of foods that produce gas
25
Which overall goal would the nurse focus on while caring for a patient with severe diarrhea?
Prevent dehydration
26
Which overall goal would the nurse select for a patient who has occasional fecal incontinence?
Maintain intact skin
27
Which overall goal would the nurse select for a patient who has occasional fecal incontinence?
Maintain intact skin
28
Which elimination outcome indicates the nurse has considered the physical abilities of the patient in a coma?
The patient will have intact skin after each bowel movement.
29
Which elimination outcome indicates the nurse has considered the physical abilities of the patient in a coma?
The patient will have intact skin after each bowel movement.
30
Which hypothesis is associated with the patient outcome “Patient will defecate without burning or pain while hospitalized”?
Hemorrhoid
31
Which cues would prompt the nurse to select a hypothesis of Risk for Constipation for a patient?
Has poor fluid intake
Is on complete bed rest
32
Which cues would prompt the nurse to develop the hypothesis of Impaired Self-Toileting for a patient?
Weakness in left leg
Paralysis of the lower extremities
Hemiparesis on the right side
33
Which cues support the nurse formulating a hypothesis of Constipation for a patient?
“My stools are like little hard stones.”
“I watch a lot of movies for entertainment.”
“I frequently take an opioid medication for my back pain.”
34
Which multidisciplinary team members would the nurse likely collaborate with when caring for a patient who has constipation from a low-fiber diet and pain medications and needs assistance with self-toileting from hip surgery?
Health care provider
Nutritionist/Dietitian
Physical therapist
35
Which goals would the nurse select for a patient with frequent watery stools?
Patient will pass soft stool within 48 hours.
Patient will defecate formed stool within 24 hours of treatment.
Patient will have two fewer episodes of diarrhea within 24 hours.
36
Which solutions would the nurse select for a patient with diarrhea caused by Clostridium difficile (C. diff)?
Fluid measures
Isolation precautions
Intake and output monitoring
37
Which hypotheses relate to the outcome of patient will pass soft, formed stools?
Constipation
Diarrhea
Fecal impaction
38
Place the steps in order that the nurse would take when determining outcomes for a patient who cannot control bowels.
Organize and link cues gathered through patient observation and physical assessment findings for bowel elimination.
Make connections among the cues that relate to bowel elimination.
Develop the hypothesis, Bowel Incontinence, and other related hypotheses.
Prioritize hypotheses.
Develop expected outcomes for bowel elimination.
39
Which cues support the hypothesis of Urinary Retention?
Bladder palpable after voiding
Urinary frequency
Diagnosis of prostate enlargement
40
During assessment of a pregnant patient, the nurse recognizes the cues of urinary frequency and small volume urine leakage as supportive of the hypothesis of Urinary Incontinence. Knowledge of which physiologic process provides the rationale for this hypothesis?
A hormone causes relaxation of urethral sphincters.
41
The nurse caring for an adult patient with a urine output of 350 mL in the past 24 hours is evaluating the previously selected hypothesis of Impaired Kidney Function. Which new cues in the patient chart indicate a need to begin the clinical judgment process again and create a new hypothesis?
Serum creatinine level within expected range
Specific gravity of urine above the expected range
Urinalysis negative for protein
Serum blood urea nitrogen (BUN)/creatinine ratio within expected range
42
A patient involved in a motor vehicle accident is transferred to your facility. Multiple patient problem hypotheses are generated. Which hypothesis is the highest priority?
Impaired airway clearance
42
A patient involved in a motor vehicle accident is transferred to your facility. Multiple patient problem hypotheses are generated. Which hypothesis is the highest priority?
Impaired airway clearance
43
Which solutions would the nurse generate for a hypothesis of Impaired Kidney Function?
Monitor serum creatinine and blood urea nitrogen (BUN) level.
Assess for swelling in extremities.
Monitor for cardiac arrhythmia.
44
Which categories can the nurse use to organize and link the patient’s skin integrity cues?
Type of wound
Type of wound bed tissue
Unexpected assessment findings
Unexpected laboratory findings
45
Which patient would the nurse see first after receiving report?
A patient with a profusely bleeding wound
46
Which expected outcome would the nurse select for a patient who has a hypothesis of Pressure Ulcer/Injury?
Patient’s Braden Scale score will stay the same or increase within 72 hours.
47
Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity?
Bone
Tendon
Muscle
48
Which hypothesis would the nurse develop for an immobile patient who has intact skin?
Risk for Impaired Skin Integrity
49
Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity?
Low prealbumin levels
Immobility
Stage 2 pressure injury
50
Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound?
Repositioning the patient
Reporting any changes in patient’s skin integrity or condition
Applying a nonsterile dressing for chronic wounds with an established treatment plan
51
Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?
Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.
52
Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days?
Therapies consistent with guidelines for treatment of wounds
Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN)
Agreement of the patient with the treatment plan
Capability of the patient to purchase supplies for home care as required
53
Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum?
Wound, ostomy, and continence nurse (WOCN)
Social worker
Nutritionist
54
Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound?
“My wound will look beefy red within 1 week.”
55
For which patient hypotheses would the nurse select turning and positioning as a solution?
Impaired skin integrity
Risk for pressure ulcer/injury
Impaired tissue integrity
Risk for impaired skin integrity
56
Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident?
Patient’s wound will exhibit granulation tissue in the wound by 1 week.
57
Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority.
Patient who is experiencing shock from a profusely bleeding wound
Patient who just had an incision eviscerate
Patient with a stage 4 pressure injury
58
The cluster of capillaries in each nephron is referred to by which term?
Glomerulus
59
Which hormone causes retention of water, resulting in an increase in blood volume?
Aldosterone
60
Which hormone causes vasoconstriction and stimulates the release of aldosterone?
Angiotensin II
61
Which statement by a student nurse indicates appropriate knowledge about the urinary bladder?
"The low pressure in the bladder during filling prevents the backward flow of
urine into the ureters."
62
Which statement is true about the structure of the urethra?
Striated muscles are responsible for voluntary control over the flow of urine
63
Which statement is true about a ureterostomy?
The ureters are transplanted into a closed-off part of the intestinal ileum.
64
The nurse is preparing to administer erythropoietin to a patient who
presents with a deficiency. The nurse knows that the patient needs this medication because of dysfunction in which organ?
Kidney
65
A patient reports not being able to pass urine completely. Even after voiding, the patient does not feel that the bladder is empty. Which test
can be done to assess the postvoid residual (PVR) in the patient?
Portable noninvasive bladder ultrasound device
66
Which substance secreted by the kidneys helps control blood pressure via vasodilation?
Prostaglandin E2
67
Which condition is a cause of transient urinary incontinence?
Fecal impaction
68
Which condition is a cause of transient urinary incontinence?
Fecal impaction
69
The nurse is reviewing the laboratory reports of a patient. The urine report shows the presence of large proteins in the urine. Which condition is the most probable cause of proteinuria?
Glomerular injury
70
The nurse is reviewing the urinalysis report for a patient. Which finding indicates possible glomerular injury?
Large proteins
71
A patient reports passing only a small amount of urine despite a normal fluid intake. This condition is referred to as which medical term?
Oliguria
72
A student nurse is learning about the structure and function of the urinary system. Which statement by the student nurse indicates effective knowledge about the ureters?
A kidney stone can result in hydroureter."
73
Which nursing intervention is the best option for a patient with newonset transient incontinence?
Look for reversible causes
74
Which type of incontinence is most likely to be associated with a urinary tract infection?
Transient incontinence
75
A patient with a bladder disorder is advised to get a urinary diversion. The patient wishes to have the type of urinary diversion that allows normal voiding. Which type of urinary diversion suits the patient’s requirement?
Orthotopic neobladder using an ileal pouch
76
A patient is scheduled for a cystoscopy. What instruction would the nurse give to this patient about cystoscopy?
The patient may have difficulty voiding after the test
77
Which part of the gastrointestinal tract plays a major role in bowel elimination?
Large Intestine
78
Which information is true about the large intestine?
It is shorter than the small intestine
It has a role in the elimination function
It can develop hemorrhoids
79
The nurse provides medication education for a group of nursing students about a stool softener that increases the secretion of water by the intestine. Which information would the nurse include in the teaching?
"It is a short-term therapy to relieve straining on defecation."
"It lowers the surface tension of feces, allowing water and fat to penetrate."
80
The nurse is explaining to a patient with gastritis about the tasks performed by the stomach. Which physiological function would the nurse include in the teaching?
Storage of food
Secretion of intrinsic factor
Production of hydrochloric acid
81
Which bowel elimination problem is associated with abdominal fullness; cramping; distention; and severe, sharp pain?
Flatulence
82
Where does normal defecation begin?
Colon
83
The nurse examines a patient’s stool specimen and notes that the stool is oily. The nurse suspects which cause of this assessment finding?
Malabsorption syndrome
84
Which medication may cause constipation?
Opioid analgesics
85
Which medication may cause constipation?
Opioid analgesics
86
Which statement describes accurate information regarding the large intestine?
Straining during a bowel movement can cause hemorrhoids.
When peristaltic contractions slow down, constipation occurs.
The colon has three functions: absorption, secretion, and elimination.
87
What is the daily recommended volume of fluid intake for a woman?
2.7 L
88
Which description is accurate about the mouth’s role in the digestive process?
Saliva produced by the salivary glands helps to dilute and soften the food.
89
Which parameter would be measured to determine the protein deficiency in the patient with a wound?
Serum albumin
Serum tranferrin
Serum prealbumin
89
Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part?
Bedsore
Pressure sore
Pressure ulcer
Decubitus ulcer
90
Which role does vitamin A play in wound healing?
Promotes wound closure
91
Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?
Blanchable erythema
92
Which blood cells are known as garbage cells?
Macrophages
93
The nurse assesses a patient’s abdominal wound and finds that the wound is in the proliferative phase of healing. Which change in the
wound might have led the nurse to this conclusion?
The wound is filled with granulation tissue
The wound contract to reduce the area that requires healing
There is re-epithelializaiton of the wound surface
94
Which vitamin would be provided to a patient to promote wound healing?
A and C
95
Phases of wound healing
Hemostasis
Inflammatory phase
Proliferative phase
Remodeling
96
Which finding is characteristic of a stage 3 pressure injury?
It has full-thickness skin loss.
The subcutaneous fat may be visible.
The bone, tendon, and muscle are not exposed
97
On assessing your patient’s sacral pressure injury, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. Which stage would be applied to this patient’s pressure injury?
Unstageable
98
Which characteristic of a stage 2 pressure injury is the nurse likely to find during a wound assessment?
It has a reddish-pink wound bed without slough.
99
Which characteristic would be indicative of abnormal healing of a primary wound?
Drainage for more than 3 days after closure
100
Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility?
Kinetic therapy
101
The edges of a patient’s surgical incision are approximated, and no drainage is noted. Which type of healing does this signify?
Primary intention
102
Which stage of pressure injury is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue
consistency (firm or soft), and/or pain?
1
