Practice Questions

Front 1

The nurse recognizes that urinary elimination changes may occur even in healthy elders because:

Back 1

The amount of urine retained after voiding increases.
Rationale: The capacity of the bladder may decrease with age BUT the muscle is weaker and can cause urine to be retained. Elders do not ignore the urge to void, but may have difficulty getting to the toliet in time. The kidneys produce LESS concentrated urine with age.

Front 2

During assessment of the client w/ urinary incontinence, the nurse is most likely to assess the following:

Back 2

Perineal skin irritation
Fluid intake of less than 1,500mL/day
History of frequent UTI's.
Rationale:The perineum may become irritated by frequent contact w/ urine. Normal fluid intake is 1,500mL. per day and clients often decrease their urine intake to minimize urine leakage. UTI's contribute to incontinence.

Front 3

What is an appropriate nursing management of a client wearing a condomn catheter?

Back 3

Check the penis for adequate circulation 30 minutes after applying.

ChANGE CONDOM EVERY 24 HOURS. Tubing is taped to leg or a leg bag. An indwelling catheter is taped to the lower abdomen or upper thigh. A one inch space should be left between the penis and the end of the condom.

Front 4

During the straight catheterization of a female client, if the catheter slips into the vagina, the nurse should:

Back 4

Leave the catheter in place and get a new sterile catheter.

Front 5

Which of the following statements indicates a need for further teaching of the home care client with a long-term indwelling catheter?
1.)I will keep the collection bag below the level of the bladder at all times.
2.)Intake of cran. juice may help decrease the risk of infection.
3.)Soaking in a warm tub bath may decrease the irritation associated w/ the catheter.
4.)I should use clean technique when emptying the collection bag.

Back 5

3.) Soaking in a tub bath may decrease irritation.
Rationale:A bath would increase the risk of infection. All of the other statements are appropriate.

Front 6

During the shift report , the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the BR. What is an appropriate nursing diagnosis?

Back 6

Urge Urinary Incontinence
Rationale:Key phrase"Urge to void."
Stress Incontinence: cough, sneeze, or jars the body resulting in an accidental loss or urine.

Front 7

A female client has a UTI. List appropriate teaching:

Back 7

Review symptoms of UTI w/ client
shower rather than bath.
Cotton undergarments
Increase fluids
Front to back wipe

Front 8

What are some techniques a nurse can use to promote continence?

Back 8

Because the bladder is still contracting, unlike a flaccid bladder, that will not contract...the nurse should promote:
habit training, bladder training, kegel exercises, reinforcement

Front 9

What are some indications that a client has met expected outcomes on a bladder training program?

Back 9

Practices, slow deep breathing until the urge decreases. Sometimes these urges can be premature, it is important for the client to inhibit the premature urge.
Performs pelvic muscle exercises.

Citrus juices are not recommended as they may irritate the bladder. Carbonated beverages increase diuresis, which increases the risk of incontinence.

Front 10

What should the nurse monitor to best assess a patient's renal perfusion?

Back 10

Urinary output every hour.
Rationale: adequate renal perfusion and kidney function are reflected by an hourly urine output of 30 to 50mL of urine.
Daily weights refelct fluid balance and are done with I & O every 24 hours. BP measurements reflect cardiac and circulatory functioning and fluid BALANCE, not renal perfusion.

Front 11

The nurse collects data about a patient regarding a risk for stress incontinence. Which is a major contributing factor for this condition?
1.)Decreased bladder capacity
2.)Spinal cord dysfuction
3.)Cognitive Impairment
4.)Weak pelvic muscles

Back 11

Decreased bladder capacity is related to URGE incontinence, not stress.
2.) Spinal cord dysfuction is related to refelx incontinence, not stress.
3.) Cognitive would lead to total incontinence, not stress.
4.) Stess incontinence is an immediate involuntary loss of urine during an increase in-intra abdominal pressure. (Laughing, coughing) It is related to weak pelvic muscles.

Front 12

An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should assess for which of the following?
1.)Increased B.P.
2.)Weak, rapid pulse
3.)Moist mucous membranes
4.)Jugular vein distention

Back 12

Weak rapid pulse=dehydration.
Moist mucous mebranse, Increased B.P. and Jugular vein distention are all indicative of fluid volume excess
.

Front 13

A man brings his elderly wife to the Emergency Department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?
1.)Start an I.V.
2.)Review the results of serum electrolytes
3.)Offer the woman foods that are high in sodium and potassium content.

Back 13

Review the results of serum electrolytes.

Front 14

The nurse administers an IV solution of D5 1/2 NS to a postoperative client. This is classified as what type of intravenous solution?

Back 14

Hypertonic
These solutions draw fluid OUT of the vascular compartments.
Not to be used on client w/ dehydration.

Hypotonic solutions provide free water to treat cellular dehydration.

Front 15

Changes in vital signs may indicate, or in some cases precede, fluid, electrolyte, and acid-base imbalances.

An increased body temp. (fever) can be a sign of what?

Back 15

Dehydration or increased body fluid losses.

Front 16

Tachycardia is an early sign of?
(rapid pulse rate)

Back 16

Hypovalemia (blood volume deficit)

Front 17

Changes in respiratory rate and depth may cause?

Back 17

respiratory-acid base imbalance.

Front 18

Nursing Diagnoses that relate to greater output than input after looking at an I&O record of a client:

Back 18

Deficient fluid volume
Impaired Oral Mucous Membranes
Decreased Cardiac Output

Front 19

Example of Nursing Diagnosis related to fluid volume overload?

Back 19

Impaired Gas Exchange

Front 20

Which of the following statements indicates a need for further teaching regarding treatment for hypokalemia?
1.)I will use avocado in my salads.
I will be sure to check my heart rate before I take my digoxin.
I will take my potassium in the morning after eating breakfast.
I will stop using my salt substitute.

Back 20

Salt substitutes contain potassium.
All of the other options are appropriate.

Front 21

An elderly man is admitted to the medical unit w/ a diagnosis of dehydration. Which of the signs or symptoms are most represenative of a sodium imbalance?
1.)Hyperreflexia
2.)Mental confusion
3.)Irregular pulse
4.)Muscle weakness

Back 21

Mental confusion
Rationale: Sodium contributes to the fuction of neural tissue. Calcium contributes to the fuction of muscle contraction, so Hyperflexia and muscle weakness are indicative of Hypocalcemia.. Potassium and calcium contribute to cardiac function, so irregular pulse is most likely to be associated with K+ and Ca++.

Front 22

A client is admitted to the hospital for hypocalcemia. Nursing interventions related to which system would have the highest priority?
1.)Renal
2.)Cardiac
3.)Gastrointestinal
4.)Neuromuscular

Back 22

Neuromuscular.
The major signs and symptoms of hypocalcemia are due to increased neuromuscular activity.

Front 23

The nurse would assess for signs of hypomagnesemia in which of the following clients? Select all that apply.
1.)A client with renal failure.
2.)A client with pancreatitis
3.)A client taking magnesium-containing antacids.
4.)A client with excessive nasogastric drainage.
5.)A client with chronic alcoholism.

Back 23

Hypomagnesium:
A client with pancreatitis
Excessive nasogastric drainage
Chronic alcoholism

Hypermagnesium:
Renal Failure
A client taking magnesium-containing antacids.

Front 24

A patient receiving a tube feeding develops diarrhea. The nurse understands that the primary reason tube feedings cause diarrhea is because they are:

Back 24

HYPERTONIC
Rationale: Hypertonic solutions have a greater concentration of solutes than does the blood. The high osmolarity of a hypertonic tube feeding exerts an osmotic force that pulls fluid into the stomach and intestine, reulting in intestinal cramping and diarrhea.

Front 25

When the nurse assesses a patient, which adaptation indicates a potassium deficiency?
1.)Increased B.P.
2.)Muscle weakness
3.)Chest pain
4.)Dry hair

Back 25

1.)Hypertension is associated with hypervolemia, NOT a potassium deficiency.
2.)Potassium is an essential component in the sodium-potassium pump, cellular metabolism, and MUSCLE contraction. Patient adaptations associated with a potassium deficiency (hypokalemia) include muscle weakness, fatigue, lethargy, leg cramps, and depressed deep-tendon reflexex.
Chest pain is associated witha myocardial infarction (heart attack) and pulmonary embolus, not a potassium deficiency.
4.)Dry hair is associated with malnutrition and hypothyroidism, not a potassium deficiency.

Front 26

The nurse suspects that an older patient may have a problem with excess fluid volume when the patient's skin appears:
1.)Dry and scaly
2.)Taut and shiny
3.)Red and irritated
4.)Thin and inelastic

Back 26

With excessive fluid volume, the increased hydrostatic pressure moves fluid from the inravascular compartment into the interstitial compartment. As fluid collects in the interstitial compartment (edema) the skin appears TAUT and SHINY.

Front 27

The nurse determines that inflammation of a vein may have occurred at an intravenous insertion site if when touchin the area it:
1.)Feels soft
2.)Seems cool
3.)Produces pallor
4.)Causes discomfort

Back 27

1.)The localized edema associated with the inflammatory response causes the infected area to feel firm, not soft.
2.)The localized vasodilation associated with the inflammatory response increases blood flow to the affected area, causing it to feel warm not cool.
3.)Localized vasodilation causes erythema not pallor.
4.)The physiologic response associated with the inflammation of a vein (phlebitis) causes movement from the intravascular compartment to the interstitial compartment. Pressure of fluid on nerve endings causes discomfort.

Front 28

When a patient is under extreme stress there is an increased production of ADH and aldosterone. Considering the effect of these hormones in the body, the nurse should expect a decreased in the patients:

Back 28

urine output

Front 29

The nurse is monitoring a patient who is receiving I.V. fluid. The nurse suspects fluid overload when assessment reveals:
1.)Chills, fever, and generalized discomfort
2.)Blood in the tube close to insertion site.
3.)Dyspnea, headache, and increased BP
4.)Pallor, discomfort, and swelling at the insertion site.

Back 29

IV fluid flows directly into the circulatory system via a vein. Excess intravascular volume (hypervolemia) causes hypertension, pulmonary edema, and headache.

Front 30

The nurse should notify the physician when a critically ill patient's hourly urine output first falls below:

Back 30

30mL

Front 31

The nurse understands that excess fluid in the interstitial compartment results from:

Back 31

Hydrostatic pressure: is the pressure exerted by a fluid within a compartment, such as blood within the vessels. Hydrostatic pressure moves fluids from an area of greater pressure to an area of lesser pressure.

Front 32

When the nurse evaluates a patient's fluid intake and output the fluid intake should be:

Back 32

Slightly more than fluid output

Front 33

The physician orders a diuretic for a patient who is retaining fluid. The nurse should encourage the patient to ingest nutrients rich in:

Back 33

Potassium.
Most diuretics affects the renal mechanisms for tubular secretion and reabsorption of electrolytes particularily potassium. Because of potassium's narrow therapeutic window of 3.5-5.0 mEq/L and its role in the sodium potassium pump, and muscle contraction, depleted potassium must be supplemented by increasing the dietary intake of foods high in potassium.

Front 34

What is a sigmoidoscopy?

Back 34

the sigmoid colon and rectum are visualized and may be biopsied.

Front 35

What is another diagnositc used to visualized the bowel?

Back 35

Colonoscopy. (Visualization and biopsy if needed of large and potions of the small colon.

Front 36

What is standard preparation for diagnostic tests visualizing the bowel?

Back 36

All require the client to be NPO for 12hr. prior to the procedure and to ingest nothing but clear liquids 24 hr. prior to the procedure.
A bowel prep using laxatives is commonly prescribed
Moderate sedation (benzodiazepine and an opiod)

Front 37

Before treating constipation with laxatives it is best to what?

Back 37

Increase fiber and water consumption

Front 38

What is the last resort for stimulating defecation?

Back 38

Enemas

Front 39

Causes of constipation:

Back 39

frequent use of laxatives
advanced age
inadequate fluid & fiber
immobilization due to injury
a sedentary lifestyle

Front 40

Causes of diarrhea:

Back 40

viral gastroenetritis
bacterial gastoenteritis
over use of laxatives
food-borne pathogens
inflammatory bowel disease
irritable bowel syndrome

Front 41

signs and symptoms of constipation:

Back 41

abdominal bloating/cramping
straining at defecation

Front 42

signs and symptoms of diarrhea:

Back 42

a.k.a. dehydration:
Tachycardia (rapid pulse rate)
hypotension (low b.p.)
fever
lethargy
poor skin turgor
abdominal cramping

Front 43

Ureterostomy:

Back 43

A type of urinary diversion
one or both ureters ti the abdominal surface w/ stoma

Front 44

Nephrostomy:

Back 44

a tube from the renal pelvis to the abdominal surface w/ stoma.

Front 45

Factors affecting urinary elimination:

Back 45

Age (full bladder control 4-5 yrs.)
Enlargement of the prostate after 40 leading to frequency, hesitancy, retention, incontinence, and UTI's.
Childbirth leading to stress incontinence , which may be managed with Kegel exercises
Older adult clients lose muscle tone leading frequency. Also, Inefficient emptying of the bladder (residual) and increased incidence of nocturia.
Diet: Increased sodium leads to decreased urination.
Caffeine and alcohol lead to increased urination
Spinal cord injury
Acute and chronic disease sonditions
Psychosocial factors: emotional stress outdoor toilets public (not enough time. quick breaks in elementary schools)
Pain: artritis or painful joints cause immobility, which leads to delay
Surgery
Medications: Diuretics

Front 46

Diagnostic tests (Urination)

KUB

Back 46

x-ray to determine the size, shape, and position of the kidney's.

Front 47

IVP

Back 47

Intravenous pyelogram (contrast to view ducts, pelvis, ureters, bladder, and urethra. Determine if allergt to shellfish or iodine.

Front 48

Cytoscopy:

Back 48

uses an endoscope to visualize the bladder and urethra.