3003073
Descripción
Test por hammylovesyou, actualizado hace más de 1 año
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Creado por hammylovesyou
hace casi 9 años
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Pregunta 1
Pregunta
A patient is having fewer than normal bowel movements with the difficult passage of hard, dry feces. The nurse would document this as
Respuesta
-
Impaction
-
Flatulance
-
Hemorroids
-
Constipation
Pregunta 2
Pregunta
A common cause of lower urinary tract infection would be
Respuesta
-
Kinked or blocked urethral catherter
-
Emotional Anxiety
-
Multiple childbirths
-
High fluid intake
Pregunta 3
Pregunta
Health promotion activities that the nurse might include in patient teaching to assist a patient in achieving normal defecation would include
Respuesta
-
Frequent use cathartics and laxatives
-
Lying flat to achieve continence on the bedpan
-
Limiting strenuous exercise that would hinder bowel functioning
-
Assure that the patient provides time to defecate when feels the urge to do so
Pregunta 4
Pregunta
When caring for a patient with an indwelling catheter the nurse knows that it is necessary to maintain the closed urinary drainage system. While caring for the patient the nurse would
Respuesta
-
Place all excess tubing off the bed to prevent the patient from lying on the tubing
-
Be sure to plan to reinsert the catheter at intermittent intervals
-
Maintain patency of the system and monitor urine flow
-
Remove catheter to reduce the risk of urinary tract infection
Pregunta 5
Pregunta
When documenting a common symptom of urinary alteration, the nurse would correctly document voiding a diminished urine output of 325 cc over 24 hours as
Respuesta
-
Oliguria
-
Polyuria
-
Urinary retention
-
Dribbling
Pregunta 6
Pregunta
A patient was admitted with prostate gland enlargement. The patient continues to demonstrate urinary frequency with only small amounts voided with each void and is restless. The patient is most likely experiencing
Respuesta
-
Urinary retention
-
Functional incontinence
-
Residual urine
-
Dysuria
Pregunta 7
Pregunta
Your patient is an alert 40-year-old male, who is timid and reluctant to talk about his urinary retention. Which part of this plan of care could create stress for the patient and possibly increase his inability to urinate?
Respuesta
-
Assist patient in assuming his usual voiding position.
-
Pull curtains around patient to provide privacy during voiding.
-
Stay with the patient while he is voiding.
-
Offer the urinal on a regular schedule.
Pregunta 8
Pregunta
During removal of a fecal impaction, which of the following could occur because of vagal stimulation?
Respuesta
-
Bradycardia
-
Atelectasis
-
Tachycardia
-
Decrease bowel sounds in all four quadrants.
Pregunta 9
Pregunta
A caregiver of an 80-year-old patient tells the nurse that her mother frequently experiences nocturia and is sometimes incontinent. Following instructions about strategies to resolve the elimination problems, the nurse determines that the caregiver need further instructions when the caregiver says:
Respuesta
-
"I should be sure that my mother drink 2500 mL by 6:00 in the evening."
-
"I need to discourage my mother from drinking a cup of coffee at supper."
-
"My mother needs her walker at the bedside and a night light on in the bathroom to keep her safe."
-
"Have Mom take her diuretic medication in the morning so she urinates during the day."
Pregunta 10
Pregunta
When planning for the elimination needs of a patient, the nurse understands that:
Respuesta
-
Peristalsis increases after ingestion of food
-
Emotional stress initially decreases peristalsis
-
Enema solutions should be administered at room temperature
-
Intrathoracic pressure decreases when straining during defecation
Pregunta 11
Pregunta
When differentiating among the types of urinary incontinence, the nurse understands that stress incontinence occurs:
Respuesta
-
With a urinary tract infection
-
In response to emotional strain
-
As a result of increased intra-abdominal pressure
-
When a specific volume of urine is in the bladder
Pregunta 12
Pregunta
When caring for a patient who is unable to tolerate a large amount of enema fluid, which solution should the nurse anticipate that the physician will order?
Respuesta
-
Hypertonic fluid
-
Normal saline
-
Soapsuds
-
Tap water
Pregunta 13
Pregunta
When collecting a urine specimen for routine urinalysis from a patient, the nurse keeps in mind which of the following?
Respuesta
-
A sterile specimen is required for collection.
-
Results may be altered if a sample is left standing at room temperature for a long time.
-
The external meatus requires cleaning with antiseptic soap and water before voiding.
-
A clean-catch midstream specimen is necessary.
Pregunta 14
Pregunta
Which of the following would the nurse incorporate into the teaching plan for a patient to promote healthy urinary functioning?
Respuesta
-
Drinking more than 2,000 mL of fluid per day will cause fluid retention.
-
The healthy adult should drink four to six 8-ounce glasses of water per day.
-
Children need fewer reminders to drink because of greater thirst sensitivity.
-
Caffeine-containing beverages should be monitored to prevent excess intake.
Pregunta 15
Pregunta
When a person has a fever or diaphoresis, how would the urine output be described?
Respuesta
-
Decreased and highly concentrated
-
Decreased and highly dilute
-
Increased and concentrated
-
Increased and dilute
Pregunta 16
Pregunta
The physician has ordered an indwelling catheter inserted in a hospitalized male patient. The nurse is aware of which of the following considerations?
Respuesta
-
The male urethra is more vulnerable to injury during insertion.
-
In the hospital, a clean technique is used for catheter insertion.
-
The catheter is inserted 2″ to 3″ into the meatus.
-
Since it uses a closed system, the risk for urinary tract infection is absent.
Pregunta 17
Pregunta
Nursing care for a patient with an indwelling catheter includes which of the following?
Respuesta
-
Irrigation of the catheter with 30 mL of normal saline solution every 4 hours
-
Disconnecting and reconnecting the drainage system quickly to obtain a urine specimen
-
Encouraging a generous fluid intake if not contraindicated by the patient’s condition.
-
Telling the patient that burning and irritation are normal, subsiding within a few days
Pregunta 18
Pregunta
After surgery, Ms. Young is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding?
Respuesta
-
Pouring warm water over Ms. Young’s fingers
-
Having Ms. Young ignore the urge to void until her bladder is full
-
Using a warm bedpan when Ms. Young feels the urge to void
-
Stroking Ms. Young’s leg or thigh
Pregunta 19
Pregunta
Mr. Cheng, a hospitalized patient with diabetes mellitus, has developed a UTI. He is 80 years old and has an indwelling catheter in place. Which factor is most likely the cause of his UTI?
Respuesta
-
The close proximity of the male genitalia to the rectum
-
Decreased immunity
-
A high urine glucose level
-
The indwelling urinary catheter
Pregunta 20
Pregunta
Which of the following terms denotes a patient’s inability to void even though the kidneys are producing urine that enters the bladder?
Respuesta
-
Urgency
-
Retention
-
Oliguria
-
Dysuria
Pregunta 21
Pregunta
Mrs. D’Ambrosia, an alert, ambulatory, older nursing home resident, voids frequently and has difficulty making it to the bathroom in time. The nurse planning her care is aware of which of the following?
Respuesta
-
Incontinence is to be expected in a woman Mrs. D’Ambrosia’s age.
-
One of every 10 nursing home residents is incontinent.
-
Kegel exercises performed at regular intervals throughout the day may be helpful.
-
An indwelling catheter should be inserted as soon as possible.
Pregunta 22
Pregunta
The priority treatment option for Mrs. D’Ambrosia would most likely involve which of the following?
Respuesta
-
Behavioral techniques
-
Pharmacologic measures
-
Surgical intervention
-
Use of absorbent products
Pregunta 23
Pregunta
A patient taking phenazopyridine (Pyridium, a urinary tract analgesic) should be cautioned that her urine may change to what color?
Respuesta
-
Pale yellow
-
Green
-
Orange-red
-
Brown
Pregunta 24
Pregunta
Mr. Bales is 60 years old and alert. He is timid and reluctant to talk about his urinary retention problem. Which part of this plan could create stress for Mr. Bales and possibly increase his inability to urinate?
Respuesta
-
Assisting him in assuming his normal voiding position
-
Pulling curtains around him to provide privacy during voiding
-
Staying with him while voiding
-
Offering the urinal on a regular schedule
Pregunta 25
Pregunta
Which of the following is a nursing priority when caring for a male patient with a condom catheter?
Respuesta
-
Preventing the tubing from kinking to maintain free urinary drainage
-
Not removing the catheter for any reason
-
Fastening the condom tightly to prevent the possibility of leakage
-
Maintaining bed rest at all times to prevent the catheter from slipping off
Pregunta 26
Pregunta
A patient has a nursing diagnosis of Impaired Urinary Elimination related to maturational enuresis. You recognize that your patient is which of the following?
Respuesta
-
An adult older than 65 years of age who is incontinent
-
A child older than 4 years of age who has involuntary urination
-
A 12-month-old child who has involuntary urination
-
A patient with neurologic damage resulting in bladder dysfunction
Pregunta 27
Pregunta
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Of the information below, which is least important for the evaluation process?
Respuesta
-
The incontinence pattern
-
State of physical mobility
-
Medications being taken
-
Age of the patient
Pregunta 28
Pregunta
If a patient was instructed to avoid foods that may have a laxative effect, the nurse would advise the patient to avoid which of the following foods?
Respuesta
-
Cheese
-
Alcohol
-
Eggs
-
Pasta
Pregunta 29
Pregunta
Which of the following is a true statement about the effects of medication on bowel elimination?
Respuesta
-
Diarrhea commonly occurs with amoxicillin clavulanate use.
-
Anticoagulants cause a white discoloration of the stool.
-
Narcotic analgesics increase gastrointestinal motility.
-
Iron salts impair digestion and cause a green stool.
Pregunta 30
Pregunta
Mr. J. has a fecal impaction. The nurse correctly administers an oil-retention enema by doing which of the following?
Respuesta
-
Administering a large volume of solution (500–1,000 mL)
-
Mixing milk and molasses in equal parts for an enema
-
Instructing the patient to retain the enema for at least 30 minutes
-
Administering the enema while the patient is sitting on the toilet
Pregunta 31
Pregunta
As the nurse prepares to assist Mrs. P. with her newly created ileostomy, she is aware of which of the following?
Respuesta
-
An appliance will not be required on a continual basis
-
The size of the stoma stabilizes within 2 weeks
-
Irrigation is necessary for regulation
-
Fecal drainage will be liquid
Pregunta 32
Pregunta
Which class of laxative acts by causing the stool to absorb water and swell?
Respuesta
-
Bulk-forming
-
Emollient
-
Lubricant
-
Stimulant
Pregunta 33
Pregunta
Mr. T. is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test by explaining that it allows which of the following?
Respuesta
-
Visual examination of the esophagus and stomach
-
Visual examination of the large intestine
-
Radiographic examination of the large intestine
-
Fluoroscopic examination of the small intestine
Pregunta 34
Pregunta
A bowel training program includes which of the following?
Respuesta
-
Using a diet that is low in bulk
-
Decreasing fluid intake to 1,000 mL
-
Administering an enema once a day to stimulate peristalsis
-
Allowing ample time for evacuation
Pregunta 35
Pregunta
Your patient complains of excessive flatulence. When reviewing the patient’s dietary intake, which food, if eaten regularly, would you identify as possibly responsible?
Respuesta
-
Meat
-
Cauliflower
-
Potatoes
-
Ice cream
Pregunta 36
Pregunta
A barium enema should be done before an upper gastrointestinal series because of which of the following?
Respuesta
-
Retained barium may cloud the colon.
-
Barium can cause lower gastrointestinal bleeding.
-
The physician’s orders are in that sequence.
-
Barium is absorbed readily in the lower intestine.
Pregunta 37
Pregunta
Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this?
Respuesta
-
They will cause a fecal impaction.
-
They will cause chronic constipation.
-
They change the pH of the gastrointestinal tract.
-
They inhibit the intestinal enzymes.
Pregunta 38
Pregunta
When explaining the action of a hypertonic solution enema, the nurse incorporates which of the following as the basis for action?
Respuesta
-
Bowel mucosa irritation
-
Diffusion of water out of colon
-
Osmosis of water into colon
-
Softening of fecal contents
Pregunta 39
Pregunta
Which of the following are included in the nursing plan of care to prevent adverse effects when caring for a patient with a nasogastric tube in place for gastric decompression? Select all that apply.
Respuesta
-
Irrigate with saline.
-
Measure the length of the exposed tube.
-
Measure the pH of the aspirated tube contents.
-
Administer frequent oral hygiene.
Pregunta 40
Pregunta
During removal of a fecal impaction, which of the following could occur because of vagal stimulation?
Respuesta
-
Bradycardia
-
Atelectasis
-
Tachycardia
-
Cardiac tamponade
Pregunta 41
Pregunta
Which of the following would be a common nursing diagnosis for the patient with an ileostomy?
Respuesta
-
Disturbed Body Image
-
Constipation
-
Delayed Growth and Development
-
Excess Fluid Volume
Pregunta 42
Pregunta
Which of the following is an appropriate nursing action to promote regular bowel habits?
Respuesta
-
encouraging the patient to avoid moving his bowels until a certain time of the day
-
encouraging the patient to avoid excess fluid intake and too much fiber
-
avoiding strenuous exercise to limit stress on abdominal muscles and impair peristalsis
-
assisting the patient to as normal position as possible to defecate
Pregunta 43
Pregunta
How many mLs does the bladder hold before we get the desire to void?
Respuesta
-
500-600mL
-
400-500mL
-
150-200mL
-
900-1000mL
Pregunta 44
Pregunta
When do most children develop urinary control?
Respuesta
-
Between the age of 1 and 2.
-
Before the age of 1.
-
Between the ages 5 and 7.
-
Between the ages of 2 and 5.
Pregunta 45
Pregunta
What are liquids that decrease urine formations?
Respuesta
-
Cola
-
High sodium content beverages
-
Coffee
-
Water
-
Tea
Pregunta 46
Pregunta
Anticoagulants may cause hematuria. (blood in urine)
Respuesta
- True
- False
Pregunta 47
Pregunta
Diuretics can lighten the color of urine to pale yellow.
Respuesta
- True
- False
Pregunta 48
Pregunta
Phenazopyridine can turn the urine black or brown.
Respuesta
- True
- False
Pregunta 49
Pregunta
Antidepressants or Beta complex vitamins turn the urine pale yellow.
Respuesta
- True
- False
Pregunta 50
Pregunta
Antiparkinson drugs can turn your urine black or brown.
Respuesta
- True
- False
Pregunta 51
Pregunta
Anuria is 24-hour urine output less than 500mL.
Respuesta
- True
- False
Pregunta 52
Pregunta
Dysuria is pain or difficult urination.
Respuesta
- True
- False
Pregunta 53
Pregunta
Oliguria is an increased amount of urine over a given amount of time.
Respuesta
- True
- False
Pregunta 54
Pregunta
Polyuria is excessive output of urine. (diuresis)
Respuesta
- True
- False
Pregunta 55
Pregunta
Pyuria is pus in the urine and makes it appear cloudy.
Respuesta
- True
- False
Pregunta 56
Pregunta
Stress incontinence is coughing, sneezing, laughing, or other physical activities like childbirth, menopause, obesity, or straining.
Respuesta
- True
- False
Pregunta 57
Pregunta
Reflex urination is experiencing emptying of the bladder without the sensation of the need to void.
Respuesta
- True
- False
Pregunta 58
Pregunta
Total incontinence is urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation.
Respuesta
- True
- False
Pregunta 59
Pregunta
Total Incontinence is a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation.
Respuesta
- True
- False
Pregunta 60
Pregunta
For a clean voided (midstream), a sterile urine specimen is not required for a routine uri-nalysis. Collect urine by having the patient void into a clean bedpan
Respuesta
- True
- False
Pregunta 61
Pregunta
Sterile specimen means that the patient voids and discards a small amount of urine; continues voiding in a sterile specimen container to collect the urine.
Respuesta
- True
- False
Pregunta 62
Pregunta
Characteristics of healthy urine (select all that apply):
Respuesta
-
Straw colored, pale yellow, or amber
-
Clear or translucent
-
Odor is aromatic
-
pH is 3.0 ( 2.0-5.0)
-
Gravity is 2.005-2.030
Pregunta 63
Pregunta
Intravenous pyelogram is the radiographic examination of the kidney and ureter after a contrast material is injected intravenously. It is used to diagnose kidney and ureter disease and impaired renal function.
Respuesta
- True
- False
Pregunta 64
Pregunta
Cystoscopy is the direct visual examination of the bladder, ureteral orifices, and urethra with a cystoscope. It is used to view, diagnose, and treat disorders of the lower urinary tract, interior bladder, urethra, male prostatic urethra.
Respuesta
- True
- False
Pregunta 65
Pregunta
Retrograde pyelography is the radiographic and endoscopic examination of the kidneys and ureters after a contrast material is injected into the renal pelvis through the ureter.
Respuesta
- True
- False
Pregunta 66
Pregunta
Antibody is an immunoglobin produced by the body in response to a specific antigen.
Respuesta
- True
- False
Pregunta 67
Pregunta
Antigen is a foreign material capable of inducing a specific immune response.
Respuesta
- True
- False
Pregunta 68
Pregunta
Anaerobic is bacteria that require oxygen to live and grow.
Respuesta
- True
- False
Pregunta 69
Pregunta
Aerobic is bacteria that require oxygen to live and grow.
Respuesta
- True
- False
Pregunta 70
Pregunta
An animal or person on or within which microorganisms live.
Respuesta
-
Reservoir
-
Vector
-
Host
-
Virus
Pregunta 71
Pregunta
An infection that occurs as a result of a treatment or diagnostic procedure.
Respuesta
-
Pathogen
-
Iatrogenic
-
Nosocomial
-
Droplet precuation
Pregunta 72
Pregunta
Medical asepsis is practices designed to reduce the number and transfer of pathogens; synonym for clean technique.
Respuesta
- True
- False
Pregunta 73
Pregunta
Surgical asepsis are practices that render and keep objects and areas free from microorganisms; synonym for sterile technique.
Respuesta
- True
- False
Pregunta 74
Pregunta
A vector can be (select all that apply):
Respuesta
-
Tick
-
Lice
-
A person
-
A rat
Pregunta 75
Pregunta
Virulence is the inability to produce a disease.
Respuesta
- True
- False
Pregunta 76
Pregunta
Exudate is a fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells.
Respuesta
- True
- False
Pregunta 77
Pregunta
Drainage that is comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria.
Respuesta
-
Serosanguineous
-
Serous
-
Necrosis
-
Purulent
Pregunta 78
Pregunta
Drainage that is a mix of serum and red blood cells.
Respuesta
-
Eschar
-
Serosanguineous
-
Serous
-
Purulent
Pregunta 79
Pregunta
Drainage that is composed of clear, serous portion of the blood and from serous membranes.
Respuesta
-
Serous
-
Serosanguineous
-
Purulent
-
Eschar
Pregunta 80
Pregunta
Incubation period, prodromal stage, full stage of illness, and the convalescent period are the stages in order of an infection.
Respuesta
- True
- False
Pregunta 81
Pregunta
A person is most infectious during the incubation stage.
Respuesta
- True
- False
Pregunta 82
Pregunta
Incubation Period is the interval period between the pathogen’s invasion of the body and the appearance of symptoms of infection.
Respuesta
- True
- False
Pregunta 83
Pregunta
Convalescent period is the recovery period of an infection.
Respuesta
- True
- False
Pregunta 84
Pregunta
What are the cardinal signs and symptoms of inflammation?
Respuesta
-
Redness
-
Heat
-
Moisture
-
Edema
-
Pain
-
Loss of function
Pregunta 85
Pregunta
The protective mechanism to the inflammatory response is localization, attack, remove dead damaged tissue and repair/replace.
Respuesta
- True
- False
Pregunta 86
Pregunta
When the injury is flooded with blood to promote wound healing is called vasoconstriction.
Respuesta
- True
- False
Pregunta 87
Pregunta
Vasoconstriction is when the wound is confined of blood to limit tissue damage.
Respuesta
- True
- False
Pregunta 88
Pregunta
During the cellular response there is increased cellular permeability and WBCs move into area-Clean wound-consume debris which results in pain, edema, loss of function.
Respuesta
- True
- False
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