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