In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

In assessing the appropriateness of removing a suprapubic
catheter, the nurse recognizes that the patient’s residual urine must
be less than which of the following amounts on two separate
occasions (morning and evening)?
a) 100 cc
If the patient complains of discomfort or pain, however, the suprapubic
catheter is usually left in place until the patient can void successfully.
b) 30 cc
Residual urine may be greater than 30 cc and still allow discontinuance
of a suprapubic catheter.
c) 50 cc
Residual urine may be greater than 50 cc and still allow discontinuance
of a suprapubic catheter.
d) 400 cc
Residual urine that is greater than 100 cc indicates that the suprapubic
catheter cannot be discontinued.
by

1 Answer

Answer :

a) 100 cc
If the patient complains of discomfort or pain, however, the suprapubic
catheter is usually left in place until the patient can void successfully.
by

Related questions

When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Description : When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the ... or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Last Answer : a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the patient is likely demonstrating signs of a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Description : When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse ... heterotrophic ossification. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

Last Answer : a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

Description : When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in ... residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely.

Last Answer : a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity. b) Vital capacity The nurse anticipates decreased vital capacity. c) Gas exchange and diffusing capacity The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. d) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling catheter, the patient is placed on a timed voiding schedule, usually two to three hours. At the given time interval, the patient is instructed to void. a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

Description : Bladder retraining following removal of an indwelling catheter begins with instructing the patient to follow a 2-3 hour timed voiding schedule. Immediately after the removal of the indwelling ... in the bladder after voiding, straight catheterization may be performed for complete bladder emptying.

Last Answer : a) encouraging the patient to void immediately. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within two to three hours.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

Which of the following terms refers to failure of fragments of a fractured bone to heal together? a) Nonunion When nonunion occurs, the patient complains of persistent discomfort and movement at the fracture site.

Description : Which of the following terms refers to failure of fragments of a fractured bone to heal together? a) Nonunion When nonunion occurs, the patient complains of persistent discomfort and movement at the ... growth of the fragments of a fractured bone in a faulty position, forming an imperfect union.

Last Answer : a) Nonunion When nonunion occurs, the patient complains of persistent discomfort and movement at the fracture site.

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone? a) Stage IV A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. b) Stage III A stage III ulcer extends into the subcutaneous tissue. c) Stage II A stage II ulcer exhibits a break in the skin through the epidermis or dermis. d) Stage I A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Description : During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone? a) Stage IV A stage IV pressure ulcer ... area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Last Answer : a) Stage IV A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone.

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is noted. b) Stage IV A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. c) Stage II A stage II ulcer exhibits a break in the skin through the epidermis or dermis. d) Stage I A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Description : During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is ... area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Last Answer : a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is noted.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. b) 30-35 seconds Applying suction for 30-35 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.

Description : When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general ... suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

Last Answer : a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts. b) Requires a physician’s order. Teaching, as a function of nursing, is included in all state nurse practice acts. c) Must be approved by the physician. Health education is a primary responsibility of the nursing profession. d) Must focus on wellness issues. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Description : Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state ... restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Last Answer : a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Description : Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the ... term home IV therapy (eg, Port A Cath, Mediport, Hickman Port, P.A.S. Port).

Last Answer : a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Antimicrobial barrier?Acticoat dressings used in the treatment of burn wounds can be left in place for five days. a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

Description : Antimicrobial barrier?Acticoat dressings used in the treatment of burn wounds can be left in place for five days. a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days ... ) two days. antimicrobial barrier dressings can be left in?Acticoat place for up to five days.

Last Answer : a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Description : 51. Albert came to the hospital with chest pain and fever. After a thorough assessment by the doctor, he was admitted for pericarditis management. The nurse positions the client to reduce pain and discomfort. Describe this position.

Last Answer : C. Sit the client upright and lean forward

41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

Description : When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field ... . d) urgent care. Field triaged patients who require urgent care will be categorized as green.

Last Answer : a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

Description : When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi's sarcoma. Kaposi's sarcoma is ... syphilis. A painless chancre or ulcerated lesion is a typical finding in the patient with syphilis.

Last Answer : a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

When the female patient demonstrates thickening, scaling, and erosion of the nipple and areola, the nurse recognizes that the patient is exhibiting signs of a) Paget’s disease. Paget’s disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola. b) acute mastitis. Acute mastitis is demonstrated by nipple cracks or abrasions along with reddened and warm breast skin and tenderness.

Description : When the female patient demonstrates thickening, scaling, and erosion of the nipple and areola, the nurse recognizes that the patient is exhibiting signs of a) Paget's disease. Paget's disease ... the breast and demonstrates an orange peel apearance of breast skin with enlargement of skin pores.

Last Answer : a) Paget’s disease. Paget’s disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

The nurse who admitted the patient recognizes that Billroth II procedure means A. Enterostomy B. Esophagojejunostomy C. Gastroduodenostomy D. Gastrojejunostomy

Description : The nurse who admitted the patient recognizes that Billroth II procedure means A. Enterostomy B. Esophagojejunostomy C. Gastroduodenostomy D. Gastrojejunostomy

Last Answer : D. Gastrojejunostomy

When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as the a) pulmonary artery wedge pressure. When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary arty until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure.

Description : When the balloon on the distal tip of a pulmonary artery catheter is inflated and a pressure is measured, the measurement obtained is referred to as the a) pulmonary artery wedge ... Cardiac output is determined through thermodilution involving injection of fluid into the pulmonary artery catheter.

Last Answer : a) pulmonary artery wedge pressure. When the balloon is inflated, the tip of the catheter floats into smaller branches of the pulmonary arty until it can no longer be passed and the pressure is recorded, reflecting left atrial pressure and left ventricular end-diastolic pressure.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Description : The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding ... encouraged to void every 2-3 hours during the day and completely empty the bladder.

Last Answer : a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.

Description : A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient's response to stimuli. A score of 7 or ... 3 is interpreted as least responsive. d) most responsive. A GCS score of 15 is interpreted as most responsive.

Last Answer : a) coma. The Glasgow Coma Scale (GCS) is a tool for assessing a patient’s response to stimuli. A score of 7 or less is generally interpreted as coma.

When irrigating a colostomy, the nurse lubricates the catheter and gently inserts it into the stoma no more than _______ inches a) 3” The nurse should insert the catheter no more than 3 inches. b) 2” Insertion of the catheter 2 inches is inadequate. c) 4” Insertion of the catheter 4 inches is excessive and not recommended. d) 5” Insertion of the catheter 5 inches is excessive and not recommended.

Description : When irrigating a colostomy, the nurse lubricates the catheter and gently inserts it into the stoma no more than _______ inches a) 3 The nurse should insert the catheter no more than 3 inches. b ... and not recommended. d) 5 Insertion of the catheter 5 inches is excessive and not recommended.

Last Answer : a) 3” The nurse should insert the catheter no more than 3 inches.

Which of the following statements describes benign paroxysmal positional vertigo (BPPV)? a) The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur. BPPV is a brief period of incapacitating vertigo that occurs when the position of the patient’s head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur.

Description : Which of the following statements describes benign paroxysmal positional vertigo (BPPV)? a) The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur. ... as acetaminophen. BPPV is frequently stimulated by head trauma, infection, or other events.

Last Answer : a) The vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur. BPPV is a brief period of incapacitating vertigo that occurs when the ... vertigo is usually accompanied by nausea and vomiting; however hearing impairment does not generally occur.

The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Description : When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's ... rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Last Answer : a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and immediate action? A. Stop the intern and do the catheterization yourself B. Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Description : When the intern-in-charge did the skin prep and catheterized the client, the circulating nurse noticed when the intern withdrew the catheter from the vagina. What is your appropriate and ... . Offer to change the catheter C. Alcoholize the tip of the catheter before reinserting the catheter

Last Answer : B. Offer to change the catheter

Of the following areas for assessing the patient profile, which should be addressed after the others? a) Body image The patient is often less anxious when the interview progresses from information that is less personal to information that is more personal. b) Education Educational level is relatively impersonal and readily revealed by the patient. c) Occupation Occupation is relatively impersonal and readily revealed by the patient. d) Environment Housing, religion, and language are relatively impersonal and readily revealed by the patient.

Description : Of the following areas for assessing the patient profile, which should be addressed after the others? a) Body image The patient is often less anxious when the interview progresses from ... ) Environment Housing, religion, and language are relatively impersonal and readily revealed by the patient.

Last Answer : a) Body image The patient is often less anxious when the interview progresses from information that is less personal to information that is more personal.

42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Description : 42. The nurse is to inject Vitamin B intramuscularly to another elderly client. Before injecting, the nurse explained that the client may feel some discomfort. This is an example of

Last Answer : C. Anticipatory response

The nurse reading the physician’s report of an elderly patient’s physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

Description : The nurse reading the physician's report of an elderly patient's physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is ... red moles. Cherry angioma is the term that is used to describe a bright red mole.

Last Answer : a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

When the patient’s eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Description : When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not ... Paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Last Answer : a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient’s serum electrolytes anticipating which abnormality? a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). b) Hypercalcemia Hypercalcemia would likely be demonstrated by asystole. c) Hypomagnesemia Hypomagenesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. d) Hyponatremia Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).