NU 120 WEEK 1

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lauratwinoaks
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NU 120 WEEK 1
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2013-12-08 20:13:35
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NU 120 WEEK
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NU 120 WEEK 1
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  1. A FEMALE PATIENT REPORTS THAT SHE IS EXPERIENCING BURNING ON URINATION, FREQUENCY, AND URGENCY.  THE NURSE NOTES THAT A CLEAN-VOIDED URINE SPECIMEN IS MARKEDLY CLOUDY.  THE PROBABLE CAUSE OF THESE SYMPTOMS AND FINDINGS IS
    A.  CYSTITIS
    B.  PYELONEPHRITIS
    C.  DYSURIA
    D.  HEMATURIA
    A.  CYSTITIS
    (this multiple choice question has been scrambled)
  2. A MALE PATIENT RETURNED FROM THE OPERATING ROOM 6 HOURS AGO WITH A CAST ON HIS RIGHT ARM. HE HAS NOT YET VOIDED.  WHICH ACTION WOULD BE THE MOST BENEFICIAL IN ASSISTING THE PATIENT TO VOID
    A.  SUGGEST HE STAND AT THE BEDSIDE
    B.  STAY WITH THE PATIENT
    C.  GIVE HIM THE URINAL TO USE IN BED
    D.  TELL HIM THAT, IF HE DOESN'T URINATE, HE WILL BE CATHETERIZED
    A.  SUGGEST HE STAND AT THE BEDSIDE
    (this multiple choice question has been scrambled)
  3. ELIMINATION CHANGES THAT RESULT FROM INABILITY OF THE BLADDER TO EMPTY PROPERLY MAY CAUSE WHICH OF THE FOLLOWING (SELECT ALL THAT APPLY).
    A.  INCONTINENCE
    B.  FREQUENCY
    C.  URGENCY
    D.  URINARY RETENTION
    E.  URINARY TRACT INFECTION
    • A.  INCONTINENCE
    • B.  FREQUENCY
    • C.  URGENCY
    • D.  URINARY RETENTION
    • E.  URINARY TRACT INFECTION
  4. AN OLDER MALE PATIENT STATES THAT HE IS HAVING PROBLEMS STARTING AND STOPPING HIS STREAM OF URINE AND HE FEELS THE URGENCY TO VOID.  THE BEST WAY TO ASSIST THIS PATIENT IS TO
    A.  INITIATE KEGEL EXERCISES
    B.  HELP HIM STAND TO VOID
    C.  PLACE A CONDOM CATHETER
    D.  HAVE HIM PRACTICE CREDE'S METHOD
    A.  INITIATE KEGEL EXERCISES
    (this multiple choice question has been scrambled)
  5. SINCE REMOVAL OF THE PATIENT'S FOLEY CATHETER, THE PATIENT HAS VOIDED 50 TO 100 ML EVERY 2 TO 3 HOURS.  WHICH ACTION SHOULD THE NURSE TAKE FIRST
    A.  CHECK FOR BLADDER DISTENTION
    B.  ENCOURAGE FLUID INTAKE
    C.  DOCUMENT THE AMOUNT OF EACH VOIDING FOR 24 HOURS
    D.  OBTAIN AN ORDER TO RECATHETERIZE THE PATIENT
    A.  CHECK FOR BLADDER DISTENTION
    (this multiple choice question has been scrambled)
  6. TO MINIMIZE THE PATIENT EXPERIENCING NOCTURIA, THE NURSE WOULD TEACH HIM OR HER TO
    A.  SET UP A TOILETING SCHEDULE
    B.  DOUBLE VOID
    C.  LIMIT FLUIDS BEFORE BEDTIME
    D.  PERFORM PERINEAL HYGIENE AFTER URINATING
    C.  LIMIT FLUIDS BEFORE BEDTIME
    (this multiple choice question has been scrambled)
  7. A PATIENT WITH A FOLEY CATHETER CARRIES THE COLLECTION BAG AT WAIST LEVEL WHEN AMBULATING.  THE NURSE TELLS THE PATIENT THAT HE OR SHE IS AT RISK FOR (SELECT ALL THAT APPLY)
    a.  infection
    b.  retention
    c.  stagnant urine
    d.  reflux of urine
    • A.  INFECTION
    • D.  REFLUX OF URINE
  8. THE PATIENT IS INCONTINENT, AND A CONDOM CATHETER IS PLACED.  THE NURSE SHOULD TAKE WHICH ACTION
    A.  USE STERILE TECHNIQUE FOR PLACEMENT
    B.  CHANGE THE CONDOM EVERY 48 HOURS
    C.  SECURE THE CONDOM WITH ADHESIVE TAPE
    D.  ASSESS THE PATIENT FOR SKIN IRRITATION
    D.  ASSESS THE PATIENT FOR SKIN IRRITATION
    (this multiple choice question has been scrambled)
  9. AFTER A TRANSURETHRAL PROSTATECTOMY A PATIENT RETURNS TO HIS ROOM WITH A TRIPLE LUMEN INDWELLING CATHETER AND CONTINUOUS BLADDER IRRIGATION.  THE IRRIGATION IS NORMAL SALINE AT 150 ML/HR.  THE NURSE EMPTIES THE DRAINAGE BAG FOR A TOTAL OF 2530 AFTER AN 8 HOUR PERIOD.  HOW MUCH OF THE TOTAL IS URINE OUTPUT
    1320 ML
  10. THE NURSE DIRECTS THE NAP TO REMOVE A FOLEY CATHETER AT 1300.  THE NURSE WOULD CHECK IF THE PATIENT HAS VOIDED BY
    A.  1600
    B.  1400
    C.  1700
    D.  2300
    C.  1700
    (this multiple choice question has been scrambled)
  11. THE POSTOPERATIVE PATIENT HAS DIFFICULTY VOIDING AFTER SURGERY AND IS FEELING "UNCOMFORTABLE" IN THE LOWER ABDOMEN.  WHICH ACTION SHOULD THE NURSE IMPLEMENT FIRST
    A.  ENCOURAGE FLUID INTAKE
    B.  CATHETERIZE THE PATIENT
    C.  TURN ON THE BATHROOM FAUCET AS HE TRIES TO VOID
    D.  ADMINISTER PAIN MEDICATION
    C.  TURN ON THE BATHROOM FAUCET AS HE TRIES TO VOID
    (this multiple choice question has been scrambled)
  12. THE PATIENT IS TO HAVE AN INTRAVENOUS PYELOGRAM 9VP).  WHICH OF THE FOLLOWING APPLY TO THIS PROCEDURE (SELECT ALL THAT APPLY_
    A.  NOTE ANY ALLERGIES
    B.  MONITOR INTAKE AND OUTPUT
    C.  PROVIDE FOR PERINEAL HYGIENE
    D.  ASSESS VITAL SIGNS
    D.  ENCOURAGE FLUIDS AFTER THE PROCEDURE
    • A.  NOTE ANY ALLERGIES
    • D.  ENCOURAGE FLUIDS AFTER THE PROCEDURE
  13. THE NURSE ASSESSES THAT THE PATIENT HAS A FULL BLADDER, AND THE PATIENT STATES THAT HE OR SHE IS HAVING DIFFICULTY VOIDING.  THE NURSE WOULD TEACH THE PATIENT TO
    A.  USE CREDE'S METHOD
    B.  KEEP A VOIDING DIARY
    C.  USE THE DOUBLE VOIDING TECHNIQUE
    D.  PERFORM KEGEL EXERCISES
    A.  USE CREDE'S METHOD
    (this multiple choice question has been scrambled)
  14. THE PATIENT STATES THAT SHE "LOSES URINE" EVERY TIME SHE LAUGHS OR COUGHS.  THE NURSE TEACHES THE PATIENT MEASURES TO REGAIN URINARY CONTROL.  THE NURSE RECOGNIZES THE NEED FOR FURTHER TEACHING WHEN THE PATIENT STATES
    A.  I HAVE TRIED URINATING EVERY 3 HOURS
    B.  i WILL PERFORM MY KEGEL EXERCISES EVERY DAY
    C.  I JOINED WEIGHT WATCHERS
    D.  I DRINK TWO GLASSES OF WINE WITH DINNER
    D.  I DRINK TWO GLASSES OF WINE WITH DINNER
    (this multiple choice question has been scrambled)
  15. THE NURSE NOTES THAT THE PATIENT'S FOLEY CATHETER BAG HAS BEEN EMPTY FOR 4 HOURS.  THE PRIORITY ACTION WOULD BE TO
    A.  NOTIFY THE HEALTH CARE PROVIDER
    B.  ASSESS THE PATIENT'S INTAKE
    C.  IRRIGATE THE FOLEY
    D.  CHECK FOR KINKS IN THE TUBING
    D.  CHECK FOR KINKS IN THE TUBING
    (this multiple choice question has been scrambled)
  16. THE NURSE IS APPLYING AN EXTERNAL CONDOM-TYPE CATHETER.  WHICH NURSING INTERVENTION MINIMIZES THE RISK OF SKIN IRRITATION AND INFECTION
    1.  APPLYING THE CONDOM SHEATH SO THE END OF THE CATHETER IS 7 TO 12.5 CM (3 TO 5 INCHES) FROM THE TIP OF THE PENIS
    2.  SHAVING THE PUBIC AREA SO HAIR DOES NOT ADHERE TO THE CONDOM OR IS PULLED DURING REMOVAL
    3.  PROVIDING HYGIENE BEFORE APPLYING THE CONDOM TYPE CATHETER
    4.  APPLYING TAPE TO THE CONDOM SHEATH TO KEEP IT SECURELY IN PLACE
    3.  PROVIDING HYGIENE BEFORE APPLYING THE CONDOM TYPE CATHETER
  17. PLACE THE FOLLOWING STEPS FOR INSERTION OF AN INDWELLING CATHETER IN A FEMALE PATIENT IN APPROPRIATE ORDER
    A.  INSERT AND ADVANCE CATHETER
    B.  LUBRICATE CATHETER
    C.  INFLATE CATHETER BALLOON
    D.  CLEAN URETHRAL MEATUS WITH ANTISEPTIC
    E.  DRAPE PATIENT  WITH THE STERILE SQUARE AND FENESTRATED DRAPES
    F.  WHEN URINE APPEARS, ADVANCE ANOTHER 2.5 TO 5 CM (1 TO 2 INCHES)
    G.  PREPARE STERILE FIELD AND SUPPLIES
    H.  GENTLY PULL CATHETER UNTIL RESISTANCE IS FELT
    I.  ATTACH DRAINAGE TUBING
    E, G, B, D, A, F, C, H, I
  18. WHAT IS A CRITICAL STEP WHEN INSERTING AN INDWELLING CATHETER INTO A MALE PATIENT
    1.  QUICKLY INFLATE THE CATHETER BALLOON WITH STERILE SALINE
    2.  SECURE THE CATHETER DRAINAGE TUBING TO THE BED SHEETS
    3.  ADVANCE TO THE BIFURCATION OF THE DRAINAGE AND BALLOON PORTS
    4.  ADVANCE UNTIL URINE FLOWS AND THEN INSERT 1/4 INCH (0.6CM) MORE
    3.  ADVANCE TO THE BIFURCATION OF THE DRAINAGE AND BALLOON PORTS
  19. THE NURSE IS PREPARING TO REMOVE AND INDWELLING URINARY CATHETER.  WHICH NURSING INTERVENTIONS SHOULD THE NURSE IMPLEMENT (SELECT ALL THAT APPLY)
    1.  ATTACH A 5 ML SYRINGE TO THE INFLATION PORT
    2.  ALLOW THE BALLOON TO DRAIN INTO THE SYRINGE BY GRAVITY
    3.  INITIATE A VOIDING RECORD/BLADDER DIARY
    4.  PULL CATHETER QUICKLY
    5.  WITH STEADY FORCE, PULL BACK ON THE SYRINGE PLUNGER
    • 2.  ALLOW THE BALLOON TO DRAIN INTO THE SYRINGE BY GRAVITY
    • 3.  INITIATE A VOIDING RECORD/BLADDER DIARY
  20. WHICH NURSING INTERVENTIONS ARE APPROPRIATE IN THE CARE OF A PATIENT WITH AN ESTABLISHED SUPRAPUBIC CATHETER (SELECT ALL THAT APPLY)
    1.  USING STERILE TECHNIQUE, CLEAN THE SKIN CLOSE TO THE CATHETER WITH A CIRCULAR MOTION
    2.  WIPE AWAY ANY DRAINAGE ON THE CATHETER BY WIPING DOWN THE CATHETER TOWARD THE INSERTION SITE
    3.  INSPECT THE INSERTION SITE FOR ERYTHEMA, EDEMA, DISCHARGE, OR TENDERNESS
    4.  SECURE CATHETER TO ABDOMEN WITH TAPE OR A TUBE HOLDER DEVICE
    5.  APPLY TENSION TO THE CATHETER WHEN CLEANING THE SITE AND TUBING
    • 3.  INSPECT THE INSERTION SITE FOR ERYTHEMA, EDEMA, DISCHARGE, OR TENDERNESS
    • 4.  SECURE CATHETER TO ABDOMEN WITH TAPE OR A TUBE HOLDER DEVICE
  21. THE URINE FLOW HAS STOPPED IN A PATIENTS INDWELLING URINARY CATHETER AND THE NURSE ASSESSES TENDERNESS AND DISTENTION OVER THE LOWER ABDOMEN.  WHAT WOULD BE AN INITIAL NURSING ACTION
    1.  IRRIGATING THE CATHETER WITH STERILE WATER OR SALINE
    2.  ASSESSING THE CATHETER DRAINAGE TUBING FOR KINKING
    3.  ENCOURAGING FLUID INTAKE
    4.  REMOVING THE CATHETER
    2.  ASSESSING THE CATHETER DRAINAGE TUBING FOR KINKING
  22. WHICH INSTRUCTIONS SHOULD THE NURSE GIVE THE NURSING ASSISTIVE PERSONNEL (NAP) CONCERNING AN AMBULATORY PATIENT WHO HAS HAD AN INDWELLING URINARY CATHETER REMOVED THAT DAY
    1.  LIMIT ORAL FLUID INTAKE TO AVOID URINARY INCONTINENCE
    2.  EXPECT PATIENT COMPLAINTS OF SUPRAPUBIC FULLNESS AND DISCOMFORT
    3.  REPORT THE TIME AND AMOUNT OF FIRST VOIDING
    4.  HAVE PATIENT STAY IN BED AND USE A URINAL OR BEDPAN UNTIL FIRST VOIDING
    3.  REPORT THE TIME AND AMOUNT OF FIRST VOIDING
  23. WHICH PATIENT CONDITION IS APPROPRIATE FOR THE INSERTION OF AN INDWELLING URINARY CATHETER
    1.  STAGE 1 PRESSURE ULCER EXPOSED TO LEAKING URINE
    2.  PATIENT UNABLE TO INDEPENDENTLY TOILET
    3.  ELEVATED POSTVOID RESIDUAL
    4.  URINARY INCONTINENCE
    3.  ELEVATED POSTVOID RESIDUAL
  24. WHICH SIZE INDWELLING URINARY CATHETER IS BEST FOR AN ADULT FEMALE PATIENT
    1.  18 FR, 5ML BALLOON
    2.  16 FR, 30 ML BALLOON
    3.  14 FR, 5 ML BALLOON
    4.  12 FR, 30 ML BALLOON
    3.  14 FR, 5 ML BALLOON
  25. A PATIENT WITH HEMATURIA HAS A THREE WAY INDWELLING URINARY CATHETER WITH CONTINUOUS BLADDER IRRIGATION (CBI) AND IS COMPLAINING OF LOWER ABDOMINAL PAIN.  WHAT SHOULD BE THE NURSE'S FIRST ACTION
    1.  INCREASING THE RATE OF THE CBI
    2.  CHECKING URINE FLOW TO THE DRAINAGE BAG
    3.  DECREASING THE RATE OF THE CBI
    4.  TAKING THE PATIENTS TEMPERATURE
    2.  CHECKING URINE FLOW TO THE DRAINAGE BAG

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