Lifespan Exam 2 Comprehensive Questions

Wound ostomy continence nurse

A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, which members of the inter professional health care team would be most appropriate for a referral?

History of surgery of the anus or rectum

The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. Which data is most important for the nurse to investigate first?

Ascending colostomy

While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, from the stoma that is located in the upper right quadrant of the abdomen. What hypothesis about the type of ostomy should the nurse conclude?

Drinking at least eight glasses of fluid each day

The patient was admitted with diarrhea. Which priority action will the nurse teach the patient?

Spinach salad with dressing

The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient’s meal request specifies which food choice?

Acute pain

A patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient?

“I should drink clear liquids only for 24 hours before the procedure

A patient is scheduled for a colonoscopy. After pre procedure teaching by the nurse, the patient demonstrates understanding when he makes which statement?

Increasing fiber in a diet

A patient is experiencing diarrhea. After patient education, which behavior by the patient shows that he teaching was effective.

Assist the patient to a left side-lying position.

Raise container, release clamps, and allow solution fill the tubing before administration.

Clamp the tubing after solution is instilled.

When administering a cleansing enema, which actions should the nurse implement? Select all the apply

Active range of motion daily.

Walk 10-15 minutes a day.

Follow a high-fiber diet.

Maintain a positive attitude.

The nurse is providing education to patients at a gastrointestinal clinic. One of the topics is to promote good bowel health. Which of the following should the nurse include in this education? Select all that apply

Check to see if the catheter is patent

A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform?

Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimens container

Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter?

“I will wipe from the front to back after voiding.”

A female patient has had frequent urinary tract infections. Which statement by the patient indicates the the nurse’s teaching on prevention has been effective?

History of allergies

A patient is scheduled for an IV pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out?

Taking the urinary tract analgesic phenazopyridine

A diet that includes a large number of beets or blackberries

An enlarged prostate or kidney stones

High concentrations of bilirubin secondary to liver disease

Dehydration

Infection

When emptying a patient’s catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? Select all that apply

Cleanse the peristomal skin with mild soap water

What self-care measure is most important for the nurse to include when developing a teaching plan for a patient who will be discharged with a urostomy?

Maintaining strict aseptic technique

An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the priority concern of the nurse performing the procedure?

Assess the tubing for kinks and ensure downward flow

The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining, and the patient’s bladder is distended. What action should the nurse take next

Leave the catheter in place and insert a new catheter into the urethra

The nurse is placing an indwelling catheter in a female patient. The nurse accidentally inserts the catheter into the vagina. What is the next action for the nurse to implement.

Palpating the patient’s bladder for distention before scanning for possible retention.

Which nursing intervention would be the highest priority when caring for a patient complaining of voiding small amounts of urine in relation to his fluid intake?

The presence of a stage 1 pressure injury

On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment cue indicate to the nurse?

Cover the wound with saline-moistened gauze

Notify the surgeon

Four days after abdominal surgery, the patient is getting out of bed, and feels something “pop” in his abdominal wound. An increase in the amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. Which are the priority nursing interventions? Select all that apply

Usually is inserted in surgery

Allows for accurate measurement of wound drainage

Which features are characteristics of a closed drainage system, such as a Jackson-Pratt (JP) drain? Select all that apply

Using an incontinence cleanser

Frequent position changes

Applying a moisture barrier ointment

The nurse is planning care for the patient with urinary and fecal incontinence. Which nursing interventions are priority? Select all that apply

30-degree side-lying

Based on knowledge of areas at greater risk for development of a pressure injury in the bedridden patient, the nurse identifies which position to minimize this risk?

Pressure and shear

A patient who has suffered a stroke is unable to maintain his position while seated in a chair for part of the day. What does the nurse recognize as the patient's greater risk factor for development of pressure injuries?

High-calorie, high-protein drink

A patient has a stage 3 pressure injury on the coccyx. Which food will be most beneficial in improving the healing process?

Irrigate the wound before collecting the culture material

Which technique is used to collect and aerobic culture specimen from a wound?

A 72-year-old with diabetes and cardiovascular disease who had surgical repair of a broken hip

Which patient is at highest risk for impaired wound healing?

Approximated

Which best describes a fresh surgical wound that has been closed with sutures or staples making the two edges of the wound meet?

Stage II pressure injury

A client is being admitted to the medical-surgical floor directly from their PCP's office. Upon admission assessment, the nurse notes a wound on the right heel with partial thickness loss. What stage of pressure injury would the nurse document this?

Healed stage III pressure injury

The nurse is caring for a client who has a stage III pressure injury that is healed. The client is getting ready to discharge to an assisted living facility. How would the nurse document the pressure injury?

Can you describe your usual skin care regimen?

Do you smoke?

Have you had any recent unintended weight loss?

Does it seem to take a long time for wounds to heal?

How would you describe your overall skin condition?

The nurse is admitting a client in pre-op for surgery. What should the client be asked upon doing the skin assessment? Select all that apply

An 83 year old client that refuses to ambulate. The client has a history of depression and malnutrition.

A 43 year old client that has diabetes. The client has been able to ambulate once daily during the hospital stay. The client eats 25% of meals.

A 22 year old client that is healing from a motor vehicle injury. The client has lost mobility in their legs and has very little appetite.

The nurse is caring for a group of clients on a medical-surgical floor. The nurse knows that which of the following clients is at higher risk for pressure injury? Select all that apply

The buttocks

The shoulders

Back of the head

The heels

The nurse is caring for multiple clients who are all at risk for pressure ulcers. The nurse knows which areas are the highest risk for pressure injury? Select all that apply

Braden score of 12 — High risk

Braden score of 8 — Very high risk

Braden score of 14 — Moderate risk

Braden score of 16 — Mild risk

Match the following Braden scores to the risk for pressure injury.

The nurse notes a “healing ridge” when inspecting the incision.

The nurse is caring for a client who had abdominal surgery 7 days ago. How does the nurse determine that the incision is mending successfully?

The nurse measure length, then width, then depth.

The nurse is assessing the client's skin upon admission and notes a wound on the client's left arm. How does the nurse correctly measure the wound?

1. Wet gauze with sterile saline and place over the wound.

2. Do not leave the client. Call the client’s physician.

3. Call the charge nurse for additional help.

4. Document the event.

The nurse is caring for a client who is day 1 post-op from an abdominal surgery. The client pushes their call light and reports that they heard a "popping" sound and felt an increase in drainage from their incision site. Prioritize the nurses actions.

Every 2 hours

The nurse is caring for a client in a long term care facility. The client is completely immoble and requires turning and repositioning. How often should the client be repositioned?

A barrel chest

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which significant finding does the nurse anticipate when inspecting the chest?

Patient’s respiratory secretions will become thicker so they are not moved when coughing.

What is the desired outcome related to the nursing diagnosis of Impaired Airway Clearance?

Place patient in upright position

Call respiratory therapy

Assess vital signs

Listen to lung sounds

The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The patient has albuterol treatments scheduled every 6 hours and PRN and is on oxygen 2L/min via nasal cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering the patient’s room to administer medications, the nurse notes that the patient is in acute respiratory distress. Which priority interventions would the nurse take to safely manage the care of this patient? Select all that apply

Nonrebreather mask at a flow rate of 5 L/min

When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen?

Assess heart rate, respiratory rate, oxygen saturation, and lung sounds prior to suctioning.

Suction intermittently for no more than 10 to 15 seconds.

Reassess heart rate, respiratory rate, oxygen saturation, and lung sounds after suctioning.

Document time, amount, and characteristics of secretions.

The nurse knows that which of the following nursing actions are indicated when suctioning a patient with a tracheostomy? Select all that apply

Alternative therapies

Nicotine replacements

Support groups

Counseling

Educating about the risks of smoking

A patient admitted with a history of chronic obstructive pulmonary disease (COPD) admits to smoking 1 pack of cigarettes per day for the last 40 years. When developing a plan of care for the patient, the nurse includes smoking cessation as a priority education goal. Which interventions would the nurse include in the patient education? Select all that apply

Hemoglobin that is not saturated with the oxygen

The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient who has bluish discoloration around the lips?

Persistent aspiration of liquids

During handoff to the oncoming shift, the nurse includes in the SBAR report that the patient needs to be evaluated by speech therapy for which of the following reasons?

Decreased Pa02 levels

A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe?

Are you having pain?

Where is the pain located?

Do you have increased fatigue?

Do you have any episodes of dizziness?

Which questions would be included during a focused history on a cardiac patient to help the nurse determine the significance of the cues? Select all that apply

Restlessness

Tachypnea

Confusion

Hypertension

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? Select all that apply

Check the position of the cannula frequently

Report any nausea or difficulty breathing

Post “No smoking” signs in prominent locations

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client an family teaching by the nurse should include which of the following instructions? Select all that apply

Assist the client to Fowler’s position

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

Apply suction while withdrawing the catheter

Use a new catheter for each suctioning attempt

Apply suction for 10 to 15 seconds

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? Select all that apply

Apply the oxygen source loosely if the SpO2 decreases during the procedure

Use surgical asepsis to remove and clean the inner cannula

Clean the outer cannula surfaces in a circular motion from the stoma site outward

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? Select all that apply

Sutured surgical incision

Casted bone fracture

Laceration sealed with adhesive

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous draining on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? Select all that apply

Increase incisional pain

Fever and chills

Reddened wound edges

A nurse is collecting data from a client who is five days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? Select all that apply

Stage III pressure injury

Open burn area

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? Select all that apply

Cover the area with saline-soaked sterile dressings

Position the client supine with the hips and knees bent

A client who had abdominal surgery 24 hours ago, suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? Select all that apply

Keep the head of the bed elevated 30 degrees

Have the client sit on a gel cushion when in a chair

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? Select all that apply

Decrease or avoid caffeine

Avoid drinking alcohol

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? Select all that apply

Check to see whether the catheter is patent

A client who has an indwelling catheter reports I need to urinate. Which of the following actions should the nurse take?

Discard the first voiding

A nurse is caring for a client who has a prescription for a 24 hour urine collection. Which of the following actions should the nurse take?

Frequent sexual intercourse

Wiping from front to back to clean the perineum

Frequent catheterization

A nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTIs. Which of the following factors should the nurse include? Select all that apply

Have the client record of urination times

Gradually increase the urination intervals

Remind the client to hold urine until the next schedule, the urination time

A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? Select all that apply

The specimen cannot be contaminated with urine

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?

One medium apple with skin

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend?

Hypotension

Elevated temperature

Poor skin turgor

The nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? Select all that apply

Clamp the enema tubing

While a nurse is administering a cleaning enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

Warm the enema the solution prior to installation

Position the client on the left side with the right leg flexed forward

Lubricate the rectal tube or nozzle

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? Select all that apply