Content Exam 1 Review - Urinary, Medication Administration, Enteral Feeding (100 Flashcards)

100 flashcards created from the lecture content to review urinary, catheterization, medication administration, and enteral feeding topics.

Which type of urinary incontinence is experienced when urine leaks with sneezing, coughing, or laughing?

Stress incontinence

Which statement about cranberry juice is correct for preventing recurrent UTIs?

Drinking cranberry juice daily can prevent recurrent urinary tract infections.

Name the three most common urinary signs/symptoms of a UTI.

Frequency, burning with urination (dysuria), and dysuria.

Which portion of a urinalysis is determined by visual inspection?

Clarity

What nursing intervention is most appropriate to prevent skin breakdown from functional incontinence in a patient with Alzheimer’s?

Assist the client to the toilet on a regular schedule.

In a 24-hour urine collection, which statement indicates the collection must be restarted?

The client forgot to put the urine in the container.

Which technique demonstrates correct CAUTI prevention when caring for a catheter?

Washes the catheter moving from the meatus outward toward the drainage tube.

A left-handed nurse is preparing to perform a straight catheterization. Which action should they take?

Stand on the left side of the bed.

Place the following steps in the correct order to prepare a sterile field for catheter insertion: Perform hand hygiene, Open outer flap away from self, Open innermost flap toward self, Open side flap, Place package on work surface, Use inner surface as sterile field.

1) Perform hand hygiene. 2) Open outer flap away from self. 3) Open innermost flap toward self. 4) Open side flap, pulling to the side. 5) Place package on work surface. 6) Use inner surface of package as sterile field.

What is the proper method to obtain urine from an indwelling catheter for culture?

Obtain urine by using a sterile syringe to withdraw from the catheter sampling port.

For male intermittent urethral catheterization, which action is correct?

Grasp the penis at its base.

Which action is appropriate when a TURP patient has continuous bladder irrigation (CBI)?

Include the amount of bladder irrigation in the urine output.

If significant resistance is met during closed bladder irrigation, what is the next step?

Stop the irrigation and notify the health care provider.

Which diagnostic test should be ordered first for acute confusion on admission to determine a possible cause?

Urinalysis (UA) (to evaluate for infection or other urinary causes).

When teaching a clean catch urine collection, which of the following should be included?

Collect after urine stream is initiated; Clean perineum front to back; Use sterile technique; Use towelettes once.

In bladder retraining, what action should the nurse take?

Assist the client to the bathroom every 4 hours during the day.

What is the expected outcome after removing an indwelling urinary catheter in an older adult after 2 days?

Temporary urinary retention.

What nursing action by a newly licensed nurse requires intervention during male catheter insertion?

Pulls gently on the catheter to check for resistance after inflating the balloon.

What is the immediate action if hourly urine output is low (e.g., 60 mL total over 3 hours)?

Notify the healthcare provider and prepare for possible interventions.

Which catheter prescriptions are appropriate for indwelling use? (Select all that apply)

A client with bilateral fractures on complete bedrest; A client with heart failure on strict I&O; A client with end-of-life comfort care (depending on orders).

Rights of Medication Administration include which statements? (Select all that apply)

The right to be informed about the medication; The right to be informed if the medication is part of a research study; The right to refuse a medication.

What IM injection angle is used for adults?

90 degrees

For an enteric-coated medication, which statement is correct?

The client should not crush or chew the tablet.

When drawing phenytoin trough levels, at what time should the level be drawn if the dose is given at 0900?

0830.

On a sliding-scale insulin prescription, if the glucose is 170 mg/dL, which is a reasonable unit dose (based on typical scales)?

4 units.

Which nursing action reduces the risk of occlusion in an NG tube with medication administration?

Irrigate the tube with 30–60 mL of water after the last medication is given.

Which prescription should be questioned as potentially inappropriate for IM administration?

Dosogluteal (outer buttock), due to nerve damage

What should you do after administering an inhaled corticosteroid to prevent oral fungal infection?

Assist the client to rinse their mouth out with water.

For adults, when administering ear drops, which action is correct?

Pull the pinna up and back to straighten the ear canal.

When giving ophthalmic drops, which technique is correct?

Hold the ophthalmic solution about 2 cm above the lower conjunctival sac.

Per Joint Commission, how many client identifiers are checked for safe medication administration, and what can be used as an identifier?

Two identifiers; birth date is one of the identifiers.

Which action is most appropriate when a patient at risk for aspiration is taking oral medications?

Remain at the bedside while the client self-administers the medication.

Which site is appropriate for a 500 mg ceftriaxone IM dose (2 mL) in adults?

Ventrogluteal or Vastus Lateralis (deltoid is not preferred for 2 mL).

Which statement best describes a sterile technique when preparing to catheterize?

Perform hand hygiene and wear sterile gloves; maintain a sterile field.

What is the gold standard method to verify nasogastric tube placement before feeding?

X-ray examination.

Which client is not an appropriate candidate for nasogastric tube placement?

A client with facial trauma.

How should you determine the correct length of an NG tube to insert?

Measure from the tip of the nose to the earlobe to the xiphoid process.

Before administering tube feeds in long-term care, which action verifies placement?

Test the pH of gastric aspirate.

Which action by the nurse should prompt intervention when administering intermittent tube feedings?

Irrigating the NG tube with tap water after the feeding.

What focused NG tube assessment actions should be included? (Select all that apply)

Inspect the skin of the nostril; Verify tube placement; Check the marking on the tube at the nostril.

Diluting enteral feedings is often done to address which condition?

Diarrhea (to reduce osmolality and irritation in the GI tract).

Which assessment confirms NG placement most accurately after placement?

Obtain an X-ray.

Gastric residual monitoring helps assess what condition?

Delayed gastric emptying.

If a client begins coughing and gagging during NG tube insertion, what should the nurse do first?

Pull the NG tube back slightly.

With continuous NG feeding, a residual volume of 520 mL indicates what action?

Hold the feeding and notify the provider.

What is the correct practice for med administration via NG tube when meds are prescribed?

Use water for medication administration and flush as needed.

If an NG tube shows pH of 6.5, what is the appropriate action?

Verify placement with an X-ray.

What is the most appropriate action for a patient with edema and sudden weight gain while on continuous enteral feeding?

Assess intake and output.

When a tube is partially occluded, what is the initial nursing action?

Flush the tube gently with warm water using a syringe.

After reaching the predetermined length of an NG tube, what is the next verification step?

Obtain an X-ray examination to confirm placement.

What is the highest priority to prevent aspiration in a tube-fed patient?

Position the patient in semi-Fowler's position.

Before a gastric tube feeding, what is the most appropriate nursing action?

Check that the pH of aspirated contents is less than 5 (to verify placement).

If NG feeding shows shallow breathing and dusky color, what is the nurse’s first priority action?

Stop the tube feeding.

What is the recommended action if the NG tube residual is high before a feeding?

Hold the feeding and notify the provider.

Which action is most important when initiating enteral feeding for an immunosuppressed patient?

Use sterile water for meds and flushes.

What is the best method to verify NG tube placement if X-ray is not immediately available?

Check pH of aspirate (usually <4 for gastric placement).

Which action is most appropriate when teaching proper urine specimen collection for culture and sensitivity?

Collect after the urine stream is initiated; Clean front to back; Use sterile technique; Use towelettes once.

What nursing action helps prevent UTI associated with indwelling catheters?

Maintain closed catheter system and secure tubing to prevent tugging.

What is a sign that indicates a patient should be evaluated for a possible UTI?

New or increased urinary frequency and dysuria.

Which factor is a key risk for CAUTI?

Indwelling urinary catheter.

Which patient scenario supports bladder retraining success?

Regular toilet trips with progressively longer intervals.

Which technique is appropriate for a left-handed nurse performing a straight catheterization?

Stand on the left side of the bed.

What is the recommended action when stopping enteral feeding due to suspected obstruction?

Stop the feeding and assess for symptoms; notify provider if needed.

Which step should be taken to protect the skin of a patient with functional incontinence?

Regular toileting schedule and barrier protection as needed.

What does a urine pH reading help determine in tube feeding patients?

Gastric placement and acid-base status; it helps assess gastric contents.

Which statement about right to refuse medication is correct?

Patients have the right to refuse medications.

Which instruction best supports safe administration of intramuscular injections?

Ensure the needle is at 90° to the skin for adults.

Which site is generally preferred for a 2 mL IM injection in adults?

Ventrogluteal or Vastus Lateralis.

What is the purpose of rinsing the mouth after an inhaled corticosteroid?

To prevent oral fungal infections.

What is a key step when opening a glass ampule to withdraw medication?

Tap the top, protect with gauze, and snap the neck away from the body.

Which action should you take when preparing a sterile field?

Perform hand hygiene before handling sterile supplies.

What is the correct handling for a clean voided urine specimen collection?

Ensure sterile technique and prevent contamination.

Which is true about using an enteral tube for nutrition?

Verification of placement and monitoring residuals are essential.

Which statement best describes the purpose of a 24-hour urine collection?

To assess renal function over a full 24-hour period.

Which of the following is a nursing action to prevent pressure injuries in incontinence?

Keep skin clean and dry; use barrier creams as appropriate.

What is the correct response to a high gastric residual volume during continuous feeding?

Hold feeding and assess patient; notify provider as needed.

Which practice helps reduce the risk of medication errors at the point of care?

Verify the five rights and two identifiers before administration.

What is the optimal patient position to reduce aspiration during NG feeding?

Semi-Fowler’s position.

Which action demonstrates compliance with sterile technique during catheter insertion?

Drape the patient and maintain a sterile field around the insertion area.

Which statement correctly describes a clean technique for collecting a midstream urine sample?

Use clean gloves, cleanse the perineal area front to back, and collect after urine flow begins.

What is the recommended nursing action when a patient experiences urinary retention after catheter removal?

Monitor voiding patterns and provide reassurance; anticipate intermittent voids.

Which nursing action is essential when caring for a patient with a urinary catheter to prevent CAUTI?

Keep the drainage bag below bladder level and keep spigot clean.

What is the recommended method to secure a urinary catheter after insertion?

Secure tubing to the upper thigh to prevent tugging.

Which condition most commonly requires an indwelling catheter in an immobile patient?

Complete bedrest due to fractures.

When performing a sterile field, which surface becomes the sterile field?

The inner surface of the opened sterile package.

Which factor most strongly increases the risk of urinary tract infection in hospital patients?

Presence of an indwelling urinary catheter.

What is the recommended approach to aspiration risk in enteral feeding?

Keep the head of the bed elevated and assess residuals per protocol.

Which action is appropriate when a patient has an NG tube and is vomiting?

Stop feeding and assess for obstruction or tube displacement.

What should be done if a nurse suspects a misplacement of an NG tube and cannot confirm visually?

Obtain an X-ray to confirm placement.

What is a key consideration when mixing insulin in one syringe?

Draw up regular (clear) insulin first, then NPH (cloudy) insulin.

What is the standard method to verify placement of a nasogastric tube in a non-emergency setting?

X-ray confirmation is the most reliable method.

What is the minimum normal urine output per hour?

30 mL

What infection risk increases with indwelling urinary catheters?

CAUTI

A nurse is teaching a client about a 24 hour urine collection. Which instruction is correct?

Keep the urine refrigerated or on ice during the collection

What does a urine specific gravity of 1.035 indicate?

dehydration

Why do we use the Z track method?

prevents medication leakage and reduces irritation

A nurse is administering an IM injection into the deltoid muscle. At what angle should the nurse insert the needle?

90

A nurse is giving medications for a client. Which medication should the nurse question before crushing?

enteric-coated aspirin

Which action by the nurse is correct when opening a glass ampule for medication administration?

snap the ampule neck away towards the body using a gauze pad.

What is the gold standard for NG tube placement confirmation?

x-ray