NUR 155 exam 2 Questions And Answers Rated A+ New Update Assured Satisfaction-Galen collage of nursing

The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis? 1. Flattened neck veins when the client is in the supine position 2. Full and bounding pedal and post-tibial pulses 3. Pitting edema located in the feet, ankles, and calves 4. Shallow respirations with crackles on auscultation Normally, neck veins are distended when the client is in the supine position. These veins flatten as the client moves to a sitting position. The other three responses are characteristic of the nursing diagnosis of Excess Fluid Volume. Focus: Prioritization The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding by the nurse indicates a need to contact the prescriber and question the order? A. The patient is recovering from a traumatic brain injury. Correct B. The patient has not had a bowel movement for 3 days. C. The patient is to have a lower GI series the following morning. D. The patient had an upper GI series performed the previous day. The nurse is caring for an elderly patient whose dementia has become worse over the last 24 hours. The nurse suspects that the patient may have developed a urinary tract infection and obtains a urine sample. Which assessment findings prompt the nurse to contact the provider to obtain an order for urine culture and sensitivity testing? ( Select all that apply.) A. Urinary dipstick testing is positive for nitrates. Correct B. The urine appears cloudy with a foul odor. Correct C. The urine is concentrated and dark amber in color. D. The urine smells faintly like sweet fruit. E. The patient is urinating more frequently than usual. Correct F. The patient is normally continent but has been incontinent twice. Correct 1. A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. b. Reassure the patient that it is not possible to void while catheterized. c. Catheterize the patient again with a larger gauge catheter. d. Notify the primary care provider. Answer: a Checking the position and patency of the catheter first will determine whether the problem is mechanical or physiologic. At times, the end of the catheter may become lodged up against the side of the bladder, preventing the flow of urine into the tubing. Telling the patient that is impossible to void while catheterized is erroneous. Catheterizing the patient with a larger-gauge catheter is unnecessary at this point, as is contacting the primary care provider. 2. Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. Tell the patient to void and pour the urine into a labeled specimen container. b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container. c. Instruct the patient to discard the first void and collect the next void for the specimen. d. Have the patient keep all voided urine for 24 hours in a chilled, opaque collection container. Answer: b Urine specimens for culture and sensitivity testing must be collected in sterile containers using the clean-catch, midstream method whenever possible. All voided urine specimens should be collected directly into the specimen container, not transferred to another, potentially contaminated receptacle. Discarding the entire first void and saving urine in a chilled, opaque container are both procedures for conducting a 24-hour urine collection. 5. 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.) a. Taking the urinary tract analgesic phenazopyridine b. A diet that includes a large number of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake f. Dehydration g. Infection Answer: a, b, c, d, f, g Urine may appear orange when a patient is taking phenazopyridine. Urine can appear red or pink with a diet including beets or blackberries and if blood is present in the urine, which may be secondary to an enlarged prostate or kidney stones. Urine often has a brownish appearance when liver disease such as hepatitis or cirrhosis is present. Dehydration and infection can also change the color of the urine. Carbohydrate intake does not typically cause urine to be discolored.