The infection control nurse is reviewing data for the medical-
surgical unit. The nurse notices an increase in postoperative
infections from Aspergillus. Which type of health care-
associated infection will the nurse report?
Exogenous
The nurse, upon reviewing the history, discovers the patient has
dysuria. Which assessment finding is consistent with dysuria?
Burning upon urination
Which nursing action will most likely increase a patient's risk
for developing a health care-associated infection?
Uses a clean technique for inserting a urinary catheter
An 86-year-old patient is experiencing uncontrollable leakage of
urine with a strong desire to void and even leaks on the way to
the toilet. Which priority nursing diagnosis will the nurse
include in the patient's plan of care?
,Urge urinary incontinence
Upon palpation, the nurse notices that the bladder is firm and
distended; the patient expresses an urge to urinate. Which
question is most appropriate?
When was the last time you voided
While receiving a shift report on a patient, the nurse is informed
that the patient has urinary incontinence. Upon assessment,
which finding will the nurse expect?
Reddened, irritated skin on buttocks
A nurse is inserting a catheter into a female patient. When the
nurse inserts the catheter, no urine is obtained. The nurse
suspects the catheter is not in the urethra. What should the nurse
do?
Leave the catheter in the vagina as a landmark for insertion of a
new, sterile catheter
A patient asks about treatment for stress urinary incontinence.
Which is thenurse's best response?
,Perform pelvic floor exercises
Which assessment question should the nurse ask if stress
incontinence is suspected?a. "Do you think your bladder feels
distended?"b. "Do you empty your bladder completely when
you void?"c. "Do you experience urine leakage when you cough
or sneeze?"d. "Do your symptoms increase with consumption of
alcohol or caffeine?"
Do you experience urine leakage when you cough or sneeze
The nurse is preparing to test a patient for postvoid residual with
a bladder scan. Which action will the nurse take?
Measure bladder within 10 minutes after patient voids
The nurse is emptying an ileostomy pouch for a patient. Which
assessment finding will the nurse report immediately?
Presence of blood in the stool
A nurse is checking orders. Which order should the nurse
question?
A Kayexalate enema for a patient with severe hypokalemia
, A nurse is performing an assessment on a patient who has not
had a bowel movement in 3 days. The nurse will expect which
other assessment finding?
Hypoactive bowel sounds
A patient is receiving opioids for pain. Which bowel assessment
is a priority?
Constipation
A terminally ill patient is experiencing constipation secondary to
pain medication. Which is the best method for the nurse to
improve the patient's constipation problem?
Use a laxative
A palliative team is caring for a dying patient in severe pain.
Which action is the priority?
Enhance the patient's quality of life
A veteran is hospitalized after surgical amputation of both lower
extremities owing to injuries sustained during military service.