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Basic Care Elimination Rationales

Basic Care Elimination Rationales

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Published by: rhymes2u on Jul 23, 2009
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02/05/2013

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1
Basic Care Elimination
1.
 
What would be the priority of care for a client who presents with nausea, diarrhea, muscle weakness, and anabnormal ECG and is taking aldactone, zestril, and glucotrol?a.
 
Evaluate the potassium level.b.
 
Evaluate the sodium level.c.
 
Review the importance of eating bananas.d.
 
Assess for signs and symptoms of dehydration.
Aldactone is a potassium-sparing diuretic, and when given with zestril, there is a potential problem withhyperkalemia. Option #2 is inaccurate. Option #3 is high in potassium and could contribute to the complication of hyperkalemia. While Option #4 is appropriate, it is not a priority to Option #1. Since the client has alreadydeveloped an abnormal ECG, it is apparent there is alteration in the fluid and electrolytes.
 
2.
 
An order has been received to obtain a consent for an intravenous pyelogram (IV P). The most importantinformation for the nurse to obtain is:a.
 
color of urine.b.
 
renal history.c.
 
last bowel movement.d.
 
iodine sensitivity.
The fluoroscopic exam of the urinary track is visualized after an injection of a radiopaque dye. People who haveiodine sensitivity may have an allergic reaction. Although Options #1, #2, and #3 are important in the overallassessment, they do not specifically address iodine sensitivity.
 
3.
 
Which assessment would be most appropriate
for
monitoring a clients state of hydration?a.
 
Daily weight.b.
 
I&O.c.
 
Skin turgor.d.
 
Characteristic of lips and mucous membranes.
Daily weight is the most appropriate evaluation out of these options. It is the most measurable. While Options #2,#3 and #4 are correct, they are not a priority to Option #1.
 
4.
 
Upon auscultation of a clients bowel sounds, the nurse notes soft gurgling sounds occurring every 5-20 seconds.This indicates:a.
 
excessive intestinal motility.b.
 
reduced intestinal peristalsis.c.
 
normal sounds.d.
 
rapid gastric emptying
Option #3 is the correct description of bowel sounds. Options #1, #2, and #4 all reflect abnormal bowel soundsrelated to hypo or hypermotility of the GI tract.
 
5.
 
A client expresses concern as to what to expect during a gastroscopy. The nurse would explain that the
 
client:a.
 
may feel fullness in the throat and a sense of gagging during the test.b.
 
should be able to speak during the procedure.c.
 
will need no sedation to provide anesthesia.d.
 
will be able to eat or drink immediately following the procedure.
The gastroscopy is a semi-flexible tube which when inserted into the esophagus will cause gagging. Options #2 and#3 are incorrect because the client will not be able to communicate verbally during the procedure and is usuallyprovided with a sedative to relieve anxiety and facilitate insertion of the tube. Option #4 is incorrect because theclients" throat is anesthetized. Fluids and food should be withheld for at least 2 to 4 hours until the gag reflexreturns.
 
6.
 
Which nursing observation would relate to a postoperative complication in the client with postoperativeileostomy?a.
 
The ileostomy does not require daily irrigations to maintain function.b.
 
The stoma appears tight and there is a decreased amount of stool.c.
 
An impaction appears to be forming in the distal anal area.d.
 
A weight gain of 5 pounds related to increased fluid retention.
If there is a decrease in flow of stool in an ileostomy, along with changes in the appearance of the stoma, it wouldbe important to report these findings to the physician as they might indicate an obstruction or stoma stricture.Option #1 is incorrect because ileostomies are not irrigated. Option #3 is incorrect because the anal area is notfunctional. Option #4 is related to cardiac or renal problems.
 
 
2
7.
 
A client with a permanent colostomy on the transverse colon questions the nurse as to whether or not he willever be able to establish bowel control. The nursing response would be based on which concept?a.
 
There is little chance that the client will gain adequate control with this colostomy.b.
 
Control may be achieved with colostomy irrigations twice a day.c.
 
Daily colostomy irrigations and diet are frequently used to maintain colostomy control.d.
 
A high residue diet that provides bulk to the stool may be used to maintain bowel control.
Diet and irrigations are the common methods used for colostomy control. Option #1 is incorrect because clientsgradually are able to control and adapt to their individual bowel evacuation routines. Option #2 is incorrectbecause irrigation of the colostomy is usually needed only once a day. Option #4 is incorrect because diet may assistin control but cannot be used alone and irrigations are more successful.
8.
 
A client on chemotherapy has a WBC count of 1,200/mm. Based on this data, which nursing action should betaken first?a.
 
Check temperature q 4h.b.
 
Monitor urine output.c.
 
Assess for bleeding gums.d.
 
Obtain an order for blood cultures.
It is important to monitor for infection which would be evidenced by an elevated temperature in a client who hassuch a low WBC count. Option #2 is important to monitor because of problems of increased uric acid excretionfrom chemo-therapeutic drugs but is not applicable to this situation. Option #3 would be associated with a lowplatelet count. Option #4 would be secondary to Option #1.
9.
 
Which of the following statements, if made by a client with oliguric renal failure, would indicate a need forfurther teaching?a.
 
"I will only eat processed foods in moderation."b.
 
"I must limit the amount of salt I eat."c.
 
"I won't eat pickles and green olives anymore."d.
 
"I will use a salt substitute instead of table salt."
Option #4 is correct. Many salt substitutes contain potassium and could lead to hyperkalemia in clients with renalfailure. This must be clarified with the client. Options #1, #2, and #3 indicate an understanding by the client of theneed to limit sodium intake.
10.
 
A client is to receive cimetidine (Tagamet) 300 mg PO QID and Mylanta. The reason for administering thesedrugs at least 1 hour apart is:a.
 
both drugs act to coat the stomach lining.b.
 
antacids have no effect on absorption of cimetidine.c.
 
antacids enhance absorption of cimetidine.d.
 
antacids interfere with absorption of cimetidine.
Antacids interfere with absorption of several drugs. Care should be taken when scheduling them with drugs suchas cimetidine (Tagamet) so that full benefit of dose can be given. Options #1, #2, and #3 are incorrect.
 
11.
 
A 77-year-old client with iron deficiency anemia has been started on ferrous sulfate tablets. However, they makethe client vomit. The best instructions to assist in minimizing this side effect would be to take the medication:a.
 
before meals.b.
 
in the early morning.c.
 
after meals.d.
 
bedtime.
While the preferred method for taking ferrous sulfate is on an empty stomach, to reduce the side effect of vomiting,it may be administered after meals. If the client does not experience any side effects, the ideal time is I hour before,or 2 hours after, meals. Option #1 is incorrect since the client can develop gastrointestinal problems and mayexperience anorexia as a result. Options #2 and #4 are incorrect since it may cause nausea.
 
12.
 
A client with lung cancer and bone metastasis is grimacing and states, "I am a little uncomfortable. May I havesomething for pain?" Which nursing action should be taken first before administering his pain medication?a.
 
Check the chart to determine last medication.b.
 
Encourage client to refocus on something pleasantc.
 
Notify physician that medication is not working.d.
 
Assess the severity and location of pain.
The first step is to assess the clients pain and determine its severity. Option #1 is incorrect because assessment isdone prior to checking the chart for information. Option #2 is incorrect because the pain of metastatic cancer doesnot usually lend itself to non medical measures. Option #3 may be secondary. Further pain management includesintervention before pain becomes intense.
 
3
13.
 
A client has alopecia as a result of chemotherapy and is concerned as to the extent of her hair loss. Whichexplanation by the nurse would be most appropriate?a.
 
Explain how dose and type of medication administered will be the determining factor for hair regrowth.b.
 
Reassure client that hair will look as good as before treatment, maybe even better.c.
 
Describe how hair will not grow back unless special measures are used during chemotherapy.d.
 
Explain how the color and texture of the new hair maybe different, but the hair loss is usually notpermanent.
Reassuring the client that hair will grow back after the completion of chemotherapy is important. Some clients willbegin to have hair growth before the course of chemotherapy is finished. Option #1 is secondary to Option #4.Options #2 and #3 are incorrect
.
 14.
 
Which nursing observations would relate to the complication of intestinal obstruction following an exploratorylaparotomy?a.
 
Protruding soft abdomen with frequent diarrhea.b.
 
Distended abdomen with ascites.c.
 
Minimal bowel sounds in all four quadrants.d.
 
Distended abdomen with complaints of pain.
If an obstruction is present, the abdomen will become distended and painful. Options #1and #2 do not supportintestinal obstruction. Option #3 is incorrect because immediately postoperative abdominal surgery, a clients bowelsounds are absent or decreased.
 
15.
 
A client with prostatic cancer is admitted to the hospital with neutropenia. Which signs and symptoms are mostimportant for the nurse to report to the next shift?a.
 
Arthralgia and stiffness.b.
 
Vertigo and headache.c.
 
General malaise and anxiety.d.
 
Temperature elevation and lethargy.
With a low WBC (neutropenia), the client is at risk for the development of infection. Options #1 and #2 could beexperienced but are rot most important. Option #3 is more closely associated with anemia.
 
16.
 
A client with chronic cancer pain has been receiving Demerol 100 mg PO q4h PRN for pain, without much relief.Which change in narcotic pain management would be the most valid suggestion to make to the physician?a.
 
Decrease to twice a day.b.
 
Decrease to every 6 hours PRN.c.
 
Give every 4 hours around the clock.d.
 
Give every 2 hours PRN.
Research shows that around-the-clock (ATC) administration of analgesics is more effective in maintaining bloodlevels to alleviate the pain associated with cancer. Options #1 and #2 actually decrease the amount of painmedication. Option #4 might be too frequent an interval.
17.
 
Which priority is first when inserting an indwelling urinary catheter?a.
 
Aseptic technique.b.
 
Taping the catheter to the leg.c.
 
Instilling water into the balloon.d.
 
Inserting the catheter to the point where the urine flows.
Prevention of infection is apriority. When ever a foreign tube is being introduced into the body, there is always achance for infection to occur. Option #2 is incorrect. Option #3 is incorrect because it should be sterile water andeven then is not a priority. Option #4 contains incorrect information as the catheter is usually inserted 2-3 inchesbeyond the flow of urine
.
 18.
 
Based on the assessment findings of oliguria, hyperkalemia, and increased BUN on a client
in
chronic renalfailure, an appropriate nursing diagnosis would be:a.
 
fluid volume excess and electrolyte imbalanceb.
 
related to decreased urinary outputc.
 
altered nutrition less than body requirements related to anorexia and dietary restrictions.d.
 
knowledge deficit regarding condition and treatment regimen.
In renal failure, oliguria is accompanied by an increased BUN, increased serum potassium, and decreased renalblood flow. Option #2 is incorrect because it addresses other information not in the question. Option #3 does nothave related to as part of the diagnosis. Option #4 is incorrect because oliguria is decreased urinary output, notincreased urinary output.
 

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