DownloadedbyMaryWambui.(marywambui7925@yahoo.com)lOMoARcPSD|12311162
HESIRemediationNclexPN2022
MedicalSurgical(TheUniversityofTexasatArlington)Agradestuvia lOMoARcPSD|12311162
DownloadedbyMaryWambui.(marywambui7925@yahoo.com)HESIRemediation(NCLEX-PN)
NCLEX-PNRemediation
Elimination
Amaleclientreportsdysuria,nocturia,anddifficultystartingtheurinarystream.A
cystoscopyandbiopsyoftheprostateglandhavebeenscheduled.Afterthe
proceduretheclientreportsaninabilitytovoid.Whatshouldthenursedo?
Rationale:Palpateabovethepubicsymphysis
Afullbladderispalpablewithurinaryretentionanddistention,whicharecommon
problemsafteracystoscopybecauseofurethraledema.Fluidsdilutetheurineandreduce
thechanceofinfectionaftercystoscopyandshouldnotbelimited.Althoughurinary
retentioncanoccur,itisnotexpected;thenursemustassesstheextentofbladder
distentionanddiscomfort.Moreconservativenursingmethods,suchasrunningwateror
placingawarmclothovertheperineum,shouldbeattemptedtoprecipitatevoiding;
catheterizationcarriesariskofinfection.
Anurseisobtainingahealthhistoryfromthemotherofa15-month-oldtoddler
withceliacdisease.Thenurseexpectsthemothertoindicatewhatabouther
toddler?
Rationale:Hasbulky,foul,frothystools
Steatorrhea(fatty,foul-smelling,frothy,bulkystools)occurswithceliacdiseasebecause
ofanintolerancetogluten;toxicsubstances,whichcandamagetheintestinalmucosal
cells,accumulateandcausediarrhea.Drinkinglargeamountsoffluidisaresponseto
dehydration.Withceliacdiseasesomethirstmayoccur,butitisnotcontinuous.
Althoughinfantswithceliacdiseaseareirritable,thissignistoovagueforaccurate
evaluation.Irritabilityissymptomaticofavarietyofproblems,rangingfromcuttingof
teethtoleukemia.Concentratedurineisassociatedwithaurinarytractinfectionor
dehydration;thissignistoovaguetopermitaccurateevaluation.
Aclientwithanilealconduitisbeingpreparedfordischarge.Aspartofthe
dischargeteaching,whatdoesthenurseinstructtheclienttodo?
Rationale:Maintainfluidintakeofatleast2Ldaily
High-fluidintakeflushestheilealconduitandpreventsinfectionandobstructioncaused
bymucusoruricacidcrystals.Alcoholisnotcontraindicatedwithanilealconduit.Agradestuvia lOMoARcPSD|12311162
DownloadedbyMaryWambui.(marywambui7925@yahoo.com)Notifyingthehealthcareproviderifthestomasizedecreasesisexpected;asedema
decreases,thestomawillbecomesmaller.Soapandwaterontheperistomalareahelp
preventirritationfromwasteproducts.
Aclientisscheduledforatransurethralresectionoftheprostate(TURP).Which
statementmadebytheclientmostindicatestheneedforfurtherpreoperative
teaching?
Rationale:"Myincisionwillprobablybepainful"
TheTURPprocedureisperformedbyinsertionofascopedeviceintotheurethratoreach
theprostatefromwithintheurinarytract.Noincisionismadetoreachtheprostate,
thereforetheclientstatementaboutanincisionbeingpainfulaftersurgerywarrants
furtherevaluatingandteachingbythenurse.Theclientisdemonstratingcorrect
knowledgeabouttheTURPprocedurebystatingthataftersurgeryhisurinewillbered,
hewillhaveacatheter,andhewillneedtoincreasefluidintake.
Ahealthcareproviderprescribesbisacodyl(Dulcolax)foraclientwithcardiac
disease.Thenurseexplainstotheclientthatthisdrugactsbydoingwhat?
Rationale:Stimulatingperistalsis
Bisacodylstimulatesnerveendingsintheintestinalmucosa,precipitatingabowel
movement.Bisacodylisnotabulkcathartic.Bulk-forminglaxatives,suchaspsyllium
hydrophilicmucilloid(Metamucil),formsoft,pliantbulkthatpromotesphysiological
peristalsis.Bisacodylisnotastoolsoftener.Stoolsofteners,suchasdocusatesodium,
permitfatandwatertopenetratefeces,whichsoftensanddelaysthedryingofthefeces.
Bisacodylisnotanemollient.Emollientlaxatives,suchasmineraloil(Kondremul),
lubricatethefecesanddecreaseabsorptionofwaterfromtheintestinaltract.
Amaleclientwithabrainattack(cerebrovascularaccident)hasregainedcontrolof
bowelmovementsbutstillisincontinentofurine.Tohelpreestablishbladder
control,thenurseshouldencouragetheclienttodowhat?
Rationale:Assumeastandingpositionforvoiding
Assumingastandingpositionforvoidingreducestension(physicalandpsychological),
facilitatesthemovementofurineintothelowerportionofthebladder,andrelaxesthe
externalsphincter(increasingpressureandinitiatingthemicturitionreflex).Bladder
trainingshouldbeinstitutedbyencouragingvoidingeveryonetotwohoursand
progressivelyincreasingthetimebetweenattempts.Voidingshouldbeencouragedat
regularandfrequentintervalsduringwakinghours,notjustintheafternoon.Fourlitersis
alargefluidintakeandisunnecessary;itwillresultinalargevolumeofurine,probably
increasingthefrequencyofincontinence.Agradestuvia lOMoARcPSD|12311162
DownloadedbyMaryWambui.(marywambui7925@yahoo.com)AnurseiscaringforaclientwithaT-tubeafteranopencholecystectomy.What
specificactionshouldthenurseincludeintheplanofcare?
Rationale:Monitorthecolorofthestool
AT-tubemaintainspatencyofthecommonbileductuntilinflammationsubsides;when
theductispatentandbileentersthegastrointestinaltract,thecolorofstoolisbrown.
Anklepumpingpreventsvenousstasisifaclientisnotabletoambulate.Absenceofbile
affectstheabilitytodigestfats,notcarbohydrates.AT-tubedrainsbygravity;itisnota
self-containedsuctiondevicelikeaHemovac,socompressionisnotnecessary.
Afour-year-oldchildwithanewcolostomyistobedischargedinseveraldays.
Whatshouldthenurseteachtheparentsabouttheirchild'shomecare?
Rationale:Encouragingphysicalactivity
Contactgamesmayberestricted,butotherphysicalactivitiesshouldbeencouraged.The
stomashouldbeinspectedmoreoftenthanoncedailytoensureadequatecirculation.
Increasedfluidintakeisneededtocompensateforfecalfluidloss.Thedietshouldnotbe
restrictedatthetimeofdischarge.Boththeparentsandthechildwilllearnwhichfoods
arepoorlytolerated,andtheywilladjustthedietaccordingly.
Anurseisassessingaclientwithhypothyroidism.Whichclinicalmanifestations
shouldthenurseexpecttheclienttoexhibit?Selectallthatapply.
Rationale:Coolskin,constipation,periorbitaledema,anddecreasedappetite
Coolskinisrelatedtothedecreasedmetabolicrateassociatedwithinsufficientthyroid
hormone.Constipationresultsfromadecreaseinperistalsisrelatedtothereductioninthe
metabolicrateassociatedwithhypothyroidism.Periorbitalandfacialedemaarecaused
bychangesthatcausemyxedemaandthird-spacefluideffusionseeninhypothyroidism.
Decreasedappetiteisrelatedtometabolicandgastrointestinalmanifestationsofthe
hypothyroidism.
Aclientisscheduledforligationofhemorrhoids.Whichdietdoesthenurseexpect
tobeprescribedinpreparationforthissurgery?
Rationale:Low-residue
Alow-residuedietlimitsstoolformation.Blanddietsusuallyareemployedinthe
managementofupper,notlower,gastrointestinaldisturbances.AlthoughacleardietisAgradestuvia
