nurs 2207b hesi remediation nclex pn med surgnurs 2207b hesi remediation nclex pn med surgnurs 2207b hesi remediation nclex pn med surgnurs 2207b hesi remediation nclex pn med surgnurs 2207b
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Abraham Baldwin Agricultural College
NURS 2207B HESI Remediation Med surg
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NCLEX-PN Remediation
Elimination
A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A
cystoscopy and biopsy of the prostate gland have been scheduled. After the
procedure the client reports an inability to void. What should the nurse do?
Rationale: Palpate above the pubic symphysis
A full bladder is palpable with urinary retention and distention, which are common
problems after a cystoscopy because of urethral edema. Fluids dilute the urine and reduce
the chance of infection after cystoscopy and should not be limited. Although urinary
retention can occur, it is not expected; the nurse must assess the extent of bladder
distention and discomfort. More conservative nursing methods, such as running water or
placing a warm cloth over the perineum, should be attempted to precipitate voiding;
catheterization carries a risk of infection.
A nurse is obtaining a health history from the mother of a 15-month-old toddler
with celiac disease. The nurse expects the mother to indicate what about her
toddler?
Rationale: Has bulky, foul, frothy stools
Steatorrhea (fatty, foul-smelling, frothy, bulky stools) occurs with celiac disease because
of an intolerance to gluten; toxic substances, which can damage the intestinal mucosal
cells, accumulate and cause diarrhea. Drinking large amounts of fluid is a response to
dehydration. With celiac disease some thirst may occur, but it is not continuous. Although
infants with celiac disease are irritable, this sign is too vague for accurate evaluation.
Irritability is symptomatic of a variety of problems, ranging from cutting of teeth to
leukemia. Concentrated urine is associated with a urinary tract infection or dehydration;
this sign is too vague to permit accurate evaluation.
A client with an ileal conduit is being prepared for discharge. As part of the
discharge teaching, what does the nurse instruct the client to do?
Rationale: Maintain fluid intake of at least 2L daily
High-fluid intake flushes the ileal conduit and prevents infection and obstruction caused
by mucus or uric acid crystals. Alcohol is not contraindicated with an ileal conduit.
Notifying the health care provider if the stoma size decreases is expected; as edema
decreases, the stoma will become smaller. Soap and water on the peristomal area help
prevent irritation from waste products.
, A client is scheduled for a transurethral resection of the prostate (TURP). Which
statement made by the client most indicates the need for further preoperative
teaching?
Rationale: "My incision will probably be painful"
The TURP procedure is performed by insertion of a scope device into the urethra to reach
the prostate from within the urinary tract. No incision is made to reach the prostate,
therefore the client statement about an incision being painful after surgery warrants
further evaluating and teaching by the nurse. The client is demonstrating correct
knowledge about the TURP procedure by stating that after surgery his urine will be red,
he will have a catheter, and he will need to increase fluid intake.
A health care provider prescribes bisacodyl (Dulcolax) for a client with cardiac
disease. The nurse explains to the client that this drug acts by doing what?
Rationale: Stimulating peristalsis
Bisacodyl stimulates nerve endings in the intestinal mucosa, precipitating a bowel
movement. Bisacodyl is not a bulk cathartic. Bulk-forming laxatives, such as psyllium
hydrophilic mucilloid (Metamucil), form soft, pliant bulk that promotes physiological
peristalsis. Bisacodyl is not a stool softener. Stool softeners, such as docusate sodium,
permit fat and water to penetrate feces, which softens and delays the drying of the feces.
Bisacodyl is not an emollient. Emollient laxatives, such as mineral oil (Kondremul),
lubricate the feces and decrease absorption of water from the intestinal tract.
A male client with a brain attack (cerebrovascular accident) has regained control of
bowel movements but still is incontinent of urine. To help reestablish bladder
control, the nurse should encourage the client to do what?
Rationale: Assume a standing position for voiding
Assuming a standing position for voiding reduces tension (physical and psychological),
facilitates the movement of urine into the lower portion of the bladder, and relaxes the
external sphincter (increasing pressure and initiating the micturition reflex). Bladder
training should be instituted by encouraging voiding everyone to two hours and
progressively increasing the time between attempts. Voiding should be encouraged at
regular and frequent intervals during waking hours, not just in the afternoon. Four liters is
a large fluid intake and is unnecessary; it will result in a large volume of urine, probably
increasing the frequency of incontinence.
, A nurse is caring for a client with a T-tube after an open cholecystectomy. What
specificaction should the nurse include in the plan of care?
Rationale: Monitor the color of the stool
A T-tube maintains patency of the common bile duct until inflammation subsides; when
the duct is patent and bile enters the gastrointestinal tract, the color of stool is brown.
Ankle pumping prevents venous stasis if a client is not able to ambulate. Absence of bile
affects the ability to digest fats, not carbohydrates. A T-tube drains by gravity; it is not a
self-contained suction device like a Hemovac, so compression is not necessary.
A four-year-old child with a new colostomy is to be discharged in several days. What
should the nurse teach the parents about their child's home care?
Rationale: Encouraging physical activity
Contact games may be restricted, but other physical activities should be encouraged. The
stoma should be inspected more often than once daily to ensure adequate circulation.
Increased fluid intake is needed to compensate for fecal fluid loss. The diet should not be
restricted at the time of discharge. Both the parents and the child will learn which foods
are poorly tolerated, and they will adjust the diet accordingly.
A nurse is assessing a client with hypothyroidism. Which clinical manifestations
should the nurse expect the client to exhibit? Select all that apply.
Rationale: Cool skin, constipation, periorbital edema, and decreased appetite
Cool skin is related to the decreased metabolic rate associated with insufficient thyroid
hormone. Constipation results from a decrease in peristalsis related to the reduction in the
metabolic rate associated with hypothyroidism. Periorbital and facial edema are caused
by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism.
Decreased appetite is related to metabolic and gastrointestinal manifestations of the
hypothyroidism.
A client is scheduled for ligation of hemorrhoids. Which diet does the nurse expect
to be prescribed in preparation for this surgery?
Rationale: Low-residue
A low-residue diet limits stool formation. Bland diets usually are employed in the
management of upper, not lower, gastrointestinal disturbances. Although a clear diet is
low in residue, it does not meet nutritional needs. A high-protein diet is indicated
postoperatively to promote healing.
, A client who had a transurethral resection of the prostate is transferred to the
postanesthesia care unit with an intravenous (IV) line and a urinary retention
catheter. For which major complication is it most important for the nurse to assess
during the immediate postoperative period?
Rationale: Hemorrhage
After transurethral surgery, hemorrhage is common because of venous oozing and
bleeding from many small arteries in the area. Following transurethral surgery, sepsis is
unusual, and if it occurs, it will manifest later in the postoperative course; phlebitis is
assessed for, but it is not the most important complication; and leaking around the IV
catheter is not a major complication.
A nurse is caring for a client who is experiencing urinary incontinence. The client
has an involuntary loss of small amounts (25 to 35 mL) of urine from an
overdistended bladder. What should this should be documented in the medical
record as?
Rationale: Overflow incontinence
Overflow incontinence describes what is happening with this client; overflow
incontinence occurs with retention of urine with overflow of urine. Urge incontinence
describes a strong need to void that leads to involuntary urination. Stress incontinence
occurs when a small amount of urine is expelled because of an increase in intraabdominal
pressure that occurs with coughing, lifting, or sneezing. Reflex incontinence is an
involuntary loss of urine at fairly predictable intervals when certain urinary bladder
intervals are reached.
After an abdominal hysterectomy the client returns to the unit with an indwelling
catheter. The nurse notes that the urine in the client's collection bag has become
increasingly sanguineous. What complication does the nurse suspect?
Rationale: An incisional nick in the bladder
During an abdominal hysterectomy the urinary bladder may be nicked accidentally. The
client is not likely to have an infection with bleeding so soon. Bleeding would be present
from other sites, such as the incision, as well as in the urine bag. The uterus is removed
with a hysterectomy; therefore there is no uterine bleeding
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