Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
concepts of nursing
hesi remediation case study 2
| Question | Answer |
|---|---|
| In which sequence should the nurse perform the abdominal assessment? | Inspection, auscultation, percussion, palpation. |
| Which action is most important for the nurse to perform? | auscultate bowel sounds |
| Which is the most important action for the nurse to perform when assessing bowel sounds? | listen for up to five minutes begin in right lower quadrant |
| The nurse auscultates for the client's bowel sounds and hears faint gurgling after 3 minutes. Which assessment finding should the nurse document? | Hypoactive bowel sounds. |
| How should the nurse respond? | tell me what is making you feel so upset |
| Which response by the nurse will encourage continued verbalization by the client? | It sounds as if you have had another experience that did not go well. |
| The client continues and states that she did everything her healthcare provider (HCP) told her to do. The client is conveinced that the surgery must caused this and that they must have made a mistake in surgery. Which explanation by the nurse is accurate? | Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved. |
| Which postoperative medication is most likely to contribute to constipation? | Morphine sulfate, an opioid analgesic. |
| The nurse instructs the client on which activity that would minimize risk for constipation? | Getting out of bed and ambulating. |
| What impact does insufficient fluid intake have on the client's bowel patterns? | This inadequate fluid intake has contributed to her constipation |
| Before administering the rectal suppository, how should the client be positioned? | Sim’s |
| When administering the rectal suppository, the nurse asks the client to take several slow, deep breaths. What is the rationale for this instruction? | Relax the anal sphincter and reduce discomfort. |
| After administering the rectal suppository, how should the nurse document this action? | 0900. One bisacodyl suppository administered per rectum for constipation, as prescribed. |
| Which statement provides the best documentation describing the outcome from the suppository administration? | 1100. Client reports producing six, 0.25 inch, hard pellets of brown stool following suppository administration. |
| To determine the presence of a fecal impaction, the nurse would prepare the client for which probable prescribed procedure(s)? (Select all that apply.) | -Radiographic exam -Digital rectal exam |
| The unlicensed assistive personnel (UAP) obtains sterile gloves and lubricant for the nurse and offers to perform the procedure since the nurse is busy. Which action is the most important for the nurse to implement? | Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed. |
| While performing the digital rectal exam, the nurse understands that the client may experience vagal nerve stimulation. This can result in which change in vital signs? | Decreased pulse rate |
| When receiving the verbal prescription over the telephone, the nurse repeats the prescription back to the HCP, who sounds angry and shouts, "Are you questioning my prescription?" Which approach by the nurse is the best response to the angry HCP? | I want to ensure that I transcribe this prescription correctly to avoid error. |
| What action should the nurse implement? | Administer the enema as prescribed and obtain the HCPs signature the next day |
| What actions should the nurse take to relieve the abdominal cramping? | -Slow the rate of the infusion -Roll the clamp to stop the enema until cramping subsides |
| How will the nurse accurately explain the amount of fluid using household measurements? | 3 cups |
| The nurse encourages the client to increase her daily oral fluid intake to 2 liters of fluid for the next few days. This is equivalent to how many 8-ounce cups of fluid daily? | Eight |
| Which type of foods should the nurse recommend? | High fiber |
| The nurse uses the hospital breakfast menu as a teaching tool. Which breakfast selection by the client indicates that she understands teaching about dietary measures to promote bowel regularity? | Orange juice and oatmeal with raisins. |
Created by:
colby.caswell