Elimination

The nurse monitors the patient with erysipelas for which symptoms that may indicate complications related to the condition? Select all that apply.

The nurse is supervising the care of a patient with a stage II pressure injury on the coccyx. Which intervention by the student nurse prompts the nurse to intervene with further education?

The nurse in the burn ICU is caring for a patient with third degree burns over 33% of the body. Which assessment best indicates that fluid resuscitation has been adequate?

The patient with a history of colon cancer presents to the emergency department reporting significant abdominal pain, bloating, and vomiting. Which question to garner more information about the emesis is most important?  

Four hours after a rectal resection for treatment of rectal cancer, the patient is noted to be pale and diaphoretic. Which assessments are the priority? Select all that apply.  

The nurse is caring for the patient who underwent colon resection and ileostomy creation two days ago. Upon assessment, the nurse notes 40 mL of dark green liquid in the ostomy bag. Which action by the nurse is correct?  

At 48 hours after a bowel resection surgery for colon cancer, the colostomy is noted to be moist and purple. Which additional assessment is most important?  

The nurse is caring for a patient 6 hours after a transurethral resection of the prostate and notes decreased urine output. Which is the most likely cause of the decreased urine output? 

During postoperative day 1 after a suprapubic prostatectomy, which assessment is most important for the drainage from the surgical wound?  

The nurse most closely monitors the temperature for the patient who underwent which procedure?  

The nurse counsels the patient with prostate cancer to choose transurethral resection of the prostate based on which characteristic? 

The patient undergoing continuous bladder irrigation (CBI) following a prostatectomy reports an extreme need to urinate. Which action by the nurse is most appropriate? 

The nurse performs a shift assessment on the patient who has been undergoing continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP) for 3 days and notes the output to be an amber color. Which action by the nurse is most appropriate?

The nurse is preparing an informational session for individuals at risk for prostate cancer. Which statement does the nurse include in the talk?  

The nurse assesses the patient who has received continuous bladder irrigation (CBI) therapy since a transurethral resection of the prostate (TURP) 24 hours ago. Which assessment is the priority to report?  

The nurse is caring for the patient with prostate cancer and left-sided heart failure who underwent transurethral resection of the prostate (TURP) 12 hours ago. Clots are noted in the continuous bladder irrigation (CBI) outflow. Which action by the nurse is most appropriate?  

The nurse clarifies the order for a perineal prostatectomy for treatment of prostate cancer in the patient with which condition?   

At 48 hours postop from a prostatectomy, the patient is noted to have pink output from the continuous bladder irrigation (CBI) system. Which action by the nurse is most appropriate?  

The nurse reviews the patient’s 24-hour intake and output for the patient with continuous bladder irrigation (CBI). The CBI intake is 2000 mL and the output is 2600 mL. Which action by the nurse is most appropriate?  

During a shift assessment 14 hours after a prostatectomy, the nurse notes bright red drainage in the continuous bladder irrigation (CBI) drainage bag. Which assessment is most important?  

The 62-year-old male patient presents to the office complaining of difficulty urinating, with a weak stream, waking multiple times in the night to urinate, and the feeling of not completely emptying the bladder that has been occurring for months. Which test must be performed first for this patient? 

The 3-year-old patient with acute pyelonephritis has the following orders:  Medications: 8 mg/kg ciprofloxacin IV q8h  Activity level: ambulatory as tolerated  Intravenous fluids: Infuse D5W with 0.25% NaCl via peripheral IV at 50 mL/h  Diet: Normal   The nurse is coordinating care for the patient with the unlicensed assistive personnel. Which statement by the UAP prompts further education by the nurse? 

The patient with severe psoriasis has been prescribed methotrexate. The nurse instructs the patient to schedule which follow-up tests? Select all that apply.   

The patient on bowel rest has been prescribed 10% dextrose total parenteral nutrition at 50 mL/h, intravenous lipids 3 grams/kg/day, and 10 mg intravenous famotidine every other day. Which information in the patient’s chart prompts the nurse to contact the provider? 

The patient with chronic alcoholism begins parenteral nutrition (PN) at a rate of 50 mL/h for treatment of severe malnutrition. Four hours after the infusion begins, the patient’s urine output increases from 40 mL/h to 200 mL/h. The nurse contacts the provider to request which order?  

The patient is receiving parenteral nutrition while NPO for a bowel obstruction. Review the patient’s lab results and decide which change to the parenteral nutrition the nurse clarifies with the provider.   Blood urea nitrogen = 34 mg/dL   Serum Creatinine = 2.1 mg/dL  Potassium = 6.1 mEq/dL  Sodium = 131 mEq/dL  Chloride = 100 mEq/dL  Bicarbonate = 18 mEq/dL

The nurse is providing preprocedural teaching for the patient scheduled for a cystectomy for bladder cancer. Which statement by the patient indicates teaching was effective? 

The patient with bladder cancer is scheduled for a cystectomy and creation of an internal ileal reservoir. Which statement by the patient indicates an understanding of the teaching?  

The patient has undergone a cystectomy with ureterosigmoidostomy. Which nursing interventions are included in the care plan? Select all that apply. 

On Monday, the patient receiving chemotherapy for cervical cancer has an unsealed radiation source instilled into the uterus. Tuesday morning, the patient vomits after breakfast. Which action does the nurse take while cleaning the emesis?  

The patient with uterine cancer has a sealed radiation implant placed into the uterus. Which action by the nurse promotes safety? 

The nurse is caring for the patient who is at the nadir for bone marrow suppression. Which order does the nurse clarify with the provider?  

The patient is scheduled for a posterior pelvic exenteration and the nurse has provided preprocedural teaching. Which statement indicates a need for further teaching?  

Which interventions does the nurse include in care for the patient who underwent a total pelvic exenteration for a cancer diagnosis one day ago? Select all that apply.  

The nurse is evaluating the understanding of the patient who has been taught to perform a colostomy irrigation. Which action requires further teaching? 

The home health nurse is assessing the patient with a colostomy. Which finding indicates the patient is performing the tap water irrigations too frequently?  

The nurse assesses the patient being treated for bipolar disorder for which signs of toxicity?  

The patient being treated for bipolar disorder is found to be lethargic, confused, and obtunded. It is determined that the morning dose of lithium was not taken. Which order does the nurse anticipate first?  

The 24-year-old otherwise healthy patient with bipolar disorder is found unconscious and brought to the emergency department. The patient is mildly febrile, significantly tachycardic, tachypneic, and hypotensive, with poor skin turgor and 5 second capillary refill. The patient’s EKG is notable for inverted T waves and sinus tachycardia. Which orders does the nurse anticipate for this patient? Select all that apply.  

The 78-year-old resident of a nursing home is brought to the emergency department for abdominal pain that is not responsive to oxycodone. She takes captopril, atenolol, lovastatin, and glyburide in addition to the oxycodone. Upon assessment, her abdomen is full and mildly tender. She has positive bowel sounds and reports passing gas but no stools for 96 hours. She denies anorexia or vomiting. A digital rectal examination is performed and stool is found in the rectum. The nurse anticipates being ordered to perform which intervention for this patient?  

The nurse is planning care for the 78-year-old patient with recurrent fecal impaction. The patient has prostate cancer that has metastasized to the bone. In addition to palliative chemotherapy, the patient receives a fentanyl transdermal patch and intravenous hydromorphone. The patient is neutropenic and thrombocytopenic. The nurse works with the provider to plan which intervention to manage the opioid-induced constipation and subsequent fecal impaction? 

The 36-hour-old neonate who was born at 37 weeks gestation to a G3P2 mother has yet to pass meconium. The baby was born by cesarean section due to refractory preeclampsia with severe features. The mother reports the baby has been breastfeeding well after a slow first 12 hours. Upon assessment, the baby appears well with good tone and responsiveness. The baby’s anus is patent and the abdomen is soft and rounded; bowel sounds present. The mother denies emesis in the baby. An abdominal x-ray is obtained, which is normal. The nurse informs the mother that which test will be performed next? 

During the 1-hour assessment of the healthy, full-term neonate born to the 25-year-old G1P1 mother, the nurse notes the urethral meatus is on the ventral part of the penile shaft just proximal to the glans. The assessment is also notable for widely-spaced, downward-slanting eyes that resemble the baby’s father. The nurse provides which information to the parents?  

During the shift assessment of the healthy, full-term neonate born 24 hours ago to the 25-year-old G1P1 mother who had an uncomplicated pregnancy and delivery, the nurse notes the urethral meatus is on the ventral part of the penile shaft. The assessment is also notable for wide-spaced, downward-slanting eyes that resemble the baby’s father. The baby is pink, well-perfused, and breathing comfortably with normal heart and lung sounds. The mother reports the child is breastfeeding every 2 hours and has voided and stooled several times. Which additional assessment is most important? 

The 12-hour-old neonate was born at 39 weeks to a G2P2 mother after an uncomplicated pregnancy and delivery. Slight oligohydramnios was noted during the pregnancy. The neonate has not urinated. Upon assessment, the nurse notes stable vital signs and suprapubic distention. The nurse contacts the provider to advocate for which initial intervention?