NURS_347_01_SP25_Exam 3
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1. A nurse is caring for a postoperative patient who has not had a bowel movement in three days despite being on a high-fiber diet. The patient reports abdominal discomfort and bloating. What is the priority nursing intervention?
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Perform digital rectal stimulation to facilitate stool passage.
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Assess for bowel sounds and palpate for distention.
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Encourage ambulation and increased oral fluid intake.
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Administer a prescribed laxative.
Explanation
Explanation
Correct Answer: (B) Assess for bowel sounds and palpate for distention.
Assessment always comes first in the nursing process before any intervention is implemented. Before treating postoperative constipation, the nurse must assess bowel sounds and palpate for abdominal distention to determine the nature and severity of the problem and rule out more serious complications such as paralytic ileus or bowel obstruction. These findings will guide the appropriate intervention and ensure that treatments such as laxatives or ambulation are safe and appropriate for the patient's current condition.
Why the other options are incorrect:
A. Digital rectal stimulation is an invasive intervention that should only be performed after thorough assessment confirms it is appropriate and safe. Performing it without prior assessment is premature.
C. Encouraging ambulation and increased fluid intake are appropriate interventions for constipation but must follow assessment. They may be insufficient or inappropriate if a more serious underlying condition such as ileus is present.
D. Administering a laxative is a valid intervention for constipation but must be preceded by assessment. If the patient has a bowel obstruction, administering a laxative could be harmful.
Correct Answer: (B) Assess for bowel sounds and palpate for distention.
Assessment always comes first in the nursing process before any intervention is implemented. Before treating postoperative constipation, the nurse must assess bowel sounds and palpate for abdominal distention to determine the nature and severity of the problem and rule out more serious complications such as paralytic ileus or bowel obstruction. These findings will guide the appropriate intervention and ensure that treatments such as laxatives or ambulation are safe and appropriate for the patient's current condition.
Why the other options are incorrect:
A. Digital rectal stimulation is an invasive intervention that should only be performed after thorough assessment confirms it is appropriate and safe. Performing it without prior assessment is premature.
C. Encouraging ambulation and increased fluid intake are appropriate interventions for constipation but must follow assessment. They may be insufficient or inappropriate if a more serious underlying condition such as ileus is present.
D. Administering a laxative is a valid intervention for constipation but must be preceded by assessment. If the patient has a bowel obstruction, administering a laxative could be harmful.
2.
- Fill in the blank by selecting the best option from the drop-down boxes. The process of (1) allows free movement of particles and solutes across a membrane.
- osmosis / diffusion / active transport / capillary filtration
- osmosis
- diffusion
- active transport
- capillary filtration
Explanation
Explanation
Diffusion is the process by which particles and solutes move freely across a membrane from an area of higher concentration to an area of lower concentration. This movement is passive, meaning it requires no energy, and continues until equilibrium is reached on both sides of the membrane. Diffusion is fundamental to gas exchange in the lungs and nutrient transport at the cellular level.
Why the other options are incorrect:
Osmosis refers specifically to the movement of water across a semipermeable membrane from an area of low solute concentration to high solute concentration. It applies to water movement, not free movement of particles and solutes.
Active transport requires energy in the form of ATP to move substances across a membrane against their concentration gradient, from low to high concentration. It is not a free or passive movement.
Capillary filtration involves the movement of fluid out of capillaries due to hydrostatic pressure differences and is a specific vascular mechanism, not a general description of free particle and solute movement across a membrane.
Diffusion is the process by which particles and solutes move freely across a membrane from an area of higher concentration to an area of lower concentration. This movement is passive, meaning it requires no energy, and continues until equilibrium is reached on both sides of the membrane. Diffusion is fundamental to gas exchange in the lungs and nutrient transport at the cellular level.
Why the other options are incorrect:
Osmosis refers specifically to the movement of water across a semipermeable membrane from an area of low solute concentration to high solute concentration. It applies to water movement, not free movement of particles and solutes.
Active transport requires energy in the form of ATP to move substances across a membrane against their concentration gradient, from low to high concentration. It is not a free or passive movement.
Capillary filtration involves the movement of fluid out of capillaries due to hydrostatic pressure differences and is a specific vascular mechanism, not a general description of free particle and solute movement across a membrane.
3. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?
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A client who has heart failure.
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A client who has a new diagnosis of adrenal insufficiency.
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A client who is receiving treatment for diabetic ketoacidosis.
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A client who has abdominal ascites.
Explanation
Explanation
Correct Answer: (A) A client who has heart failure.
Heart failure results in the heart's inability to pump blood effectively, leading to fluid accumulation in the lungs, extremities, and body tissues. Fluid restriction is a standard management strategy for heart failure to prevent further fluid overload, reduce the workload on the heart, and minimize symptoms such as pulmonary edema and peripheral edema. Restricting fluid intake helps the body maintain a more balanced fluid state when the heart cannot adequately manage excess volume.
Why the other options are incorrect:
B. Adrenal insufficiency results in deficiency of cortisol and aldosterone, leading to fluid loss and low blood pressure. These clients typically require fluid replacement and corticosteroid therapy, not fluid restriction.
C. Diabetic ketoacidosis causes severe dehydration due to osmotic diuresis from hyperglycemia. Treatment requires aggressive fluid resuscitation with intravenous fluids, making fluid restriction contraindicated in this condition.
D. Abdominal ascites involves fluid accumulation in the peritoneal cavity, commonly due to liver cirrhosis. While sodium restriction is often prescribed, fluid restriction is not universally the first-line prescription and is less specific compared to the clear fluid restriction indication seen in heart failure.
Correct Answer: (A) A client who has heart failure.
Heart failure results in the heart's inability to pump blood effectively, leading to fluid accumulation in the lungs, extremities, and body tissues. Fluid restriction is a standard management strategy for heart failure to prevent further fluid overload, reduce the workload on the heart, and minimize symptoms such as pulmonary edema and peripheral edema. Restricting fluid intake helps the body maintain a more balanced fluid state when the heart cannot adequately manage excess volume.
Why the other options are incorrect:
B. Adrenal insufficiency results in deficiency of cortisol and aldosterone, leading to fluid loss and low blood pressure. These clients typically require fluid replacement and corticosteroid therapy, not fluid restriction.
C. Diabetic ketoacidosis causes severe dehydration due to osmotic diuresis from hyperglycemia. Treatment requires aggressive fluid resuscitation with intravenous fluids, making fluid restriction contraindicated in this condition.
D. Abdominal ascites involves fluid accumulation in the peritoneal cavity, commonly due to liver cirrhosis. While sodium restriction is often prescribed, fluid restriction is not universally the first-line prescription and is less specific compared to the clear fluid restriction indication seen in heart failure.
4. A community health nurse is providing education on child safety. Who does the nurse identify as the highest risk for choking and suffocation?
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A 3-year-old eating cheerios for a snack
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A toddler playing with his older brother's wooden blocks
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A 4-year-old drinking a glass of milk
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An infant sleeping in the prone position
Explanation
Explanation
Correct Answer: (D) An infant sleeping in the prone position
Infants sleeping in the prone, or face-down, position are at the highest risk for suffocation. This position is the leading risk factor for Sudden Infant Death Syndrome (SIDS) because infants lack the neck strength and motor control to reposition themselves if their airway becomes obstructed by the mattress or bedding. The safe sleep guideline universally recommended is to always place infants on their backs to sleep on a firm, flat surface.
Why Other Options are Incorrect:
A. A 3-year-old eating cheerios carries some choking risk, but cheerios are small, lightweight, and dissolve easily, making them one of the safer snack options for young children. The risk is significantly lower compared to an infant in the prone position.
B. A toddler playing with wooden blocks poses a risk only if the blocks are small enough to be swallowed. Standard wooden blocks are typically too large to be a choking hazard, though supervision is always recommended.
C. A 4-year-old drinking milk presents minimal choking or suffocation risk under normal circumstances. Liquid aspiration is possible but far less immediately life-threatening than an infant sleeping face-down.
Correct Answer: (D) An infant sleeping in the prone position
Infants sleeping in the prone, or face-down, position are at the highest risk for suffocation. This position is the leading risk factor for Sudden Infant Death Syndrome (SIDS) because infants lack the neck strength and motor control to reposition themselves if their airway becomes obstructed by the mattress or bedding. The safe sleep guideline universally recommended is to always place infants on their backs to sleep on a firm, flat surface.
Why Other Options are Incorrect:
A. A 3-year-old eating cheerios carries some choking risk, but cheerios are small, lightweight, and dissolve easily, making them one of the safer snack options for young children. The risk is significantly lower compared to an infant in the prone position.
B. A toddler playing with wooden blocks poses a risk only if the blocks are small enough to be swallowed. Standard wooden blocks are typically too large to be a choking hazard, though supervision is always recommended.
C. A 4-year-old drinking milk presents minimal choking or suffocation risk under normal circumstances. Liquid aspiration is possible but far less immediately life-threatening than an infant sleeping face-down.
5. It is 2 pm and a patient who is 2-days postoperative reports to the nurse, "I do not want to get out of bed because I have pain from the surgery. I will walk tomorrow with a new nurse." Which intervention from the nurse is most appropriate?
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Educate the patient on the importance of early ambulation to prevent surgical complications
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Per the patient's request, ask the nurse assigned for tomorrow's shift to ambulate with the patient
-
Encourage the patient to ambulate today and administer pain medication after ambulation
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Reassure the patient that pain is normal and document "Patient refuses, will try again in 48 hours"
Explanation
Explanation
Early postoperative ambulation is a critical component of surgical recovery that prevents serious complications including deep vein thrombosis, pulmonary embolism, atelectasis, pneumonia, and ileus. The nurse's priority is to educate the patient about why ambulation is essential so the patient can make an informed decision. Addressing the patient's knowledge deficit regarding the importance of early mobility is the most therapeutic and appropriate first intervention when a patient is refusing ambulation due to pain concerns.
Why the other options are incorrect:
B. Deferring ambulation to the next shift nurse respects the patient's request but delays a medically necessary intervention. At two days postoperative, ambulation should not be postponed, as the risks of immobility accumulate rapidly.
C. Encouraging ambulation and then administering pain medication after is incorrect in sequencing. Pain medication should ideally be given before ambulation so that the patient can tolerate and participate in the activity more effectively, not after the exertion is already complete.
D. Reassuring the patient that pain is normal and documenting a 48-hour delay is inappropriate and potentially harmful. Waiting 48 hours to attempt ambulation again significantly increases the patient's risk of preventable postoperative complications and does not reflect adequate nursing advocacy or standard of care.
Early postoperative ambulation is a critical component of surgical recovery that prevents serious complications including deep vein thrombosis, pulmonary embolism, atelectasis, pneumonia, and ileus. The nurse's priority is to educate the patient about why ambulation is essential so the patient can make an informed decision. Addressing the patient's knowledge deficit regarding the importance of early mobility is the most therapeutic and appropriate first intervention when a patient is refusing ambulation due to pain concerns.
Why the other options are incorrect:
B. Deferring ambulation to the next shift nurse respects the patient's request but delays a medically necessary intervention. At two days postoperative, ambulation should not be postponed, as the risks of immobility accumulate rapidly.
C. Encouraging ambulation and then administering pain medication after is incorrect in sequencing. Pain medication should ideally be given before ambulation so that the patient can tolerate and participate in the activity more effectively, not after the exertion is already complete.
D. Reassuring the patient that pain is normal and documenting a 48-hour delay is inappropriate and potentially harmful. Waiting 48 hours to attempt ambulation again significantly increases the patient's risk of preventable postoperative complications and does not reflect adequate nursing advocacy or standard of care.
6. A nurse is caring for a post-operative patient receiving opioid pain medication through a PCA pump. The patient has been out of bed once per shift since surgery and has been able to eat and drink. In the past 24 hours, they have had 350 mL of fluid intake. Match each assessment finding below with the likely clinical cause(s).
Assessment Finding — Side Effect of Opioids / Poor Fluid Intake / Immobility
Decreased peristalsis → Side Effect of Opioids / Immobility Constipation → Side Effect of Opioids Urine Output of 200 ml in 24 hours → (none checked)
- Decreased peristalsis → Side Effect of Opioids / Immobility
- Constipation → Side Effect of Opioids
- Urine Output of 200 ml in 24 hours → Poor Fluid Intake
Explanation
Explanation
Correct Answers:
Decreased peristalsis → Side Effect of Opioids and Immobility
Constipation → Side Effect of Opioids
Urine Output of 200 mL in 24 hours → Poor Fluid Intake
Opioids bind to receptors in the gastrointestinal tract and slow bowel motility, directly causing decreased peristalsis and constipation. Immobility also contributes to decreased peristalsis because physical movement stimulates bowel activity. A urine output of 200 mL in 24 hours is significantly below the normal minimum of 30 mL per hour or approximately 720 mL per day, indicating poor fluid intake of only 350 mL as the most likely cause of this reduced urinary output.
Correct Answers:
Decreased peristalsis → Side Effect of Opioids and Immobility
Constipation → Side Effect of Opioids
Urine Output of 200 mL in 24 hours → Poor Fluid Intake
Opioids bind to receptors in the gastrointestinal tract and slow bowel motility, directly causing decreased peristalsis and constipation. Immobility also contributes to decreased peristalsis because physical movement stimulates bowel activity. A urine output of 200 mL in 24 hours is significantly below the normal minimum of 30 mL per hour or approximately 720 mL per day, indicating poor fluid intake of only 350 mL as the most likely cause of this reduced urinary output.
7. A nurse is caring for an older adult who is having trouble getting to sleep at night and formulates the nursing diagnosis Disturbed sleep pattern: Initiation of sleep. Which nursing interventions would the nurse perform related to this diagnosis? Select All That Apply
-
Assess medication for side effects of sleep pattern disturbances.
-
Arrange for assessment for depression and treatment.
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Discourage napping during the day.
-
Administer diuretics in the morning.
-
Encourage patient to engage in some type of physical activity during the day.
-
Decrease fluids during the evening.
Explanation
Explanation
Correct Answer: (A, B, C, D, E, F) — All options are correct
All listed interventions are appropriate nursing actions for a patient with disturbed sleep pattern related to initiation of sleep. Certain medications can interfere with sleep, so assessing for side effects is essential. Depression is a common cause of sleep disturbances in older adults and warrants evaluation. Daytime napping reduces sleep drive at night. Administering diuretics in the morning prevents nighttime urination that disrupts sleep. Physical activity during the day promotes better sleep onset at night. Reducing fluid intake in the evening decreases the likelihood of nocturia, which commonly interrupts sleep in older adults.
Why the other options are incorrect:
There are no incorrect options in this question as all interventions A through F are evidence-based nursing actions appropriate for managing disturbed sleep pattern in an older adult.
Correct Answer: (A, B, C, D, E, F) — All options are correct
All listed interventions are appropriate nursing actions for a patient with disturbed sleep pattern related to initiation of sleep. Certain medications can interfere with sleep, so assessing for side effects is essential. Depression is a common cause of sleep disturbances in older adults and warrants evaluation. Daytime napping reduces sleep drive at night. Administering diuretics in the morning prevents nighttime urination that disrupts sleep. Physical activity during the day promotes better sleep onset at night. Reducing fluid intake in the evening decreases the likelihood of nocturia, which commonly interrupts sleep in older adults.
Why the other options are incorrect:
There are no incorrect options in this question as all interventions A through F are evidence-based nursing actions appropriate for managing disturbed sleep pattern in an older adult.
8. A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. For what type of surgery would the nurse prepare this patient?
-
Major, palliative
-
Minor, diagnostic
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Major, emergency
-
Minor, elective
Explanation
Explanation
Correct Answer: (C) Major, emergency
A ruptured spleen resulting from trauma is a life-threatening condition requiring immediate surgical intervention. This classifies the surgery as an emergency because it must be performed without delay to preserve the patient's life. It is also classified as major surgery because it involves a vital abdominal organ, carries significant risk, and requires general anesthesia with an extended recovery period.
Why the other options are incorrect:
A. Palliative surgery aims to relieve symptoms and improve comfort rather than treat or cure a condition. A ruptured spleen requires curative intervention, not palliation.
B. Minor diagnostic surgery involves low risk and is typically performed to obtain tissue samples or visualize structures. A ruptured spleen surgery is neither minor nor diagnostic in nature.
D. Elective surgery is planned and scheduled in advance at the convenience of the patient and surgeon. A traumatic rupture of the spleen is an acute emergency and cannot be delayed or scheduled electively.
Correct Answer: (C) Major, emergency
A ruptured spleen resulting from trauma is a life-threatening condition requiring immediate surgical intervention. This classifies the surgery as an emergency because it must be performed without delay to preserve the patient's life. It is also classified as major surgery because it involves a vital abdominal organ, carries significant risk, and requires general anesthesia with an extended recovery period.
Why the other options are incorrect:
A. Palliative surgery aims to relieve symptoms and improve comfort rather than treat or cure a condition. A ruptured spleen requires curative intervention, not palliation.
B. Minor diagnostic surgery involves low risk and is typically performed to obtain tissue samples or visualize structures. A ruptured spleen surgery is neither minor nor diagnostic in nature.
D. Elective surgery is planned and scheduled in advance at the convenience of the patient and surgeon. A traumatic rupture of the spleen is an acute emergency and cannot be delayed or scheduled electively.
9. Fill in the blank by selecting the best drop down response. The nurse assesses a patient and notices lower extremity edema and understands this fluid imbalance is caused by ___
Fluid shift from extracellular space to intracellular space
Fluid shift from intracellular to extracellular space
- Fluid shift from extracellular space to intracellular space
- Fluid shift from intracellular to extracellular space
Explanation
Explanation
Correct Answer: (1) Fluid shift from intracellular to extracellular space
Lower extremity edema occurs when excess fluid accumulates in the interstitial tissue, which is part of the extracellular space. This happens when fluid shifts out of the intracellular compartment or the intravascular space into the extracellular interstitial space, causing visible swelling. This fluid shift can result from decreased oncotic pressure, increased hydrostatic pressure, sodium retention, or increased capillary permeability, all of which allow fluid to accumulate outside the cells and blood vessels in the tissues.
Why the other options are incorrect:
Fluid shift from extracellular space to intracellular space would cause cells to swell internally but would not produce the visible tissue swelling and pitting edema observed in the lower extremities. Edema is by definition an abnormal accumulation of fluid in the extracellular interstitial space, not a movement of fluid into cells.
Correct Answer: (1) Fluid shift from intracellular to extracellular space
Lower extremity edema occurs when excess fluid accumulates in the interstitial tissue, which is part of the extracellular space. This happens when fluid shifts out of the intracellular compartment or the intravascular space into the extracellular interstitial space, causing visible swelling. This fluid shift can result from decreased oncotic pressure, increased hydrostatic pressure, sodium retention, or increased capillary permeability, all of which allow fluid to accumulate outside the cells and blood vessels in the tissues.
Why the other options are incorrect:
Fluid shift from extracellular space to intracellular space would cause cells to swell internally but would not produce the visible tissue swelling and pitting edema observed in the lower extremities. Edema is by definition an abnormal accumulation of fluid in the extracellular interstitial space, not a movement of fluid into cells.
10. The nurse caring for an immobile older adult patient suspects that the patient is being neglected at home due to several observations obtained during the ongoing assessment. What is the appropriate nursing action in this situation?
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Discuss the abuse with coworkers to determine what the next step should be.
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Immediately report the suspected abuse of the patient to the appropriate person.
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Inform the client's family that the patient is being neglected at home by someone.
-
Avoid reporting the abuse as it would be a privacy and confidentiality violation.
Explanation
Explanation
Correct Answer: (B) Immediately report the suspected abuse of the patient to the appropriate person.
Nurses are mandated reporters, meaning they are legally and ethically obligated to report any suspected abuse, neglect, or exploitation of vulnerable populations including older adults. Upon suspecting neglect, the nurse must immediately report to the appropriate authority such as the charge nurse, social worker, or Adult Protective Services. Prompt reporting ensures the patient's safety and initiates a proper investigation through the appropriate channels.
Why the other options are incorrect:
A. Discussing the suspected abuse with coworkers is inappropriate and unprofessional. It does not constitute a formal report and delays the necessary protective action for the patient.
C. Informing the family directly is not appropriate because the family members themselves may be the perpetrators of the neglect. Notifying them could compromise the investigation and place the patient at further risk.
D. Avoiding reporting abuse based on privacy and confidentiality concerns is incorrect and legally indefensible. Mandated reporting laws supersede general confidentiality obligations when patient safety is at risk.
Correct Answer: (B) Immediately report the suspected abuse of the patient to the appropriate person.
Nurses are mandated reporters, meaning they are legally and ethically obligated to report any suspected abuse, neglect, or exploitation of vulnerable populations including older adults. Upon suspecting neglect, the nurse must immediately report to the appropriate authority such as the charge nurse, social worker, or Adult Protective Services. Prompt reporting ensures the patient's safety and initiates a proper investigation through the appropriate channels.
Why the other options are incorrect:
A. Discussing the suspected abuse with coworkers is inappropriate and unprofessional. It does not constitute a formal report and delays the necessary protective action for the patient.
C. Informing the family directly is not appropriate because the family members themselves may be the perpetrators of the neglect. Notifying them could compromise the investigation and place the patient at further risk.
D. Avoiding reporting abuse based on privacy and confidentiality concerns is incorrect and legally indefensible. Mandated reporting laws supersede general confidentiality obligations when patient safety is at risk.
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