You enter the room to start the IV infusion and insert the Foley catheter and find that the
nursing assistive personnel (NAP) has taken M.Z. to the bathroom for a bowel movement.
M.Z. asks you to help her, and, as you open the door, you observe her wiping herself from
back to front. What do you need to do at this time?
M.Z.'s UTI is probably a result of bacterial contamination of the urinary tract, which can result from
improper perineal hygiene, such as wiping from back to front. This can bring fecal organisms, such as
Escherichia coli, from the anus toward the vagina and urethra. This is a teachable moment where you
can teach M.Z. to wipe correctly, from front to back, so that bacteria from the bowel are not dragged
near the urethra.
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When the client eats lunch, serum glucose levels rise. As the pancreas releases insulin to push glucose into the cell, serum glucose levels decline. Normal serum glucose levels signal the pancreas to stop secreting insulin
The nurse describes this process as: 1. Positive feedback. 2. Homeostasis. 3. Negative feedback. 4. Diabetes mellitus.
A patient with conductive hearing loss due to otosclerosis undergoes a stapedectomy with insertion of a prosthesis. Which of the following information is most crucial to include in the patient's preoperative teaching?
A) 35% of patients will not experience restoration of hearing. B) Noticeable improvement in hearing may not be experienced for up to 6 weeks after surgery. C) The nurse must assist the patient to get out of bed on the first postoperative day. D) Close-captioned TV programs are available at the hospital to meet the needs of hearing-impaired patients.
During an assessment of the cranial nerves, a patient tells the nurse of not being able to taste sweet or salty foods. The nurse should focus additional assessment on which cranial nerve?
A) I B) V C) VII D) XII
When conducting a mental status assessment, what will the nurse assess?
1. Cognitive and affective functions 2. Cognitive and effective functions 3. Affective and memory functions 4. Affective and knowledge functions