QUESTIONS

Question 1

Using your knowledge of the urinary tract, infection, and inflammation along with textbook and library resources, match the assessment findings below to the type of urinary tract information (UTI) with which it is associated.

NOTE: Assessment findings may be associated with more than one type of UTI.

Dysuria

Urgency

Flank pain

Malaise

Frequency

Suprapubic tenderness

Gross hematuria

Fever

Nocturia

Costovertebral tenderness

Question 2

Although anyone who experiences ___________ is at risk for ____________ individuals most at risk include those ___________ and those ____________.

Question 3

Order the list of actions in which the nurse will complete them for a newly admitted client, with the first action at the top.

Verify client identity
Introduce self
Complete admission assessment
Assess current level of comfort
Administer prescribed antibiotics
Obtain prescribed blood and urine cultures

Question 4

What evidence is present in Maggie’s admission assessment to support a nursing diagnosis related to infection? Select the assessment data, or cues, that contribute to the Related to Statement and Defining Characteristics by clicking on them. Remember “P.E.S” as the data is reviewed and selected. Click the History & Physical and Nurse’s Notes tabs to complete this activity.

Maggie (preferred name) is a 43-year-old woman who appears unwell and uncomfortable admitted with upper urinary tract infection, on exam her mucous membranes are dry: suprapubic tenderness is present that increases with light palpation, severe right frank pain increases with percussion of the right costovertebral area: IV of NS infusing at 125 Ml/hr via #18 cath inserted into the R basilic vein 2 inches above the antecubital area: dressing dry and intact, skin around dressing warm with no swelling or erythema. K. Carson, RN.

Question 5

After completing the admission assessment, the nurse identifies and clusters cues, forms a hypothesis concerning Maggie’s priority care needs, and selects a nursing diagnosis. Using a nursing diagnosis textbook, select the most appropriate diagnosis label and defining characteristics, based on Maggie’s information by selecting the correct words/phrases to complete the Nursing Diagnosis below.

Risk for complications of _______________ related to_______________ as evidenced by ______________, chills, nausea, and costovertebral tenderness. K. Carison, RN.

Question 6

Based on the nursing diagnosis and information in Maggie’s EHR, select four most appropriate goals of care and drag them to the Expected Outcomes on the Plan of Care (POC).

Question 7

Sort potential interventions for Maggie’s care according to priority (high, medium, low, or contraindicated) and necessity (essential or non-essential). Drag all essential interventions into the correct category (high, medium, or low). Not all interventions (those that are non-essential or contraindicated) will be sorted into a category.

Question 8

While viewing Maggie’s plan of care the first night of her admission, the nurse taking over her case adds which high priority, essential intervention?

Strict bed rest
Monitor white blood cells (WBCs)
Contact isolation
Nothing by mouth (NPO)

Question 9

Maggie has been in the hospital for two days and is starting to feel better. Her urine and blood cultures both revealed E. Coli infection and antibiotics were started. Based on the documentation in Maggie’s HER, the nurse notes that which is expected outcomes have been met? Select all that apply. Click the Nurses’ Notes tab to complete this activity.

Question 10

Based on the documented improvement in Maggie’s state of health, which interventions can be decreased in frequency? Select all that apply?

Monitor hourly urine output
Measure vital signs g 4 hours
Monitor serum electrolytes
Monitor blood glucose g 4 hours
Daily weights
Continuous pulse oximetry monitoring
Strict intake and output (I/O)
Routine oral care
Inspect skin frequently
Reposition g 2 hours
Encourage hourly use of negative spirometer

Question 11

On the fifth day after admission to the hospital, Maggie is stable and ready for discharge to home. She will be discharged with peripherally inserted catheter (PICC) line to complete the final nine days of her intravenous (IV) antibiotic therapy. Maggie does not have a health care background and has not taken care of a PICC line or self-administered IV fluids in the past, but expressed that she and her partner are willing and able to learn what needs to be done so she can go home safely. Based on this information, and using a nursing diagnosis text, select the most appropriate nursing diagnosis to prepare Maggie for discharge. Select all that apply.

Readiness for enhanced health management
Ineffective health maintenance
Risk of infection
Readiness for enhanced resistance

Question 12

Using the drop-down menus on the Nurses’ Notes tab to complete the defining characteristics and related to statement for Maggie’s nursing diagnosis statement.

Readiness for enhanced health management related to _____________ as evidenced by ________________ and ________________.

Question 13

Since both Maggie and her partner have expressed interest in learning about caring for her PICC and IV medications at home the following goals are mutually set. Indicate the importance of meeting these outcomes for each person by dragging their pictures to the correct column (Essential, Desirable, or Needed) for each outcome.

Demonstrate correct dressing change technique

Demonstrate steps to prepare IVPB medication

Demonstrate correct technique to connect and disconnect IVPB

Demonstrate correct technique to adjust flow rate of IVPB

Verbalize ways to protect PICC site during activities of daily living

Identify three signs of adverse events to PICC and IV medication administration

Question 14

Which topics will the nursing include when teaching Maggie and her partner related to ways to protect the PICC site and signs of adverse events? Select all that apply.

Steps to clear a blocked PICC line
Avoid strenuous activity using the arm with the PICC
How to secure the insertion with a compression bandage
Do not allow animals in the same room while the medication is infusing
Signs of an occluded PICC line
Wear clothing that loosely covers the insertion site
Signs of local infection at the insertion site
Change the PICC dressing if it becomes soiled
Safe disposal of needles
Wash hands prior to connecting or disconnecting the IV tubing

Question 15

Drag the selected interventions to the category into which it fits: information on how to protect the PICC line or how to recognize an adverse effect during treatment.

Question 16

The nurse determines that further education is needed after hearing Maggie make which statements? Select all that apply?

“I will close the door to the bathroom while changing my dressing to keep my nosy cat out of the way.”
“I am so happy I do not need to do anything special to this IV when I take a bath at home.”
“I will wear shirts with loose sleeves until after the PICC is removed.”
“If I notice that the antibiotic is not infusing, I will call the home infusion nurse.”
“If the IV comes out at night, I can wait until morning to call the home infusion nurse.”

ANSWERS