assessment 4 practice test

A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?

"Eating yogurt can help decrease the amount of gas that I have." The client who has a colostomy can include yogurt into his diet to help reduce odors and intestinal gas.

A nurse is teaching a client how to do fecal occult blood testing. Which of the following statements by the client indicates a need for further teaching?

"I will continue taking my Coumadin as prescribed." The client should discontinue anticoagulants for one week prior to this testing. This statement requires clarification.

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?c

"I will need to wipe my perineal area from back to front after urination." Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.

A nurse is teaching a client who has constipation. Which of the following statements should the nurse include?

"Increase your daily fluid intake." CORRECT The client should drink about 1,900 mL (64 oz) of fluid each day to soften stool and promote peristalsis.

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

"You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon.

A nurse is teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

"You will have a stoma in your left lower abdomen." CORRECT The stoma of a sigmoid colostomy is placed in the client's left lower abdomen.

A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

"You will have a stoma placed in your right lower abdomen." CORRECT An ileostomy stoma is placed in the right lower abdomen.

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)

"Your provider might prescribe anticholinergic medications" is correct. Anticholinergic medications suppress bladder contractions and increase bladder capacity. "You should limit fluids in the evening" is correct. Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. "You should restrict your intake of caffeine" is correct. The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant. "You might require intermittent urinary catheterization" is incorrect. Intermittent urinary catheterization is used as a treatment for reflex incontinence. "You might require an anterior vaginal repair" is incorrect. An anterior vaginal repair, or colporrhaphy, is a surgical procedure for the treatment of stress incontinence.

A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?

Apply a barrier cream to the client's skin. CORRECT My Answer The nurse should apply a protective barrier cream to clean, dry skin to reduce the risk for irritation and breakdown.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the client's skin. Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left Sims' position. MY ANSWER This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The nurse should also have the client's right leg flexed to facilitate insertion.

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Check the client's medical record for the provider's prescription. The nurse should use the client's medical record to verify the provider prescribed an enema for the client.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take?

Clean the client's skin with a pH-balanced cleanser. CORRECT The nurse should clean the client's skin with a pH-balanced cleanser to decrease the risk of skin breakdown.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first?

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation. According to evidence-based practice, the nurse should first cover the area with a sterile dressing moistened with normal saline to protect the client's internal organs. The nurse should not attempt to reinsert the client's organs or viscera.

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. The nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist, sterile gauze dressing. The client's wound has dehisced, or opened along the suture line, and is now draining. The primary clinical objective in managing a dehisced wound is to keep it clean and moist, and manage any exudate. The nurse's priority action therefore is to cover the wound with a moist, sterile, saline-soaked gauze dressing.

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?

Cystitis A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?

Decreased circulation CORRECT The client who is immobile is at risk for a pressure injury due to decreased circulation to tissues.

A nurse is assessing a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

Dehydration CORRECT A client who has diarrhea is at risk for dehydration due to fluid los

A nurse is planning care for a client who has urinary incontinence. The nurse should plan to monitor the client for which of the following findings?

Dermatitis CORRECT A client who has urinary incontinence is at risk for incontinence-associated dermatitis and impaired tissue integrity.

A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor?

Diabetes mellitus Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.

A nurse is caring for a client who has a new colostomy and states they are not ready to look at the stoma. The nurse encourages the client to share their feelings about the colostomy. Which of the following teaching strategies is the nurse utilizing?

Discussion CORRECT Discussion is an active teaching method using the expression of feelings and application of the material. It is based on the affective or the cognitive domain of learning.

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazardous waste container. The nurse should discard potentially infective material, such as a dressing that contains blood and pus, in a biohazardous materials container separate from the regular trash

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound?

Film dressing CORRECT Film dressings or self-adhesive transparent dressings are used to cover superficial wounds that have minimal exudate.

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?

Furrows in the tongue In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrow

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon MY ANSWER Poultry, fish, eggs, and beef are complete proteins and are optimal sources of protein to support wound healing.

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect?

Intact skin with localized erythema CORRECT Intact skin with localized erythema is a stage 1 pressure injury.

A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? (Select all that apply.)

MY ANSWER Kidney beans is correct. Kidney beans should be included in the teaching as a source of fiber. Blackberries is correct. Blackberries should be included in the teaching as a source of fiber. Refined cereals is incorrect. Whole grain cereals, not refined cereals, should be included in the teaching as a source of fiber. Whole wheat bread is correct. Whole wheat bread should be included in the teaching as a source of fiber. Lean turkey is incorrect. Lean turkey is a source of complete protein, but should not be included in the teaching as a source of fiber.

A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area?

Montgomery straps Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips.

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

Poor skin turgor is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as skin that lacks elasticity. Bradycardia is incorrect. Frequent vomiting and diarrhea cause dehydration, which manifests as tachycardia. Hypotension is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as postural hypotension. Pale yellow urine is incorrect. Frequent vomiting and diarrhea cause dehydration, which manifests as dark yellow, concentrated urine. Flat neck veins is correct. Frequent vomiting and diarrhea cause dehydration, which manifests as flat neck veins when the client is lying supine

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?c

Serosanguineous Watery red drainage should be documented as serosanguineous.

A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

Serosanguineous drainage at this time is a manifestation of possible dehiscence. MY ANSWER Serosanguineous drainage beyond the fifth postoperative day is a manifestation of possible dehiscence and the provider should be notified.

A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Slow the flow of enema solution briefly. MY ANSWER Slowing the enema solution flow temporarily prevents cramping.

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention MY ANSWER Until the bladder regains its full tone, it is common for clients to develop urinary retention. If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.

A nurse is assessing a client who has a colostomy. Which of the following findings should the nurse report to the provider?

The stoma is pale in color. The stoma should be pinkish to cherry red in color, which indicates an adequate blood supply. If the stoma becomes pale, bluish, or dark, the nurse should report this finding to the provider immediately.

A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply?

Transparent dressing A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.

A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client's dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take?c

Verify the LPN knows how to do a dressing change. The charge nurse should attempt to see the delegated task from the perspective of the individual being delegated to. This approach clarifies the reason for lack of action by the LPN.

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching? (Select all that apply.)

Vitamin A is correct. Vitamin A is important for tissue synthesis, wound healing, and immune function. Vitamin B12 is correct. Vitamin B12 assists in the development of red blood cells, maintenance of nerve function, and is needed for cell maintenance and tissue synthesis. Vitamin C is correct. Vitamin C is important for capillary formation, tissue synthesis, and wound healing. Vitamin D is incorrect. Vitamin D functions in maintaining serum levels of calcium and phosphorus, but has no specific role in wound healing. Vitamin K is correct. Vitamin K functions as an enzyme in the synthesis of prothrombin and other proteins required for normal blood clotting.

A nurse is teaching a newly licensed nurse about obtaining a fecal occult blood test from a client. Which of the following information should the nurse include?

Wait 30 seconds after applying the developing solution to obtain the results. CORRECT The nurse should wait 30 to 60 seconds after applying the developing solution before reading the test to obtain an accurate reading.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury?

A client who is unresponsive to verbal commands and changes position occasionally. CORRECT This client is at greatest risk for a pressure injury because they have a very limited sensory perception. The nurse should monitor the client for a pressure injury.

A nurse is providing discharge teaching to a client who will be performing intermittent self-catheterization. Which of the following instructions should the nurse include?

Advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow. The nurse should instruct the client to advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow to make sure that it is completely in the bladder.

A nurse is teaching a newly licensed nurse about adverse effects of medications. The nurse should include that which of the following medications can cause diarrhea?

Aluminum-containing antacids is incorrect. Aluminum-containing antacids can cause constipation. Magnesium-containing antacids is correct. Magnesium-containing antacids can cause diarrhea due to retention of water in the intestine. Antibiotics is correct. Antibiotics can increase gastric motility and cause diarrhea. Anticholinergics/antispasmodics is incorrect. Anticholinergics/antispasmodics can cause constipation due to decreased gastric motility. Opioid narcotics is incorrect. Opioid narcotics can cause constipation due to decreased gastric motility.

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted?

Bear down. Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Bladder infection The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?

Confusion Confusion is a clinical finding of UTIs specifically associated with older adult clients.

A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

Dark-colored urine CORRECT My Answer Dark-colored urine indicates concentrated urine and is a manifestation of dehydration.

A nurse is caring for a client who has constipation and is bearing down to have a bowel movement. The nurse should monitor the client for which of the following?

Decreased heart rate CORRECT Bearing down and straining to have a bowel movement can stimulate the vagus nerve and the parasympathetic nervous system and cause bradycardia and hypotension

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?

Don sterile gloves before inserting the indwelling urinary catheter. CORRECT The nurse should don sterile gloves before inserting the indwelling urinary catheter to maintain medical asepsis.

A nurse is planning care for a client who has an infected wound with significant exudate. The nurse should plan to use which of the following dressings to cover the wound?

Hydrofiber dressing CORRECT Hydrofiber dressings are used for moderate and highly exudative wounds. Hydrofiber dressings provide high absorbency and can stay in the wound for several days.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables. The client should increase dietary intake of raw vegetables to help provide fiber in the diet, which will increase stool bulk and move the stool through the colon to prevent constipation.

A nurse in an emergency department is caring for a client who has abdominal pain. Nurses' Notes 0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk." 0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily. 0915: Fecal mass of hard, dry stool removed digitally from client per provider's order. 1015: Provided teaching to client and partner about constipation and methods to avoid further impaction.

Increase fluid intake to 1500 mL daily is correct. Drinking at least 1500 mL of fluid daily will help to soften the stool. Include probiotic foods in the daily diet is correct. Probiotic foods, such as yogurt, contain live bacterial cultures that aid in digestion by promoting regularity in bowel elimination. Increase intake of low fiber foods is incorrect. The nurse should instruct the client to increase the intake of high fiber foods, such whole-grain breads and cereals, fruits, and vegetables because these foods give bulk to stools and help promote passage through the digestive tract. Increase daily exercise is correct. Lack of exercise decreases the muscle tone of the lower digestive tract. Even minimal exercise can increase peristalsis. Avoid drinking hot liquids is incorrect. Drinking hot liquids can stimulate peristalsis and promote bowel elimination..

A nurse is caring for a client who is on bedrest and is experiencing constipation. Which of the following interventions should the nurse implement?

Increase the client's fluid intake. CORRECT The nurse should increase the client's fluid intake to soften s

A nurse is preparing to teach a group of newly licensed nurses about the first phase of wound healing. Which of the following processes should the nurse plan to discuss?c

Inflammation CORRECT Inflammation is the process that occurs during the first phase of wound healing which is also known as the inflammatory or hemostatic phase. During this phase, blood vessels constrict and clotting factors are activated.

A nurse is assessing a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia?

Muscle weakness CORRECT Hypokalemia can cause muscle weakness, hypotension, and dysrhythmias.

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Necrotic subcutaneous tissue Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with necrotic subcutaneous tissue.

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority?

Notify the surgeon. Purulent draining is a manifestation of infection and should be reported to the surgeon immediately.

An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

Obtain vital signs. MY ANSWER Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP.

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

Partial-thickness skin loss with red tissue in wound bed. CORRECT Partial-thickness skin loss with red or pink viable tissue in wound bed is a stage 2 pressure injury.

A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?

Pasta Pasta may thicken stool and is an appropriate food choice for a client with a colostomy.

A nurse is caring for a client. Nurses' Notes Medical History Diagnostic Results Nurses' Notes Day 1: 1300: Client has a 2.5 cm (1 in) x 2.5 cm (1 in) stage 2 pressure injury to dorsal lateral aspect of left heal; wound bed red, moist, approximated edges; surrounding skin inflamed, red,, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. Pedal pulse left foot 1+, unable to assess capillary refill due to toe fungus bilaterally; Pedal pulse right foot 2+. Wound care as prescribed; heel floated on pillow. Day 2: 0845: Assisted client to bathroom and return to bed. Instructed client on floating heel while in bed. Verbalized understanding. Day 4: Client has a 3 cm (1.2 in) x 3 cm (1.2 in) stage 2 pressure injury on left heal Small amount of purulent drainage noted; wound bed pink, moist, surrounding skin and wound borders inflamed, red, non-tender to palpation. Client reports pain score of 0 on 0 to 10 pain scale. heel floated on pillow.

Potassium level is incorrect. The client's potassium level is within the expected reference range. Prealbumin level is correct. The client's prealbumin level is below the expected reference range which indicates malnutrition. Adequate nutrition is required to promote wound healing. Therefore, this finding places the client at risk for delayed wound healing. History of diabetes mellitus is correct. Diabetes mellitus can cause decreased circulation and impaired tissue perfusion. Therefore, this finding places the client at risk for delayed wound healing. History of hyperlipidemia is incorrect. Hyperlipidemia places the client at risk for cardiovascular disease, rather than delayed wound healing. Wound infection is correct. Purulent wound drainage and an elevated WBC count are manifestations of a wound infection. A wound infection can cause delayed wound healing. Decreased pedal perfusion is correct. The diminished pedal pulse in the left foot, self-reported zero pain, and decreased sensation when palpated indicate there is poor perfusion. The decreased circulation of blood and nutrients will place the client at risk for delayed wound healing. Fasting blood glucose is correct. Prolonged elevated blood glucose levels will cause the diabetes mellitus, type 1 to progress, placing the client at even a greater risk.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?c

Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Purplish-colored stoma MY ANSWER A stoma that is purplish in color indicates ischemia. The nurse should notify the provider immediately.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (Select all that apply).

Relief of urinary retention is correct. Valid indications for urinary catheterization include urinary retention, bladder distention, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery. Convenience for the nursing staff or the client's family is incorrect. Performing an invasive procedure for convenience is unacceptable. Valid indications for urinary catheterization include management of urinary elimination for clients who have spinal cord injuries and prevention of urethral obstruction from blood clots following genitourinary surgery. Measurement of residual urine after urination is correct. Valid indications for urinary catheterization include measurement of residual urine after urination, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery. Routine acquisition of a urine specimen is incorrect. The nurse can obtain routine urine specimens by noninvasive methods. Valid indications for urinary catheterization include urinary retention, bladder distention, and prevention of urethral obstruction from blood clots following genitourinary surgery. An open perineal wound is correct. Valid indications for urinary catheterization include preventing irritation of wounds and rashes from urine, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery

A nurse is teaching a client who has a new colostomy. Which of the following outcomes should the nurse expect?

Report of empowerment CORRECT Education about the colostomy should provide the client with feelings of empowerment and assist the client in taking control of their care.

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Reposition the client at least every 2 hr. The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

A nurse is preparing a teaching plan for a client who has chronic constipation secondary to irregular bowel habits. Which of the following should the nurse plan to include in the teaching?

The client should follow a high-fiber diet to establish bowel regularity. MY ANSWER The client who has chronic constipation should consume a diet with high-fiber food sources, including bran and complex carbohydrates.

A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse plan to take?

Warm the enema solution to room temperature. CORRECT The nurse should plan to warm the enema solution to room temperature to promote comfort for the client and reduce the risk of abdominal cramping.

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

Weak, irregular pulse MY ANSWER Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

Withdraw 3 to 5 mL of urine from the port. MY ANSWER The nurse should withdraw the required amount of urine which would be approximately 3 to 5mL for a urine culture or 30 mL for a routine urinalysis.