NCLEX questions #5 FOUNDATIONS URINARY

For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to the client? Select all that apply a. Grilled tilapia with a fresh green side salad b. Chinese chicken and vegetables, with rice and soy sauce c. Chicken salad stuffed fresh tomato with a side of celery sticks d. Grilled hot dog on a bun with ketchup and mustard e. Bacon, egg, and cheese biscuit f. Strawberry, spinach salad with yogurt-based blue cheese dressing

b. Grilled hot dog on a bun with ketchup and mustard d. Bacon, egg, and cheese biscuit e. Chinese chicken and vegetables, with rice and soy sauce Response Feedback: The client is hyponatremic and additional salt is needed in the diet. Fresh fruits and vegetables are low in sodium. Bacon, soy, and hot dogs with ketchup and mustard are high in sodium.

A client in a long-term care facility reports to the nurse, "I have not had a bowel movement in 2 days." What is the nurse's first action? a. Instruct the caregiver to increase the client's fluid to five 8-ounce glasses per day b. Notify the health care provider and request a prescription for a large-volume enema c. Assess the client's medical record to determine the client's normal bowel pattern d. Instruct the caregiver to offer a glass of warm prune juice at mealtimes

Assess the client's medical record to determine the client's normal bowel pattern Response Feedback: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Options A, B, or D may then be implemented, if warranted.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? a. Notify the health care provider of a possible obstruction b. Clamp the catheter and recheck it in 60 minutes c. Leave the catheter in place and reattempt with another catheter d. Pull the catheter back 3 inches and redirect upward

Leave the catheter in place and reattempt with another catheter Response Feedback: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted.

When emptying 350 mL of pale-yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? a. Palpate the client's bladder for distention b. Record the amount on the client's fluid output record c. Notify the health care provider of the findings d. Encourage the client to increase oral fluid intake

Record the amount on the client's fluid output record Response Feedback: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed.

What is the most common cause of adverse drug reactions in older adults? a. Decreased hepatic metabolism b. Increased gastrointestinal (GI) absorption c. Reduced renal excretion d. Decreased serum albumin levels

Reduced renal excretion Response Feedback: Rationale:When renal excretion of a drug is decreased, it will accumulate. Reduced renal excretion is a common physiological change seen in the older adult population. The presence of multiple pathologic conditions, one of which can be hepatic impairment, also predisposes older clients to adverse drug reactions. Low serum albumin levels can cause decreased protein binding of drugs, which causes drug levels to rise. Older adults have a decline in GI motility and reduced absorption.

The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the highest priority? a. Assist the client with daily cleansing b. Tell the client that incontinence happens with aging c. Offer 200 ml of fluid every 2 hours while awake d. Take the client's temperature every 4 hours

Take the client's temperature every 4 hours Response Feedback: Indwelling urinary catheters are a major source of infection. Option A is a problem that may develop from having an indwelling catheter. Option B may or may not be true for the client. Option C is not affected by an indwelling catheter.

A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? a. "Orange juice has vitamin C that deters bacterial growth" b. Grapefruit juice increases absorption of most antibiotics" c. "Cranberry juice stops pathogens' adherence to the bladder" d. "Apple juice is the most useful in acidifying the urine"

"Cranberry juice stops pathogens' adherence to the bladder" Response Feedback: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? a. "Smoking cessation as a lifelong commitment" b. "Decreasing cholesterol levels through diet" c. "Stress management for a healthier you" d. "Monitoring your blood pressure at home"

"Decreasing cholesterol levels through diet" Response Feedback: A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol.

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? a. "I should tell the nurse if cramping occurs during the instillation of the fluid" b. "I should try and hold the fluid as long as possible after it is instilled" c. "The enema will be given while I am sitting on the toilet" d. "I know that there will be some cramping after the enema administration"

"The enema will be given while I am sitting on the toilet" Response Feedback: Rationale: The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying (Sims') position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible since this will promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping.

The nurse is changing a dressing on a surgical wound that is healing by secondary intention. The wound is very red around the edges, and red granulation tissue can be found within the wound cavity. The nurse also notes minimal serosanguineous drainage. What type of dressing would promote most effective healing of this wound? a. A dry, absorbent dressing coated with a debridement enzyme should be used to pack inside the wound b. A moisture retention dressing should be placed inside the wound and the area should be covered with a sterile dressing c. The wound should be packed with a dry, absorbent dressing and covered with a clear plastic film dressing d. A dry gauze dressing should be placed on the inside of the wound and covered with an absorbent dressing

A moisture retention dressing should be placed inside the wound and the area should be covered with a sterile dressing Rationale:Wounds that are open and healing by secondary intention (from the inside out) have very fragile granulation tissue that needs to be protected by a moist dressing that will not adhere to the tissue and damage it. If a dry dressing comes in contact with granulation tissue, it will adhere to the tissue, and when the dressing is removed, the new tissue is damaged. A debridement enzyme is used for wounds that are infected or have necrotic tissue that needs to be removed.

During shift report, the nurse is told that an assigned client has a wound that is healing by secondary intention. What would the nurse expect to find on the assessment of the wound? a. An open wound in which granulation tissue is occurring from the edges toward the center b. A surgical wound with acute inflammation around the edges of the incision c. A surgical wound that has a moderate amount of serous exudate and inflammation d. A wound that was sutured after the infection was resolved and granulation began

An open wound in which granulation tissue is occurring from the edges toward the center Rationale: Secondary intention is when the wound is healing from the edges toward the center and from the center or bottom of the wound upward. The healing occurs when an incision become infected, is opened, and is allowed to heal by formation of granulation. Primary healing occurs with clean wounds. Inflammation and some serous exudate is a normal process of healing. Tertiary healing occurs when a previously infected wound is closed after the infection is resolved.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? a. Pork chops, macaroni and cheese, and grapes b. Avocado salad, milk, and angel food cake c. Broiled fish, green beans, and an apple d. Steak, baked beans, and a salad

Broiled fish, green beans, and an apple Response Feedback: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.

The nurse is performing a dressing change on a client with an abdominal wound with a Penrose drain. What essential information will the nurse document? a. Type of dressing used, description of wound, presence of drains with character of drainage b. Status of wound healing, amount of drainage, and how the client tolerated the procedure c. Description of the wound, presence of drains and character of drainage, time and date of dressing change d. Character of drainage, client's tolerance of procedure, type of dressing used

Description of the wound, presence of drains and character of drainage, time and date of dressing change Rationale:The status of the wound, characteristics of the drainage, and time and date of dressing change are the most critical data to record. Type of dressing used is not necessary. How well the client tolerated the procedure may be charted if the client had an untoward response, but other information is more critical.

A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? a. Low-fiber diet b. Low-sodium diet c. High-fiber diet d. Full liquid diet

High-fiber diet Rationale: Constipation is the probable cause of the client's lack of bowel movements. Constipation is the difficult or infrequent passage of stools, which are hard and dry. Constipation has numerous causative factors, including psychogenic, lack of physical activity, inadequate intake of food and fiber, and medication influences. A high-fiber diet often is indicated for constipation because it will promote bulk and encourage intestinal peristalsis. A full liquid diet will add fluids but no bulk to help relieve the constipation. A low-fiber diet has little bulk to assist with the needed peristalsis. Decreasing the amount of sodium in the diet has little, if any, effect on constipation.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? a. High cholesterol level b. Low serum transferrin level c. High hemoglobin level d. Low serum albumin level

Low serum albumin level Response Feedback: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

The nurse is assessing a client who has been immobilized because of a stroke (brain accident) and subsequent left-side paralysis. What finding would indicate a complication of immobilization? a. Episodes of atrial fibrillation when coughing b. Nausea and vomiting, hyperactive bowel sounds c. Minimal bowel sounds and distended abdomen d. Minimal amount of urine that is dark and concentrated

Minimal bowel sounds and distended abdomen Rationale: Immobility often causes constipation and abdominal distention; add to that the disruption of nerve signals to the bowel secondary to the stroke. A paralytic ileus is a common complication in the client who has had a stroke. Paralytic ileus is identified by absent or minimal bowel sounds and a distended abdomen with passage of minimal flatus or stool. The urine is concentrated, and the client needs increased fluid intake. Immobility does not precipitate atrial fibrillation.

Clients who have had strokes or brain accidents frequently have total bed rest prescribed until their condition is stabilized. Which intervention prevents complications related to immobility? a. Help the client bathe two times daily b. Insert an indwelling catheter c. Develop an activity schedule with the client d. Place the client on a circulating air mattress (pressure reducing surface)

Place the client on a circulating air mattress (pressure reducing surface) Rationale:To avoid potential problems associated with immobility, such as decubitus ulcers, it will be important during the bed rest period to maintain relief of pressure on bony prominences, which a circulating air mattress would provide. The client does not need to be bathed twice a day. Indwelling catheters should be inserted only when accurate measurement of urine is necessary, or when the client cannot void. Bed rest is not an indication for an indwelling catheter. Activity schedules will be developed when the client becomes mobile, such as ambulating twice a day and physical therapy.

When irrigating a draining wound with a sterile saline solution, the nurse would follow what correct sequence of actions? a. Pour solution, wash hands, and remove soiled dressing b. Remove soiled dressing, flush wound, and wash hands c. Prepare sterile field, put on sterile gloves, and remove soiled dressing d. Wash hands, prepare sterile field, apply clean gloves for dressing removal

Wash hands, prepare sterile field, apply clean gloves for dressing removal Rationale: Handwashing should be done before beginning any procedure, especially irrigating a wound. Next, the nurse would prepare a sterile field and apply clean gloves for dressing removal. Standard precautions must be maintained.

The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the client? a. Tomato soup b. Popsicles c. Gelatin d. Apple juice e. Vanilla pudding f. Black coffee

a. Gelatin b. Black coffee c. Apple juice d. Popsicles Response Feedback: Clear liquids are transparent and liquid at room temperature. Tomato soup and vanilla pudding are included in a full liquid diet.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which nursing actions are correct? Select all that apply a. Place the client in a high Fowler position b. Assist the client in extending the neck back so the tube may enter the larynx c. None of the above d. Instruct the client to swallow after the tube has passed the pharynx e. Measure the tube from the tip of the nose to the umbilicus f. Explain that placement of the tube is painless

a. Place the client in a high Fowler position f. Instruct the client to swallow after the tube has passed the pharynx Response Feedback: (A and D) are the correct steps to follow during nasogastric intubation. Placement of an NG tube can be uncomfortable and can induce gagging. The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).