NUR 112 Exam 4

The student nurse is preparing a presentation on bowel elimination. Which potential cause(s) of diarrhea will the student include? Select all that apply. A. Depression. B. Antibiotics. C. Acute stress. D. Increased physical activity. E. Opioids.

A. Depression. B. Antibiotics. C. Acute stress.

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? A. Left side-lying. B. Right side-lying. C. Prone. D. Supine.

A. Left side-lying.

A nurse is teaching a client about collecting stool specimens for fecal occult blood testing. Which of the following should the nurse instruct the client to avoid before and during the testing period? A. Poultry. B. Vitamin E supplements. C. Yogurt. D. Calcium supplements.

A. Poultry.

A nurse is caring for a client who has dyspnea, slight cyanosis, and a respiratory rate of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange? A. Assessment. B. Diagnosis. C. Planning. D. Evaluation.

B. Diagnosis.

Which symptom is a known side effect of antibiotics? A. Abdominal bloating. B. Diarrhea. C. Constipation. D. Fecal impaction.

B. Diarrhea.

What medication causes constipation? A. Magnesium antacids. B. Iron supplements. C. Bisacodyl. D. Aspirin.

B. Iron supplements.

A nurse is collecting a blood specimen for a culture from a client. Which of the following actions should the nurse take? A. Keep the tourniquet in place from selection of the vein to completion of the collection. B. Rub the client's arm at the selected site prior to venipuncture. C. Elevate the client's arm above heart level for the venipuncture. D. Puncture the selected vein while the antiseptic solution is still visible on the skin.

B. Rub the client's arm at the selected site prior to venipuncture.

Which laboratory test is the best indicator of a client in need of TPN? A. Creatinine. B. Serum albumin. C. Hematocrit. D. Hemoglobin.

B. Serum albumin.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? A. Stop the procedure and reposition the client. B. Stop the procedure, monitor heart rate and blood pressure. C. Slow the infusion rate, have the client take deep breaths, then resume the enema. D. Slow the infusion rate, withdraw the tubing slightly, then resume the enema.

B. Stop the procedure, monitor heart rate and blood pressure.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers? A. Asparagus and turnip. B. Yogurt and buttermilk. C. Onions and garlic. D. Fish and dried lentils.

B. Yogurt and buttermilk.

Which symptom will have a great impact on the extracellular fluid for water conservation? A. Fracture B. Small laceration C. Burns D. Pain

C. Burns.

A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual? A. Every 4 hours for the first 24 hours after tube placement and every 24 hours thereafter. B. Immediately after each flush that is administered. C. Every 4 to 6 hours. D. Once per shift.

C. Every 4 to 6 hours.

A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include? A. "Place the oxygen tank in a clutter-free environment." B. "Keep the oxygen tank at least 6 feet away from a heat source." C. "Ensure you are close to electricity to use your oxygen tank." D. "Turn the valve on the oxygen tank until an alarm sounds."

A. "Place the oxygen tank in a clutter-free environment."

Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings? A. Elevated blood pressure. B. Decreased respiratory rate. C. Cyanosis. D. Peripheral edema.

A. Elevated blood pressure.

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? A. Place the client in the dorsal recumbent position on a bedpan. B. Administer the enema while the client sits on the toilet. C. Administer an antidiarrheal medication 3 hr prior to the enema. D. Instill 200 mL of fluid over an hour at 15 min intervals.

A. Place the client in the dorsal recumbent position on a bedpan.

The nurse is reviewing a client's laboratory work before administering a large-volume enema. Which laboratory result indicates that a nurse should confer with the health care provider before administering the enema? A. Platelet count of 18,000/mm^3. B. White blood cell (WBC) count of 15,200/mm3 (15.20x10^9/L). C. Serum albumin of 3.1 g/dL (31 g/L). D. Arterial pH of 5.2.

A. Platelet count of 18,000/mm^3.

The nurse is teaching a client with rectal bleeding about fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide? A. "This test will show if you have an infection in the bowel." B. "This test detects heme, a type of iron compound in blood in the stool." C. "This test will determine whether foods are contributing to rectal bleeding." D. "This test will show if you have colorectal cancer."

B. "This test detects heme, a type of iron compound in blood in the stool."

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? A. Percussion. B. Palpation. C. Auscultation. D. Inspection.

B. Palpation.

A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? A. 2.5 cm to 3.75 cm (1 to 1.5 in). B. 5 cm to 10 cm (2 to 3 in). C. 7.5 cm to 10 cm (3 to 4 in). D. 10 cm to 12.5 cm (4 to 5 in).

C. 7.5 cm to 10 cm (3 to 4 in).

The nurse is preparing to insert a nasograstric (NG) tube into an adult client. Place the following steps in the correct order. Use all options. -Direct the tube upward and backward along the floor of the nose. -Place the client in high Fowler's position. -Lubricate the tube tip with water-soluble lubricant. -Advance the tube while the client swallows. -Measure the intended length to insert the NG tube. -Instruct the client to place the chin onto the chest.

1. Place the client in high Fowler's position. 2. Measure the intended length to insert the NG tube. 3. Lubricate the tube tip with water-soluble lubricant. 4. Direct the tube upward and backward along the floor of the nose. 5. Instruct the client to place the chin onto the chest. 6. Advance the tube while the client swallows.

A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Identify the correct sequence of steps that the nurse should take. (Move the steps of the process into the box on the right, placing them in the selected order of performance. All steps must be used.) -Attach a syringe to the collection port of the indwelling catheter. -Transfer the urine to a sterile specimen container. -Withdraw 3 to 30 mL of urine. -Wipe the port with an alcohol swab or agency specified antiseptic. -Transport the specimen to the laboratory.

1. Wipe the port with an alcohol swab or agency specified antiseptic. 2. Attach a syringe to the collection port of the indwelling catheter. 3. Withdraw 3 to 30 mL of urine. 4. Transfer the urine to a sterile specimen container. 5. Transport the specimen to the laboratory.

The nurse in an outpatient provider's office is caring for a client with persistent flatus. Which client teaching will the nurse provide as to why some foods cause flatus? A. "Certain vegetables can cause flatus, as they are more difficult to digest." B. "Parasites in your stool can cause persistent flatus." C. "Drinking alcoholic beverages can cause flatus." D. "Flatus is a natural action and the cause is unknown."

A. "Certain vegetables can cause flatus, as they are more difficult to digest."

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply. A. "Have you started a new medication?" B. "Are you experiencing rectal fullness?" C. "Do you use laxatives?" D. "What are your normal bowel habits?" E. "Is the stool difficult to pass?"

A. "Have you started a new medication?" C. "Do you use laxatives?" D. "What are your normal bowel habits?"

The nurse is caring for a client who informs the nurse that it is difficult to void when experiencing stress, and asks why this happens. Which response by the nurse is appropriate? A. "Stress causes the muscles to become tense." B. "You might have a neurologic condition." C. "You require greater privacy to void." D. "What medications are you taking?"

A. "Stress causes the muscles to become tense."

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply. A. A positive family history. B. Age 50 and older. C. A history of inflammatory bowel disease. D. A diet high in fruits, vegetables, and whole grains.

A. A positive family history. B. Age 50 and older. C. A history of inflammatory bowel disease.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? A. Auscultate over the access site with the bell of the stethoscope, listening for a bruit or vibration. B. Perform venipuncture below the access site to obtain a blood sample for laboratory testing. C. Administer an IV on the arm high above the access site. D. Measure the client's blood pressure on the arm above the access site.

A. Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.

The nurse is caring for a client who has a history of renal failure. What is an accurate step when caring for the client's hemodialysis access? A. Auscultate over the site with a stethoscope to listen for a bruit. B. If a thrill is not palpable and/or a bruit is not detectable, assess for the signs in the other arm. C. Percuss the site to feel for a thrill or vibration. D. Use the affected am if an IV must be started to avoid impairment of both arms.

A. Auscultate over the site with a stethoscope to listen for a bruit.

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: A. Auscultation. B. Deep palpation. C. Percussion. D. Light palpation.

A. Auscultation.

The nurse is educating a client with a new colostomy about gas-producing foods. Which gas-producing food should the client avoid to prevent gas buildup in the colostomy bag? A. Baked beans. B. Cooked pasta. C. Fresh lettuce. D. Steamed rice.

A. Baked beans.

A nurse is preparing to insert an indwelling catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure? A. Bear down. B. Take deep breaths. C. Sip water. D. Tighten the perineum.

A. Bear down.

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend? A. Bedside commode. B. Bed pan. C. Fracture pan. D. Regular bathroom.

A. Bedside commode.

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? A. Bowel incontinence related to loss of sphincter control, as evidence by inability to delay the urge to defecate. B. Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency. C. Fecal retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis. D. Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidence by fecal incontinence.

A. Bowel incontinence related to loss of sphincter control, as evidence by inability to delay the urge to defecate.

A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? A. Closing off the glottis. B. Preventing curling of the tube in the mouth. C. Allowing the client to breathe through the mouth. D. Opening the lower esophageal sphincter.

A. Closing off the glottis.

A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experiencing social isolation. Which of the following interventions should the nurse recommend? A. Encourage the client to go to the dining room at meal times to talk with other clients. B. Suggest that the client watch television while feedings are being administered. C. Remind the client that they can have visitors after feeding administration times. D. Ask the facility chaplain to speak with the client.

A. Encourage the client to go to the dining room at meal times to talk with other clients.

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel? A. Hypertonic saline. B. Tap water. C. Mineral oil. D. Water, soap.

A. Hypertonic saline.

A nurse is caring for a client who has a suspected urinary tract infection (UTI). Which of the following urinalysis results should the nurse identify as a manifestation of a UTI? A. Leukocyte esterase. B. Trace amount of protein. C. Specific gravity of 1.010. D. pH of 6.0.

A. Leukocyte esterase.

A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding? A. Limit the time the formula hangs to 8 hr. B. Flush the tube every 8 hr. C. Deliver the formula at a brisk rate. D. Allow the feeding bag to empty before refilling it.

A. Limit the time the formula hangs to 8 hr.

A nurse is teaching a client about home collection of a stool specimen for fecal occult blood testing. Which of the following instructions should the nurse inclued? A. Obtain specimens from three different stools. B. Eat a diet low in fiber and residue. C. Avoid foods that are high in fat. D. Refrigerate the specimen card after obtaining the first sample.

A. Obtain specimens from three different stools.

Administering oxygen therapy with a nonrebreather mask has which of the following advantages? A. Offers the highest oxygen concentration of the low-flow systems. B. Provides oxygen concentrations of 40% to 60%. C. Incorporates a design that requires minimal monitoring of the client. D. Is designed for safety once the mask's valves and flaps are sealed.

A. Offers the highest oxygen concentration of the low-flow systems.

Which client(s), at risk for poor nutritional intake, would benefit from nutritional counseling from the nurse? Select all that apply. A. People with substance use problems. B. Individuals who prefer to purchase food from local farmers. C. Older adults living on fixed incomes. D. Pregnant adolescents. E. Children of middle-income parents.

A. People with substance use problems. C. Older adults living on fixed incomes. D. Pregnant adolescents.

A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective? A. Respiratory rate 14/min. B. SaO2 90%. C. Cardiac output 5.6 L/min. PaCO2 68 mm Hg.

A. Respiratory rate 14/min.

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate? A. Strongly aromatic, dark amber. B. Light yellow, clear. C. Cloudy, foul odor. D. Clear, colorless.

A. Strongly aromatic, dark amber.

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? A. Warm the enema solution prior to instillation. B. Prepare 1,500 mL of enema fluid. C. Use tap water as the enema fluid. D. Hand the enema container 24 inches above the anus.

A. Warm the enema solution prior to instillation.

A client is on bed rest and an enema has been prescribed. Which precaution(s) will be taken by the nurse to facilitate the client's comfort and participation? Select all that apply. A. Apply lubricant to the rectal tip. B. Maintain equal pressure on the enema until it is removed from the rectum. C. Instill the fluid slowly. D. Raise the client's buttocks before inserting the enema. E. Place the client in the Sims position.

All are correct. A. Apply lubricant to the rectal tip. B. Maintain equal pressure on the enema until it is removed from the rectum. C. Instill the fluid slowly. D. Raise the client's buttocks before inserting the enema. E. Place the client in the Sims position.

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? A. 42-year-old client with diarrhea twice weekly. B. 50-year-old client with a family history of polyps. C. 67-year-old client with constipation. D. 33-year-old client who reports painful elimination.

B. 50-year-old client with a family history of polyps.

A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client? A. Distilled water for humidification. B. A tracheostomy collar. C. A nasal cannula. D. An aerosol mask.

B. A tracheostomy collar.

The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment with the nurse perform to gather additional information? A. Measure abdominal girth. B. Auscultate for bowel sounds. C. Ask when the client last had a bowel movement. D. Observe the abdominal dressing.

B. Auscultate for bowel sounds.

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? A. Position the bed flat and assist the client onto his or her left side. B. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. C. Administer an oral analgesia 30 to 45 minutes before attempting insertion. D. Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point.

B. Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Pull the catheter out as quickly as possible. B. Deflate the balloon completely before removal. C. Cut the inflation port to deflate the balloon. D. Tell the client to expect to feel a tugging sensation on removal.

B. Deflate the balloon completely before removal.

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem? A. Encourage the client to confide in family members and tell them about the accidents. B. Discuss the use of protective undergarments to avoid embarrassment from incontinenc. C. Tell the client that this happens to all people when they get older. D. Inform the client that this is not normal and make a referral to a urologist.

B. Discuss the use of protective undergarments to avoid embarrassment from incontinence.

A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? A. Modular. B. Elemental. C. Polymeric. D. Specialty.

B. Elemental.

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? A. Grasp the penis at its base. B. Lift the penis perpendicular to the body. C. Hold the penis parallel to the client's body. D. Life the penis to a 45' angle to the client's body.

B. Lift the penis perpendicular to the body.

A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take? A. Instruct the client to retain the fluid. B. Lower the container to allow the solution to flow back out. C. Help the cline to the toilet or bedside commode. D. Wait 5 minutes and instill another 100 mL of fluid.

B. Lower the container to allow the solution to flow back out.

A nurse is caring for a client who has a significant risk for aspiration and requires nutritional support for about 2 weeks because they are unable to consume adequate nutrients orally. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe? A. Nasogastric tube. B. Nasointestinal tube. C. Percutaneous endoscopic gastrostomy tube. D. Percutaneous endoscopic jejunostomy tube.

B. Nasointestinal tube.

A nurse is caring for a client who has a body mass index (BMI) of 26.5. Which category should the nurse understand this client would be placed in? A. Underweight. B. Overweight. C. Healthy weight. D. Obese.

B. Overweight.

A nurse is providing teaching about risk for aspiration with a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? A. A feeling of fullness. B. Persistent coughing. C. Discomfort in the naris. D. Postfeeding belching.

B. Persistent coughing.

A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must: A. Clean the mask with soapy water once every other day. B. Reposition the elastic band frequently. C. Apply petroleum jelly around and inside the nares. D. Make sure there is adequate condensation in the tubing.

B. Reposition the elastic band frequently.

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? A. Cleansing. B. Return-flow. C. Medicated. D. Oil-retention.

B. Return-flow.

A nurse caring for a group of clients in an ambulatory care clinic is collecting urine for several prescribed diagnostic tests. For which of the following tests is a random sample voided into a clean cup appropriate? A. Urine culture and sensitivity. B. Routine urinalysis. C. Urine creatinine clearance. D. Urine pregnancy testing.

B. Routine urinalysis.

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client? A. Catheterization is necessary for 1 week. B. The birth can cause perineal swelling. C. A urinary tract infection results from the birth process. D. A neurogenic bladder results from local anesthesia.

B. The birth can cause perineal swelling.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions? A. Sterile technique must be observed by the client in the home setting. B. The client should avoid wearing tight clothes or belts near the site. C. A dressing should always be worn over the site to avoid leaking. D. The client may bathe rather than shower, provided the site is covered with gauze.

B. The client should avoid wearing tight clothes or belts near the site.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the health care provider? A. The stoma is on the abdominal surface. B. The stoma is prolapsed. C. The stoma is pink. D. The stoma has a small amount of bleeding.

B. The stoma is prolapsed.

Which factor is related to developmental changes in bowel habits for older adult clients? A. Milk products cause constipation in clients with lactose intolerance. B. Weakened pelvic muscles lead to constipation. C. Increase in dietary fiber can decrease peristalsis. D. Older adults should peel fruits before eating.

B. Weakened pelvic muscles lead to constipation.

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client? A. "Are you taking a diuretic?" B. "Are you taking phenazopyridine?" C. "Are you taking any B-complex vitamins?" D. "Are you taking levodopa?"

C. "Are you taking any B-complex vitamins?"

A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? A. A client who has a paralytic ileus. B. A client who has recently experienced facial trauma. C. A client who has dysphagia. D. A client who has a decreased appetite.

C. A client who has dysphagia.

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? A. A client who has a persistent urinary tract infection. B. A client who has urge incontinence. C. A client who is in the ICU for a gastrointestinal bleed. D. A client who has incontinence due to cognitive decline.

C. A client who is in the ICU for a gastrointestinal bleed.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet? A. A diet lacking in meat and poultry products. B. A diet lacking in refined grains, seeds, and nuts. C. A diet lacking in fruits and vegetables. D. A diet lacking in glucose and water.

C. A diet lacking in fruits and vegetables.

The nurse is caring for a client who refuses most foods on the dietary tray. Which nursing intervention is appropriate? A. Contact the healthcare provider to prescribe an appetite stimulant. B. Delegate feeding assistance to the unlicensed assistive personnel. C. Assess when client generally eats meals. D. Allow the client privacy during mealtime.

C. Assess when client generally eats meals.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing. A. Take 500 mg. B. Drink orange and grapefruit juice. C. Avoid more than 250 mg. D. Consume citrus fruits.

C. Avoid more than 250 mg.

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action? A. Remove the tubing. B. Continue infusing at a faster rate to finish the enema quicker. C. Clamp the tube for a brief period and resume at a slower rate. D. Discontinue the administration of the enema.

C. Clamp the tube for a brief period and resume at a slower rate.

A nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? A. Clear, dark amber. B. Light yellow, clear. C. Cloudy, foul odor. D. Strongly aromatic, amber.

C. Cloudy, foul odor.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? A. If portions of the stool include visible blood, mucus, or pus, discard the stool. B. Refrigerate the specimen until it is cooled before sending it to the laboratory. C. Collect 15 to 30 mL of the client's liquid stool. D. If the specimen contains barium or enema solution, document this on the container.

C. Collect 15 to 30 mL of the client's liquid stool.

A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy? A. Poor skin turgor. B. Copious respiratory secretions. C. Cracks in the oral mucosa. D. Elevated heart rate.

C. Cracks in the oral mucosa.

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? A. Nurses find the procedure distasteful and difficult to perform. B. Most clients will not consent to have digital removal of stool. C. Digital removal of stool may cause parasympathetic stimulation. D. It often causes rebound diarrhea and electrolyte loss.

C. Digital removal of stool may cause parasympathetic stimulation.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? A. Endoscopic examination, barium studies, fecal occult blood test. B. Barium studies, endoscopic examination, fecal occult blood test. C. Fecal occult blood test, barium studies, endoscopic examination. D. Barium studies, fecal occult blood test, endoscopic examination.

C. Fecal occult blood test, barium studies, endoscopic examination.

A nurse is caring for a client who needs to collect a midstream urine specimen. Which of the following actions should the nurse take? A. Give the client a clean urine cup from the laboratory. B. Instruct the client to cleanse the perineal area from back to front. C. Have the client urinate a small amount of urine before starting the collection. D. Tell the client to collect about 10 mL of urine.

C. Have the client urinate a small amount of urine before starting the collection.

Which principle should guide the nurse's collection of a fecal occult blood test? A. The results of the test will preliminarily indicate the site of a client's bleeding. B. Recent use of over-the-counter stool softeners can cause a false-positive result. C. If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period. D. The nurse must assess the client's food and medication intake for the 2 weeks prior to the test.

C. If the client is menstruating, the nurse should postpone the test until 3 days after the end of her period.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? A. It can be left in place for a long period of time. B. A sterile urine specimen can be obtained from the drainage bag tubing. C. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. D. The client can apply it himself with minimal supervision.

C. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? A. Stretch the sheath portion of the condom catheter along the length of the penis. B. Secure the sheath portion with adhesive tape. C. Leave a space between the penis and sheath portion tip. D. Reposition the foreskin after application.

C. Leave a space between the penis and sheath portion tip.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Measure the client's vital signs. B. Notify the primary care provider. C. Lower the enema fluid container. D. Stop the enema instillation.

C. Lower the enema fluid container.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved? A. Loop of Henle. B. Glomerulus. C. Nephron. D. Bowman's capsule.

C. Nephron.

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC, the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority? A. Placing the client as NPA status. B. Obtaining laboratory studies. C. Notifying the health care provider of the assessment findings. D. Checking for blood return on the CVC.

C. Notifying the health care provider of the assessment findings.

A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement? A. Measure the pH of gastric aspirate. B. Auscultate the epigastric area while injecting air. C. Obtain an x-ray. D. Place the open end of the tube in a cup of water.

C. Obtain an x-ray.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? A. Moist perineal skin. B. Absence of discharge. C. Reddened perineal skin. D. Presence of smegma.

C. Reddened perineal skin.

A nurse is caring for a client who has a stage III pressure injury on the sacral area. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury? A. Irrigate the wound with an antiseptic solution before collecting the specimen. B. Wipe the crusty area around the outside of the wound with a sterile swab. C. Rotate a sterile swab in the area of drainage. D. Collect drainage from the wound dressing.

C. Rotate a sterile swab in the area of drainage.

What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces? A. Ileostomy. B. Transverse colostomy. C. Sigmoid colostomy. D. Ascending colostomy.

C. Sigmoid colostomy.

A 70-year-old client who has 4 children and 6 grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? A. Total. B. Urge. C. Stress. D. Reflect.

C. Stress.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client? A. This urinary diversion is only temporary. B. The client will need to change the urinary pouch every 4 hours. C. The client will have to wear an external appliance to collect urine. D. Urination can be voluntarily controlled after the stoma heals from the initial surgery.

C. The client will have to wear an external appliance to collect urine.

A client having a bowel surgery asks why being NPO after surgery is necessary. Which statement by the nurse best describes the reason? A. To increase mucus in the bowel that helps to promote healing. B. To allow gas to accumulate and promote healing. C. To rest the gastrointestinal tract and promote healing. D. To prevent gas from forming in the bowel and interfere with healing.

C. To rest the gastrointestinal tract and promote healing.

A nurse is checking a client's capillary blood glucose level. Which nursing action is most appropriate? A. Have the client make a fist to encourage blood flow. B. Wipe the test site with an alcohol swab after testing. C. Touch the test strip directly to a drop of blood. D. Cleanse the test strip with an alcohol swab prior to inserting it in the meter.

C. Touch the test strip directly to a drop of blood.

The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? A. Offer larger meals and encourage the client to eat as much as is comfortable. B. Reduce the frequency of meals in order to allow the client to develop an appetite. C. Try to ensure that the client's food is attractive and sufficiently warm. D. Offer nutritional supplements and explain the potential benefits of each.

C. Try to ensure that the client's food is attractive and sufficiently warm.

A nurse is caring for a critically ill client who has COPD and requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery devices is indicated for this client? A. Simple face mask. B. Nasal cannula. C. Venturi mask. D. Face tent.

C. Venturi mask.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately? A. Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure. B. Obtained urine specimen from urinary drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port. C. Verified prescription, cleanses access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. D. Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container.

C. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.

A nurse caring for a client who has diabetes mellitus is having difficulty obtaining a capillary fingerstick blood sample from point-of-care blood glucose testing. Which of the following actions should the nurse take to help increase blood flow to the client's finger? A. Elevate the hand on a pillow. B. Pierce the skin in the middle of the finger pad. C. Wrap the finger in a warm cloth. D. Firmly milk the puncture site.

C. Wrap the finger in a warm cloth.

A parent brings a 2-year-old child to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states, "I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." Which response by the nurse is appropriate? A. "You are putting too much pressure on yourself and your child to toilet train." B. "There may be something wrong since your child should be toilet trained by 2 years of age." C. "There is nothing to worry about. Just keep the child in diapers until they stop having accidents." D. "Children vary in their readiness but daytime bowel control may be attained at 30 months."

D. "Children vary in their readiness but daytime bowel control may be attained at 30 months."

An assistive personnel (AP) is collecting a 24-hour urine specimen from a client. Which of the following statements by the AP indicates that the specimen collection will have to be restarted? A. "I used a container from the lab that has a preservative in it." B. "The client just voided into the toilet, so the next void can be collected." C. "I have the container in a plastic bucket filled with ice." D. "The client just told me that they forgot to put the urine in the container."

D. "The client just told me that they forgot to put the urine in the container."

A nurse obtains a capillary blood glucose result of 180 mg/dL from a client who has diabetes mellitus. Which of the following actions should the nurse take? A. Encourage the client to get up and exercise. B. Repeat the test using a different glucometer. C. Give the client a glass of orange juice. D. Administer insulin according to the patient's sliding scale orders.

D. Administer insulin according to the patient's sliding scale orders.

A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last? A. Urethral meatus. B. Labia minora. C. Perineum. D. Anus.

D. Anus.

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? A. Palpating the bladder above the symphysis pubis. B. Obtaining the bladder scan to check the urine volume. C. Determining any pain when palpating the lower abdomen. D. Asking the client when he or she had last urinated.

D. Asking the client when he or she had last urinated.

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? A. The duration of the procedure. B. 10 to 15 min. C. Until the client feels the urge to defecate. D. At least 30 min.

D. At least 30 min.

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? A. Irrigate the catheter. B. Assess for peripheral edema. C. Palpate the bladder for distention. D. Check the catheter for kinks.

D. Check the catheter for kinks.

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? A. Renal failure. B. Balanced fluids. C. Hypovolemia. D. Dehydration.

D. Dehydration.

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? A. Afternoon. B. Evening. C. Before bedtime. D. First thing in the morning.

D. First thing in the morning.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client? A. Urinary incontinence related to urinary tract infection. B. Risk of urinary tract infection related to dehydration. C. Impaired skin integrity related to functional incontinence. D. Impaired skin integrity related to urinary bladder infection and dehydration.

D. Impaired skin integrity related to urinary bladder infection and dehydration.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan? A. Drink a soft drink daily to prevent gas and allow fiber to break down. B. Eat more cabbage and Brussel sprouts to decrease gas and add fiber. C. Include more protein in the diet to increase fiber and decrease gas. D. Increase fiber slowly over a period of time to prevent gas.

D. Increase fiber slowly over a period of time to prevent gas.

The nurse is teaching a new mother who had decided to breastfeed her infant. What nutrient must be supplemented by the mother after the first four months of breast feeding? A. Vitamin C. B. Calcium. C. Protein. D. Iron.

D. Iron.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? A. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. B. Ask the client to bear down until the catheter is expelled. C. Remove the catheter from the vagina and attempt to insert it into the bladder. D. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

D. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? A. Prone. B. Dorsal recumbent. C. Right lateral with both knees at chest. D. Left lateral with the right leg flexed.

D. Left lateral with the right leg flexed.

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be: A. Soft semi-formed. B. Mucus-filled. C. Bloody. D. Liquid consistency.

D. Liquid consistency.

An older adult is experiencing urinary retention. What age-related physiologic change does the nurse discuss with the client that may be a contributing factor? A. Older adults who have limited support can feel powerless. B. Older adults have a decreased ability to concentrate urine. C. Older adults can have a decrease in bladder muscle tone. D. Older adults may have a decrease in contraction of the bladder.

D. Older adults may have a decrease in contraction of the bladder.

A nurse should recognize that which of the following findings is an indication for oxygen therapy? A. Respiratory rate 32/min. B. PaO2 90mm Hg. C. Fraction of inspired oxygen (FiO2) 65% for 4 days. D. Oxygen saturation (SaO2) 90%.

D. Oxygen saturation (SaO2) 90%.

A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? A. Flush the feeding tube with 30 mL of water. B. Add blue food coloring to the enteral formula. C. Ensure the formula is at room temperature. D. Place the client in Fowler's position.

D. Place the client in Fowler's position.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? A. Blood pressure 130/80 mm Hg. B. Heart rate 90 beats/min. C. Temperature 99.9'F (37.9'C). D. Skin turgor response 5 seconds.

D. Skin turgor response 5 seconds.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the nurse do first? A. Stop the administration of the enema and notify the physician. B. Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. C. Increase the flow of the enema until all of the solution has been administered. D. Stop the administration of the enema momentarily.

D. Stop the administration of the enema momentarily.

A nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the right: A. Starts the flow of oxygen. B. Provides the maximal oxygen flow. C. Provides a minimal oxygen flow. D. Stops the flow of oxygen.

D. Stops the flow of oxygen.

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? A. Reflex incontinence. B. Urge incontinence. C. Functional incontinence. D. Stress incontinence.

D. Stress incontinence.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true? A. If nocturnal incontinence is anticipated, a urinal can be placed between the legs while the client is asleep. B. Urinals must be replaced every 24 hours to reduce the risk of infection. C. Both male and female clients commonly void into a urinal in the bathroom to facilitate measurement of urinary output. D. Unless contraindicated, nurses should encourage clients to stand to use a urinal.

D. Unless contraindicated, nurses should encourage clients to stand to use a urinal.

To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose, to the earlobe and from the earlobe to the _____. A. Umbilicus. B. Xiphoid process. C. Manubrium plus 10 to 20 cm more. D. Xiphoid process plus 20 to 30 cm more.

D. Xiphoid process plus 20 to 30 cm more.

True or False: Use of an indwelling urinary catheter leads to the loss of bladder tone.

True