Exam 3 Questions

A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching? - "The procedure will be cancelled if the urinalysis indicates the presence of red blood cells." - "High frequency sound waves will be used to identify renal system structures." - "You will be able to resume your regular diet as soon as the test is complete." - "After the procedure you will be encouraged to drink plenty of fluids."

"After the procedure you will be encouraged to drink plenty of fluids." The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure.

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? "I drink at least 2 quarts of fluid every day." "The last time I voided it was painful and red-tinged." "My period ended 2 days ago." "I don't eat shellfish because it gives me hives."

"I don't eat shellfish because it gives me hives." The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? "I will wipe from the back to front with the cleansing cloth." "I should not collect a urine sample when I am menstruating." "I should let the urine cool to room temperature before sending it to the lab." "I need to urinate a small amount in the toilet before collecting the sample."

"I need to urinate a small amount in the toilet before collecting the sample." The client should begin the stream of urine in the toilet first, and then pass the container through the urine stream to obtain the sample. This action will wash off any bacteria at the distal urethra that could contaminate the sample.

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? "I'Il urinate a little then stop." "I'Il use the cleansing wipe from front to back." "I'Ill clean the inside of the container with a wipe." "I'll use each cleansing wipe twice."

"TIl use the cleansing wipe from front to back." The client should cleanse the perineal area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus.

A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching? "You should limit fluids for 12 hr following the procedure." "You may have pink-tinged urine after this procedure." "You can eat a full liquid meal up to 1 hour before the procedure." "You will be placed on your right side during the procedure."

"You may have pink-tinged urine after this procedure." The client might have blood-tinged, or pink, urine after the procedure. The client should report dark red urine because it is an indication of bleeding.

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." "You should limit fluids in the evening." "You should restrict your intake of caffeine." "You might require intermittent urinary catheterization." "You might require an anterior vaginal repair."

"Your provider might prescribe anticholinergic medications" Anticholinergic medications suppress bladder contractions and increase bladder capacity. "You should limit fluids in the evening" 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" The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant.

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Perform hand hygiene Place package on work surface. Open outermost flap away from self, Open innermost flap toward self. Open side flap, pulling to the side. Use inner surface of package as sterile field.

- perform hand hygiene - place package on work surface - open outermost flap away from self - side flaps moving to the side - open the innermost flap, toward self - use innermost surface of package as sterile field

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. Withdraw 3 to 30 ml of urine. Wipe the port with an alcohol swab or agency-specified antiseptic. Transport the specimen to the lab. Attach a syringe to the collection port of the indwelling catheter. Transfer the urine to a sterile specimen container.

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 lab.

A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria? 720 mL 550 mL 380 mL 600 ml

380 mL This urinary output indicates oliguria, which is defined as less than 400 mL of total output in 24 hr or less than 30 ml per hr.

A client who has an elevated BUN is most likely to have a manifestation of A client who reports painful urination A client who reports urinary frequency A client who has glucose in his urine

A client who reports painful urination Voiding a small amount of urine (less than 100 mL) frequently (2 to 3 times per hr), and dribbling of urine are manifestations of urinary retention.

The nurse caring for a patient receiving intravenous therapy monitors for which signs of infiltration of an intravenous (IV) infusion? (Select all that apply) A. Slowing of the IV rate B. Tenderness at the insertion site C. Edema around the insertion site D. Skin tightness at the insertion site E. Warmth of skin at the insertion site F. Fluid leaking from the insertion site

A, B, C, D, F

Which of the following is a benefit associated with electronic medication administration records? (Select all that apply.) A. Improves access to information B. Eliminates the need for the nurse to verify client identification C. Eliminates the need for the nurse to verify dosage calculations D. Reduces the risk of medication administration errors E. Allow easy substitutions by the nurse

A. Improves access to information D. Reduces the risk of medication administration errors

Which of the following is an expected outcome for a client who is recovering from an abdominal perineal resection with colostomy? The client will: A. Resume walking on the hospital floor soon after the surgery B. Eliminate fiber from the diet C. Permanently limit physical activity to light exercise D. Anticipate urinary self-catheterization

A. Resume walking on the hospital floor soon after the surgery

A nurse is preparing to insert an indwelling urinary catheter. 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

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? Use sterile technique during the insertion procedure. Inflate the catheter balloon with 20 mL of sterile water. Advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow. Use water to lubricate the catheter tip prior to inserting it.

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 caring for a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should plan to administer the client's PRN bethanechol when the client reports which of the following manifestations? Bladder spasms Severe pain. An inability to void Frequent episodes of painful urination

An inability to void Bethanechol is a cholinergic medication that stimulates the parasympathetic nervous system, thus improving the tone and motility of the smooth muscles of the urinary tract enough to initiate urination.

A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective? 1. "I'm told this test causes no discomfort." 2. "I will have to walk on a treadmill." 3. "I will need to remain NPO." 4. "I will need to take my pulse prior to the test."

Answer: 1 Explanation: 1. An echocardiogram causes no discomfort, although conductive gel is used and it may be cold.

The nurse is preparing to collect a throat culture from a client. What client response indicates to the nurse that teaching about this test has not been effective? 1. "I need to hyperextend my neck." 2. "I need to say 'ah.'" 3. "I will need to sit up." 4. "The nurse will use a light."

Answer: 1 Explanation: 1. The client should extend the tongue when a throat culture is to be taken, not hyperextend the neck.

A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Analyze the stool for dietary products and digestive secretions. 2. Detect the presence of bacteria or viruses. 3. Detect the presence of ova and parasites. 4. Determine the presence of occult blood.

Answer: 1 Explanation: 1. The nurse needs to collect and send the total quantity of stool expelled at one time instead of a small sample so that the specimen can be analyzed for dietary products and digestive secretions.

The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? 1. BNP 2. CBC 3. LDH 4. PKU

Answer: 1 Explanation: 1. The specific blood test to detect and guide treatment for heart failure is the BNP test. B-type natriuretic peptide is secreted primarily by the left ventricle in response to increased ventricular volume and pressure.

An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client? 1. Provide a clean funnel to pour the urine into the specimen cup. 2. Document that the specimen could not be obtained. 3. Catheterize the client for the specimen. 4. Ask the physician to obtain the specimen.

Answer: 1 Explanation: 1. If an older client is having difficulty with a specimen cup for a clean catch urine specimen, the nurse should provide a clean funnel to pour the urine into the container.

A client is having a lumbar puncture. In which position should the nurse place the client? 1. Lateral with head bent toward the chest and knees flexed onto the abdomen 2. Lying prone, with the knees drawn up toward the abdomen 3. Sitting bent over from the waist with legs extended 4. Supine with knees pulled toward the chest

Answer: 1 Explanation: 1. Lying in the lateral position with the head bent toward the chest and knees flexed onto the abdomen is the correct position for a lumbar puncture. In this position the back is arched, increasing the spaces between the vertebrae so that the spinal needle can be readily inserted.

The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this client's procedure? Select all that apply. 1. Date and time performed 2. The physician's name 3. The client's ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The client's status after the procedure

Answer: 1, 2, 4, 5 Explanation: 1. When documenting after a lumbar procedure, the nurse should include the date and time the procedure was performed. 2. When documenting after a lumbar procedure, the nurse should include the physician's name. 4. When documenting after a lumbar procedure, the nurse should include the color, character, and amount of cerebrospinal fluid withdrawn. 5. When documenting after a lumbar procedure, the nurse should include the client's status after the procedure.

A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? Select all that apply. 1. Tissue samples may be taken for biopsy. 2. Eating will not be permitted for 12 hours. 3. A local anesthetic is sprayed on the throat. 4. Bed rest for 8 hours is necessary after the test. 5. Informed consent is required for this procedure.

Answer: 1, 3, 5 Explanation: 1. A bronchoscopy is a sterile procedure. Tissue samples may also be taken for biopsy. 3. A local anesthetic is sprayed on the client's pharynx to prevent gagging. 5. Informed consent is required for this procedure.

A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? Select all that apply. 1. Client's tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received

Answer: 1, 3, 5 Explanation: 1. The nurse should document how well the client tolerated the procedure, as it can cause considerable discomfort. 3. The nurse should document the bone marrow biopsy site for bleeding, as this can occur. 5. The nurse should document whether the client is experiencing any pain, and whether any pain medication was provided.

The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? Select all that apply. 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen. 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the specimen immediately or refrigerate it for later pickup. 5. Clamp the drainage tubing for 30 minutes if there is no urine in the catheter.

Answer: 1, 4, 5 Explanation: 1. When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should withdraw 30 mL of urine for a routine urinalysis. 4. When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should send the specimen immediately or refrigerate it for later pickup. 5. When collecting a urine specimen from a client with an indwelling urinary catheter, the nurse should clamp the drainage tubing for 30 minutes if there is no urine in the catheter.

The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client.

Answer: 2 Explanation: 2. Collecting the specimen comes during the intratest phase.

What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning. 3. Keep the specimen on ice. 4. Void in a sterile cup.

Answer: 2 Explanation: 2. Routine urine examination is usually performed on the first voided specimen in the morning because it tends to have a higher, more uniform concentration and a more acidic pH than specimens later in the day.

A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? 1. It is the use of a magnetic field to produce an image of a body part or organ. 2. A radioisotope will be injected to determine organ functioning as being either hot or cold. 3. It produces a three-dimensional image of an organ. 4. It is more sensitive than an x-ray image.

Answer: 2 Explanation: 2. In nuclear imaging studies, a radioisotope is injected, and the body organ is determined as functioning as either hot or cold.

The nurse is collecting a sputum specimen from a client. Which action should the nurse take during the collection of this specimen? 1. Collect at least 30 mL of sputum. 2. Offer mouth care. 3. Take shallow breaths. 4. Wear a mask.

Answer: 2 Explanation: 2. Offer mouth care so that the specimen will not be contaminated with microorganisms from the mouth.

What is the responsibility of the nurse when collecting a specimen from a client? 1. Always accompany the client to collect a specimen. 2. Handle the specimen discreetly. 3. Clean technique should be used with all specimen collection. 4. Use day-old specimens.

Answer: 2 Explanation: 2. The nurse should handle the specimen discreetly to avoid embarrassing the client.

A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order? 1. To test for acid-fast bacillus 2. To assess the effectiveness of therapy 3. To identify origin, structure, function, and pathology of cells 4. To identify the specific organism

Answer: 2 Explanation: 2. The reason for this doctor's order is to assess if the therapy ordered is effective for this client.

The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? Select all that apply. 1. Clean the perineal area using a circular motion. 2. Use all towelettes provided. 3. Use each towelette once, and discard. 4. Clean the perineal area from back to front. 5. Clean the perineal area from front to back.

Answer: 2, 3, 5 Explanation: 2. To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use all towelettes provided. 3. To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use each towelette once and discard. 5. To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to clean the perineal area from front to back.

The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? Select all that apply. 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report the results to appropriate health team members

Answer: 2, 4, 5 Explanation: 2. During the posttest phase of diagnostic testing, the nurse will compare the previous and current test results. 4. During the posttest phase of diagnostic testing, the nurse will modify nursing interventions as necessary. 5. During the posttest phase of diagnostic testing, the nurse will report the results to appropriate health team members.

A client is scheduled to have abdominal ascites fluid removed. What should the nurse instruct the client about this procedure? 1. A catheter will be inserted into the bladder.2. A liver biopsy will be done.3. An abdominal paracentesis will be done.4. A thoracentesis will be done.

Answer: 3 Explanation: 3. An abdominal paracentesis is performed to remove ascites, which relieves pressure on the abdominal organs.

A client asks the nurse, "Why do I have to monitor my blood glucose levels?" What is an appropriate response from the nurse? 1. "Because your doctor ordered it." 2. "If I were you, I would monitor the blood glucose when I didn't feel good." 3. "Monitoring your blood glucose better enables you to manage your diabetes." 4. "You can eat anything you want."

Answer: 3 Explanation: 3. Blood glucose monitoring improves diabetes management. By testing one's blood, one can change the insulin regimen to maintain a normal glycemic range.

The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? 1. Apply sterile gloves. 2. Clear the throat. 3. Cough to bring up secretions. 4. Rinse the mouth with mouthwash prior to the collection

Answer: 3 Explanation: 3. Clients need to cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to expectorate the specimen into a collecting container.

A client is scheduled for a barium enema. What is the nursing priority for this client? 1. Assess bowel sounds. 2. Assess for allergies .3. Cleanse the bowel. 4. Keep the client NPO.

Answer: 3 Explanation: 3. For visualization of the colon, the bowel has to be cleansed; otherwise the test cannot be performed. Therefore, that is the first priority the nurse must keep in mind.

The nurse is reviewing laboratory results for a client. Which diagnostic study determines how well blood glucose levels have been controlled in the client? 1. Blood chemistry 2. Capillary blood glucose 3. Hemoglobin A1c 4. Serum electrolytes

Answer: 3 Explanation: 3. The glycosylated hemoglobin or hemoglobin A1c (HbA1c) is a measurement of blood glucose that is bound to hemoglobin. Hemoglobin A1c is a reflection of how well blood glucose levels have been controlled.

The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed assistive personnel.

Answer: 3 Explanation: 3. A nursing procedure or laboratory manual is often available if the nurse is unfamiliar with the procedure. If there is any question about the procedure, the nurse should call the laboratory for directions before collecting the specimen.

A client with tattooed eyeliner is scheduled for an MRI. What should the nurse instruct the client about this diagnostic test? 1. Earplugs will be provided. 2. Lie very still. 3. Report any burning sensation. 4. Wear goggles.

Answer: 4 Explanation: 4. Recent reports have shown that, in very few instances, people with tattoos or permanent cosmetics experience edema or burning in the tattoo during an MRI. Any potential problems can be avoided by wearing goggles to cover permanent cosmetics around the eyes.

The nurse is reviewing instructions provided to a client about an upcoming cystoscopy. Which client response indicates that no further teaching is required? 1. "During the procedure the physician will take x-rays." 2. "I will be awake for this procedure." 3. "The doctor will be able to see my kidneys." 4. "The scope is a lighted instrument inserted through the urethra."

Answer: 4 Explanation: 4. The cystoscope is a lighted instrument inserted through the urethra.

Which instruction should the nurse give to the client when a stool specimen is to be collected? 1. Defecate in the toilet. 2. Follow sterile technique. 3. Send at least 60 mL of specimen. 4. Void before the specimen is collected.

Answer: 4 Explanation: 4. To avoid contaminating the specimen, the client should void before the specimen is collected.

A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. What should the nurse do? 1. Continue with the test, and document that one specimen is missing. 2. End the test immediately, and send what is collected to the laboratory. 3. Document that the test cannot be completed. 4. Start the test over

Answer: 4 Explanation: 4. If the client or staff forgets and discards the client's urine during a timed collection, the procedure must be restarted from the beginning.

Which return demonstration by a client indicates that teaching about performing a blood glucose monitoring test has been effective? 1. The client punctures the fingertip. 2. The client puts on gloves. 3. The client smears the blood on the reagent strip. 4. The client washes the hands.

Answer: 4 Explanation: 4. One of the first steps the client would perform is hand washing for infection control.

Unlicensed assistive personnel (UAP) will be conducting a test on a client's urine. What should the nurse instruct the UAP about the test? Select all that apply. 1. Nothing, because the UAP can perform urine testing. 2. Remind the UAP to tell the client the results of the test. 3. Notify the physician with the results of the test. 4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test

Answer: 4, 5 Explanation: 4. The nurse should instruct the UAP to report the results of the test to the nurse. 5. The nurse should instruct the UAP to save the urine in case the nurse wants to repeat the test.

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

Answer: B. Return-flowReturn-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention. A. Cleansing enemas remove feces when a client is constipated, has a fecal impaction, or is undergoing preparation for surgery or diagnostic procedures. This type of enema would not address this client's immediate need. C. Medicated enemas are given for a variety of reasons, such as to reduce bacteria in the colon prior to surgery or to exert a systemic effect. This type of enema would not address the client's immediate need. D. Oil-retention enemas lubricate the rectum and the colon, making feces softer and easier to pass. This type of enema would not address the client's immediate need.

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. Clean the client's skin and perineum with hot water after each episode of incontinence. Check the client's skin every 8 hr for signs of breakdown. Request a prescription for the insertion of an indwelling urinary catheter.

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 should apply a moisture barrier ointment to prevent further contact of the skin with urine. breakdown. After cleansing and drying the client's skin, the nurse

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.

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 the base. B. Lift the penis perpendicular to the body. C. Hold the penis parallel to the client's body. D. Lift the penis to a 45* angle to the client's body.

B. Lift the penis perpendicular to the body.

Which of the following are appropriate client identifiers when a nurse is giving a medication? (Select all that apply). A. Room number B. Medical record number C. Date of birth D. Name of health care provider E. Last name

B. Medical record number C. Date of birth

Which of the following interventions should be implemented as part of safe medication administration practices? (Select all) A. Leave medication at the bedside to allow the client to take it when he feels ready. B. Never administer medication that has been prepared by someone else. C. Keep all controlled substances in a visible and accessible area. D. Verbal orders from a healthcare provider are acceptable if repeated twice, slowly and clearly, by the healthcare provider. E. Double check high-alert medications with another nurse before administering

B. Never administer medication that has been prepared by someone else. E. Double check high-alert medications with another nurse before administering

A nurse is administering an intramuscular injection to a 6-month- old child. Which of the following sites should she use? A. Dorsal gluteal muscle B. Vastus lateralis C. Deltoid D. Rectus femoris

B. Vastus Lateralis Preferred muscle group for administering an intramuscular injection in infants younger than 12 months

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? Pernicious anemia Dehydration Prostate enlargement Bladder infection

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 a group of newly admitted clients. For which of the clients should the nurse expect to receive a prescription for urinary catheterization? A. A client who has a persistent UTI. 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.

The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a patient. When administering the IV potassium chloride, which action should the nurse take? A. Inject it as a bolus B. Use a filter in the IV line C. Dilute it per medication instructions. D. Apply cool compress to the IV site

C. Dilute it per medication instruction

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.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Notify the provider. Check the tubing for kinks. Adjust the rate of the bladder irrigant. Irrigate the catheter.

Check the tubing for kinks. When providing client care, the nurse should first use the least restrictive intervention; nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage therefore, the nurse should check the catheter tubing for kinks. The from the catheter to prevent clotting, which could occlude the catheter lumen.

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? Urinary retention Low back pain Incontinence Confusion

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

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 hours prior to the enema D. Instill 200 mL of fluid over an hour at 15 minute intervals

Correct Answer: A. Place the client in the dorsal recumbent position on a bedpan A client who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the client over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid that is likely to be expelled. B. The angle of insertion of the rectal tube with the client in this position could result in abrasion of the rectal wall. C. An antidiarrheal medication will not correct poor sphincter control and might be counterproductive to the purpose of the enema. D. This would unnecessarily prolong the procedure and would have little or no effect on sphincter control.

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. Hang the enema container 24 inches above the anus

Correct Answer: A. Warm the enema solution prior to instillationIt is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa. B. For a large-volume cleaning enema, the recommended amount of fluid to instill for an adult client is 750 to 1,000 mL. C. Tap water is a hypotonic solution that moves fluid from the colon into the interstitial spaces and can cause circulatory overload and electrolyte imbalances. For this reason, tap water enemas cannot be given more than once, and two enemas have been prescribed for this client. D. The height of the fluid container affects the speed of instillation. The maximum recommended height is 18 inches. Hanging the container higher than that can cause rapid instillation and painful distention of the colon.

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 client to the toilet or bedside commode D. Wait 5 min and instill another 100 mL of fluid.

Correct Answer: B. Lower the container to allow the solution to flow back outReturn-flow enemas involve moving 100 to 200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process several times. A. Having the client retain the fluid is appropriate for a retention enema, not for a return-flow enema. C. Assisting the client to the toilet or commode or providing a bedpan is appropriate for a cleansing enema, not for a return-flow enema. D. This is inappropriate during the administration of a return-flow enema.

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 inches) B. 5cm to 7.5 cm (2 to 3 inches) C. 7.5cm to 10 cm (3 to 4 inches) D. 10cm to 12.5cm (4 to 5 inches)

Correct Answer: C. 7.5cm to 10 cm (3 to 4 inches)This is the appropriate length of insertion for an adult client. A. This is the appropriate length of insertion for an infant, rather than an adult. B. This is the appropriate length of insertion for a child, rather than an adult. D. This length of insertion puts the client at risk for bowel perforation.

When 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

Correct Answer: C. Lower the enema fluid container Some abdominal cramping is to be expected during enema administration. To ease the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container. A. This assessment will not relieve the client's discomfort. B. This intervention will not relieve the client's discomfort. D. Discontinuing the enema is indicated if the client's abdomen becomes rigid and distended or if there is evidence of bleeding.

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

Correct Answer: D. At least 30 minutesThe enema will be most effective in softening the stool and lubricating its passageway if the client retains the oil for a minimum of 30 min. A. This might be enough time to lubricate the rectum and the distal portion of the colon, but it is not enough time to allow the oil to penetrate the feces and soften them to facilitate elimination. B. This might be enough time to lubricate the rectum and the distal portion of the colon, but it is not enough time to allow the oil to penetrate the feces and soften them to facilitate elimination. C. This instruction is too vague to ensure the effectiveness of the enema. The client might feel an immediate need to defecate, which might result in straining because the oil has not had enough time to penetrate and soften the feces for easy elimination.

A nurse is preparing an adult client with 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

Correct Answer: D. Left lateral with the right leg flexedThis position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube. A. The prone position does not allow adequate visualization of the anus for safely inserting the rectal tube. B. This position is used for infants and small children during enema administration, but it is not optimal for adults. C. This position is difficult for clients to maintain, and it is unnecessarily extreme for enema administration.

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? Nephrosclerosis Uremia Diverticulitis Cystitis

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

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.

The client is to receive a sedative via the buccal route. Which of the following is true? A. The medication is placed under the tongue. B. This route is probably more expensive than the intramuscular route. C. The nurse should offer the client a glass of orange juice after taking the sedative. D. This method of administration would be avoided in the event of facial injuries.

D. This method of administration would be avoided in the event of facial injuries.

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? COPD Diabetes mellitus Anemia Osteoporosis

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 paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? Urge incontinence Dribbling of urine Weight gain Rectal distention

Dribbling of urine Dribbling of urine, or overflow incontinence, is an indicator of bladder distention. The nurse should perform intermittent catheterization when this occurs to prevent bladder trauma or infection. A regular schedule to drain the flaccid bladder should be established, with no longer than 8 hr. between catheterizations.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections, Which of the following actions shouid the nurse include in the client's plan of care? Cleanse the perineum from back to front. Obtain a prescription for an indwelling urinary catheter. Encourage fluid intake at and between meals. Offer the client the bedpan every 2 hr.

Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital- acquired) UTI is reduced, even for a client who has a spinal cord injury.

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take? Assist the client to the bathroom every 2 hr. Restrict oral fluid intake during waking hours. Encourage the client to hold her breath when feeling the urge to urinate. Provide adult diapers until bladder retraining is successful.

Encourage the client to hold her breath when feeling the urge to urinate. The nurse should encourage the client to take deep, slow breaths to help diminish the urge to urinate.

A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client? - "If the medicine causes an upset stomach, take an antacid at the same time." - "Limit your daily fluid intake while taking this medication." - "This medication can cause photophobia, so be sure to wear sunglasses outdoors." - "You should report any tendon discomfort you experience while taking this medication,"

- "You should report any tendon discomfort you experience while taking this medication," The nurse should instruct the client to report any tendon discomfort as well as swelling or inflammation of the tendons due to the risk of tendon rupture.

A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan? Instruct the client to take antibiotics until dysuria is no longer present. Instruct the client to avoid drinking carbonated beverages. Instruct the client to drink 240 mL of tomato juice each day. Instruct the client to drink 1 L of fluid each day.

Instruct the client to avoid drinking carbonated beverages. The nurse should instruct the client to avoid drinking carbonated beverages and caffeine to reduce bladder irritation.

A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse? - Lubricates the first 2.5 to 5 cm (2 in) of the catheter. - Dons sterile gloves before cleaning the client's meatus. - Secures the tubing to the client's upper thigh. - Pulls gently on the catheter to check for resistance after inflating the balloon.

Lubricates the first 2.5 to 5 cm (2 in) of the catheter. The nurse should lubricate the first 2.5 to 5 cm (1 to 2 in) of the catheter when inserting a catheter into a female client. The nurse should lubricate the first 15 to 17.5 cm (6 to 7 in) when inserting a catheter into a male client. cleaning the client's meatus.

A nurse in a clinic is assessing a client who has a new diagnosis of interstitial cystitis. The nurse should expect which of the following Negative urine culture Denies urgency Denies pain with urination Fever

Negative urine culture A laboratory finding of a negative urine culture is consistent with a diagnosis of interstitial cystitis since it is a non-infectious process.

A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record? Enuresis Anuria Nocturia Oliguria

Oliguria The nurse should document the client has oliguria, which is urine output between 100 mL and 400 mL of urine in 24 hr.

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? Stress incontinence Urge incontinence Overfiow incontinence Reflex incontinence

Overflow incontinence These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine? Pale pink Bright yellow Bright red Dark amber

Pale pink The client should expect to pass some small clots and tissue in his urine for few a days, which may give the urine a pale pink color. By 2 to 3 days after surgery, around the time of discharge, his urine should be clear yellow.

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? Increase fluids. Perform a bladder scan. Insert a straight catheter. Provide assistance to bathroom,

Perform a bladder scan. The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? Shakes the soiled linen to remove any toilet paper remnants Places the soiled linen on the floor before bagging it Holds the soiled linen against her body while carrying it to the linen bag Places clean linen that touched the floor in the soiled linen bag

Places clean linen that touched the floor in the soiled linen bag Linen that touches the floor or the AP drops requires laundering.

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? Deflate the catheter balloon using a sterile syringe. Measure and document the urine in the drainage bag. Remove the tape or device securing the catheter to the client's thigh Position the client supine.

Position the client supine. The first action the nurse should take using the nursing process is to place the client in a supine position. This permits adequate visualization and assessment of the perineal area and promotes client comfort and relaxation.

A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take? Raise the side rail on the working side of the bed. Use the non-dominant hand to insert the catheter. Stand on the left side of the bed. Raise the bed to a comfortable height.

Raise the bed to a comfortable height. The nurse should raise the bed to a comfortable height to prevent personal musculoskeletal injury.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? Select all that apply. Relief of urinary retention Convenience for the nursing staff or the client's family Measurement of residual urine after urination Routine acquisition of a urine specimen An open perineal wound

Relief of urinary retention Measurement of residual urine after urination An open perineal woundValid 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.

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) Report of feeling pressure Tenderness over the symphysis pubis Distended bladder Voiding 30 ml frequently - Dysuria

Report of feeling pressure Distended bladder Dysuria Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. Tenderness over the symphysis pubis is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis. Distended bladder is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder, Voiding 30 ml frequently is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine. Dysuria is incorrect. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Dysuria, or painful burning with urination, is not a finding associated with urinary retention.

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? Remind the client to tell the nurse when he has to urinate. Use adult diapers to prevent frequent clothing changes. Take the client to the bathroom every 2 hr. Request a prescription for an indwelling urinary catheter.

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 Urinary frequency for several days Blood-tinged urine Highly concentrated urine

Temporary urinary retention 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 charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? The nurse separates the client's labia with her dominant hand. The nurse coats the indwelling urinary catheter with lubricant. The nurse provides perineal care prior to inserting the urinary catheter. The nurse applies the sterile drape prior to inserting the urinary catheter.

The nurse separates the client's labia with her dominant hand. The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? Urinary tract infection Urinary incontinence Urinary frequency Urinary retention

Urinary tract infection A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCS, RBCS and bacteria, The urine often has an unpleasant odor.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? Perform catheterization when you recognize the urge to void. Hold the penis at a 30° to 45° angle when inserting the catheter. The client should Inflate the balloon when the urine flow stops. Use soap and water to wash the catheter after each use.

Use soap and water to wash the catheter after each use. The client should wash the catheter using soap and water and store it in a clean container after each use.

A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? Omeprazole Vancomycin Ondansetron Diphenhydramine

Vancomycin The nurse should identify that vancomycin, an antibiotic, to be associated with nephrotoxic adverse effects.

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? Insert the needle into the neediess port at a 60° angle. Withdraw 3 to 5 ml of urine from the port. Wipe the area of needleless port with sterile water. Don sterile gloves.

Withdraw 3 to 5 ml of urine from the port. 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.

The nurse is caring for a critically ill patient. What are the contraindications for administering medications by the oral route for this patient? (Select all that apply.) a. Vomiting b. Unconsciousness c. Fractured leg d. Penicillin allergy e. Family visitor f. Diarrhea

a. Vomiting b. Unconsciousness

a nurse is preparing to administer a cleansing enema to an adult client I prep for a diagnostic procedure. which if the following steps should the nurse take? select all that apply. a. warm the enema solution prior to installation b. position client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle d. slowly insert the tube 5 cm (2 inches) e. hang the enema container 61 cm above the clients anus

a. warm the enema solution prior to installation b. position client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle

while a nurse is administering a cleansing enema, the client reports abdominal cramping. which action should the nurse take? a. have the client hold thier breath briefly and bear down b. clamp the enema tubing c. remind the client that cramping is normal d. raise the level of the enema fluid container

b. clamp the enema tubing

a nurse is assessing a client who has had diarrhea for 4 days. which of the following findings should the nurse expect? select all that apply a. bradycardia b. hypotention c. elevated temperature d. poor skin turgor e. peripheral edema

b. hypotention c. elevated temperature d. poor skin turgor

a nurse is providing dietary teaching for a client who reports constipation. which of the following foods should the nurse reccomend? a. macaroni and cheese b. medium apple with skin c. 1 cup plain yogurt d. roast chicken with white rice

b. medium apple with skin

a nurse is caring for a client who will perform fecal occult blood testing at home. what will be included when explaining the procedure? a. eating more protein is.optimal prior to testing b. one stool specimen is sufficient for testing c. a red color change indicates a positive test d. the specimen cant be contaminated with urine

d. the specimen cant be contaminated with urine