PrepU Questions 230: Unit 2
The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? "Begin the collection when you first urinate in the morning." "Discard your first urine and begin the collection after that." "Start collecting the urine with the next time you urinate." "You will need to have a catheter inserted for this collection."
"Discard your first urine and begin the collection after that."
The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching? "A woman using an intrauterine device for contraceptive reason is at risk for developing a UTI." "I will make sure to teach my clients with diabetes mellitus to control their glucose level to help prevent a UTI." "Having sexual relationships does not put a woman at risk for developing a UTI." "Due to the physiologic changes with aging, the elderly are at risk for developing a UTI."
"Having sexual relationships does not put a woman at risk for developing a UTI."
The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter? "This is the only option for catheterization." "This is what your health care provider has prescribed." "Indwelling catheters do not hurt, and I will be careful placing it." "Let me talk to your health care provider about a condom catheter."
"Let me talk to your health care provider about a condom catheter."
The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response? "This is extremely abnormal. You will need to see your son's pediatrician." "I would only worry about this if you were raising a daughter." "It would be appropriate to place your son in incontinence undergarments." "Let's review the types of fluids that your child drinks in the morning."
"Let's review the types of fluids that your child drinks in the morning."
A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response? "I agree; please make an appointment with your health care provider." "This only happened one time, so it is nothing to worry about." "Let's review your medication history and whether you consume bladder irritants." "I suggest that you invest in incontinence undergarments."
"Let's review your medication history and whether you consume bladder irritants."
A 74-year-old man has been taking a beta-blocker for several years, and his care provider has chosen to add a diuretic to his regimen to better control his hypertension. What should the clinician teach the client about the relationship between his new medication and his nutritional health? This might make you constipated at first, so try to include more fiber in your diet. "This will make you urinate more often, so make sure you drink plenty of fluids." "Let me know if you feel nauseous after you start these pills, because it's not uncommon." "When you pick up your prescription at the pharmacy, it would be a good idea to buy some over-the-counter iron supplements as well."
"This will make you urinate more often, so make sure you drink plenty of fluids."
A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight? 130 lb 135 lb 140 lb 145 lb
145lb
A nurse assesses a 105-pound adult client who is 5 feet 8 inches tall. What is the estimated body mass index (BMI) for this client? 16 18 20 22
16
A nurse assesses a 114-pound adult client who is 5 feet 5 inches tall. What is the estimated body mass index (BMI) for this client? 19 BMI 20 BMI 21 BMI 22 BMI
19 BMI
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? 24-hour specimen clean-catch specimen random specimen intermittent specimen
24 hour specimen
A nurse is calculating the ideal body weight for a male client who 6 feet 7 inches tall and has a large body frame. Which of the following is this client's ideal body weight? 202 222 242 262
242
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet? 1 3 5 7
5
Which of the following clients will have an increased metabolic rate and require nutritional interventions? A healthy young adult who works in an office. A retired person living in a temperate climate. A person with a serious infection and fever. An older, sedentary adult with painful joints.
A person with a serious infection and fever
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? Percuss the site to feel for a thrill or vibration. Auscultate over the site with a stethoscope to listen for a bruit. Use the affected arm if an IV must be started to avoid impairment of both arms. If a thrill is not palpable and/or a bruit is not detectable, assess for these signs in the other arm.
Auscultate over the site with a stethoscope to listen for a bruit.
The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.
Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.
The nurse is assessing a client with a urinary sheath catheter. After removing the catheter, the nurse observes a break in skin integrity on the penis. What actions by the nurse would be appropriate at this time? Select all that apply. Do not reapply the urinary sheath Allow the skin to be open to air as much as possible Wash the area with soap and water and apply the catheter Arrange for a consult with a wound nurse Insert an indwelling catheter instead
Do not reapply the urinary sheath Allow the skin to be open to air as much as possible Arrange for a consult with a wound nurse
A male client who was transferred from intensive care and extubated less than 24 hours ago exhibits drooling and a weak voice. At meal time, what is the nurse's priority action? Delegate feeding the client to a nursing assistant. Place the client in semi-Fowler's position for feeding. Call the healthcare provider to request a liquid diet. Explain to the client why he should not eat anything by mouth yet.
Explain to the client why he should not eat anything by mouth yet
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? Remove the catheter every 8 hours, or more often in humid weather. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application. Fasten the condom securely enough to prevent leakage without constricting blood flow. Ensure the tip of the tubing is touching the tip of the client's penis.
Fasten the condom securely enough to prevent leakage without constricting blood flow
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease? Clients with a BMI of 23. Females with 88.9 cm (35 in) or greater waist circumference. Males with 88.9 cm (35 in) or greater waist circumference. Clients with a BMI of 20.
Females with 88.9 (35) or greater waist circumference
The nurse is caring for a client with a history of renal insufficiency and type 2 diabetes. Which prescription, if noted in the client's chart, would alert the nurse to discuss with the health care practitioner? Gentamicin 70 mg intramuscular (IM) every 8 hours Blueberry juice 10 oz by mouth (PO) daily Urine dipstick four times a day Encourage fluids intake - 2 to 3 L per day
Gentamicin 70 mg intramuscular (IM) every 8 hours
The nurse is changing a stoma appliance on an ileal conduit. Which nursing action is recommended procedure? Select all that apply. Gently remove the appliance, starting at the top and keeping the abdominal skin taut. Remove appliance faceplate by pulling appliance from skin rather than pushing. Apply a silicone-based adhesive remover by spraying or wiping as needed. Clean skin around stoma with alcohol on a gauze pad. Make sure skin around stoma is thoroughly dry by patting it dry. Apply faceplate by using firm, even pressure for approximately 60 seconds.
Gently remove the appliance, starting at the top and keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping as needed. Make sure skin around stoma is thoroughly dry by patting it dry.
hich of the following findings from a nutritional history most likely indicate the client is showing signs of an eating disorder? (Select all that apply.) Seeks help when concerned about weight Has body mass index of 16 Exercises for 30 minutes 3-5 times per week Discusses feeling fat in clothes Has body mass index of 23
Has body mass index of 16 Discusses feeling fat in clothes
When teaching a nutrition class, what would you recommend for adults older than the age of 50? Increase foods rich in vitamin B6 and saturated fats Increase foods rich in vitamin E and folic acid Increase foods rich in vitamin B12 and calcium Increase foods rich in vitamin B6 and vitamin D
Increase food rich in vitamin B12 and calcium
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? Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. Ask the client to bear down until the catheter is expelled. Remove the catheter from the vagina and attempt to insert it into the bladder.
Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
A nurse needs to record the height of a client who refuses to stand because of blisters on the feet. What alternative method should the nurse implement to obtain the client's height? Measure the arm span to estimate height Provide support or hold the client to record the height Obtain this information subjectively from the client Use a standard chart for height by age and gender
Measure the arm span to estimate height
After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings? Clothing appears too large Nails are strong Hair is thin and appears oily Oral mucosa is pink with white patches
Nails are strong
How can a nurse best assess a client's dietary habits? Assess for the presence of any chronic disease processes Obtain a 24 hour dietary recall of all foods and fluids consumed Obtain a height and weight and calculate a body mass index (BMI) Ask about how much food is eaten at an average meal
Obtain a 24 hour dietary recall of all foods and fluids consumed
A client with a body mass index of 28 tells the nurse she is concerned about her risk for hypertension. What can the nurse recommend to this client? Reducing her weight by 5% can lower her risk Structure eating so that no more than 500 calories are consumed each day. Plan to reduce weight by 20% in 6 months. Reduce daily calorie intake by 100 calories each day.
Reducing her weight by 5% can lower her risk
A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? The client is on a low protein diet. The client is dehydrated. The client has a history of osteoarthritis. The client is lactose intolerant.
The client is dehydrated
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? The client may bathe rather than shower, provided the site is covered with gauze. A dressing should always be worn over the site to avoid leaking. Sterile technique must be observed by the client in the home setting. The client should avoid wearing tight clothes or belts near the site.
The client should avoid wearing tight clothes or belts near the site.
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? This urinary diversion is only temporary. The client will need to change the urinary pouch every 4 hours. The client will have to wear an external appliance to collect urine. Urination can be voluntarily controlled after the stoma heals from the initial surgery.
The client will have to wear an external appliance to collect urine.
The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted? The novice nurse asks the client to take a deep breath when resistance was met during insertion of the catheter. The novice nurse selects an 18 French Foley catheter to insert. The novice nurse places a trash receptacle within easy reach. The novice nurse assists the client to a dorsal recumbent position with knees flexed, feet about 2 ft (0.6 m) apart.
The novice nurse selects an 18 French Foley catheter to insert.
A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly? Clean the perineal area with a gauze pad and alcohol using a different corner of the gauze with each stroke. Assist the client to a prone position with knees flexed, feet about 2 ft (0.6 m) apart, with legs abducted. Using dominant hand, hold the catheter 1 ft (0.3 m) from the tip and insert slowly into the urethra. Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.
Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe
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? Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. 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. Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure.
Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.
Parents of a 15 month old state they are worried about the rolls of fat on the toddler's thighs; so they have switched him over to skim milk. What is the nurse's best response? "You should start seeing some weight loss while he's drinking the skim milk." "As he starts walking more, he will develop more fat rolls." "Whole milk is recommended until age 2." "You should transition to skim milk by giving him 2% milk first."
Whole milk is recommended until age 2
A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic.
Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique.
A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter? a flexible sheath that is rolled around the penis a bag attached by adhesive backing to the skin around the genitals a urine drainage tube inserted but not left in place a urine drainage tube that is left in place over a period of time
a flexible sheath that is rolled around the penis
A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status? Food preparation Finances Accessibility Food preferences
accessibility
A client with a body mass index of 14 refuses to eat breakfast and cuts up the food for lunch and dinner but does not eat anything. What should the nurse suspect this client is demonstrating? cachexia bulimia nervosa anorexia nervosa metabolic syndrome
anorexia nervosa
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? anuria oliguria nocturia urinary retention
anuria
The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take? Inform the client that the health care provider will be contacted. Ask the client why he or she does not want a catheter. Gather appropriate supplies to teach the client to perform straight catheterization. Continue to place the indwelling catheter because it has been prescribed.
ask the client why he or she does not want a catheter
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Administer an IV on the arm high above the access site. Perform venipuncture below the access site to obtain a blood sample for laboratory testing. Measure the client's blood pressure on the arm above the access site.
auscultate over the access site with the bell of stethoscope, listening for a bruit or vibration
During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination? bone pain paresthesias dry flaky skin bleeding gums
bleeding gums
When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine? dehydration infection stasis blood
blood
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? Incontinence after the age of 3 years is not normal. Boys may take longer for daytime continence than girls. Boys may walk by 1 year and should be continent by 3 years. Daytime continence is usually not achieved by boys until age 5.
boys may take longer for daytime continence than girls
Which symptom will have a great impact on the extracellular fluid for water conservation? Burns Fracture Small laceration Pain
burns
A woman is reporting bladder urgency. It is most important to assess: exercise. weight. caffeine intake. vitamin supplements.
caffeine intake
The nurse should perform which priority assessment on a client with a history of a high hydrogenated fat intake? Respiratory Skin Cardiac Musculoskeletal
cardiac
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? checking that the client has signed a consent form for the procedure explaining to the client that the procedure will be painful maintaining the client without liquids before the procedure inserting a Foley catheter the morning of the procedure
checking that the client has signed a consent form for the procedure
A nurse is providing nutritional instruction to a client with cardiovascular disease. The nurse mentions a nutrient that is a necessary component of bile salts (which aid in digestion), serves as an essential element in all cell membranes, is found in brain and nerve tissue, and is essential for the production of several hormones such as estrogen, testosterone, and cortisone. The nurse warns the client, however, that this nutrient when consumed in excess can lead to heart attacks and strokes. To which of the following nutrients is the nurse referring? Cholesterol Saturated fat Unsaturated fat Protein
cholesterol
A nurse recognizes that a client may be at risk for malnutrition when which lifestyle behavior is present? Single parenthood Diabetes mellitus Excessive exercise Chronic dieting
chronic Dieting
A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first? Release a small amount of urine into the toilet. Void normally to empty the bladder. Clean each side of the urinary meatus with a separate wipe. Catch a sample of urine in the specimen container.
clean each side of the urinary meatus with a separate wipe
The 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? cloudy, foul odor light yellow, clear clear, dark amber strongly aromatic, amber
cloudy, foul odor
A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? Monitor vital signs Contact the health care provider Encourage fluids Instruct on proper wiping technique
contact the health care provider
A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women? Contract abdominal muscles 10 times per day. Squat down and then jump up to a standing position. Lie on the floor, raise, then lower your legs 20 times per day. Contract the pubic muscles for 3 seconds, then relax.
contract the pubic muscles for 3 seconds then relax
A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? reddish-brown, clear clear, light yellow dark brown, cloudy aromatic, green
dark brown
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? dehydration hypovolemia balanced fluids renal failure
dehydration
A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. Diabetes Hypertension Sleep apnea Anorexia Cirrhosis
diabetes, hypertension, sleep apnea
The nurse has placed a urine collection bag on an infant. How often should the nurse check the bag to see if the infant has voided? Every 15 minutes Every 30 minutes Every 45 minutes Every 60 minutes
every 15 minutes
Upon assessment, the nurse determines the client has a body mass index (BMI) of 45. This finding indicates the client is which of the following? Extremely obese Underweight Normal weight Obese
extremely obese
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? before bedtime afternoon evening first thing in the morning
first thing in the morning
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? Having the client sign a consent form for the procedure Explaining to the client that the procedure will be painful Maintaining the client without liquids before the procedure Inserting a Foley catheter the morning of the procedure
having the client sign a consent form for the procedure
The nurse is caring for an adult female client whose BMI is 38.7. The nurse should instruct the client that she is at greater risk for heart attack. osteoporosis. rheumatoid arthritis. stomach cancer.
heart attack
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data? Fluid volume, excessive Imbalanced nutrition Activity intolerance Knowledge deficit
imbalanced nutriton
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? indwelling urethral catheter intermittent urethral catheter Foley catheter retention catheter
intermittent urethral catheter
The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? Loosen the internal muscles used to prevent or interrupt urination. Keep muscles contracted for at least 10 seconds. Relax muscles for at least 5 minutes between Kegels. Perform these exercises two times daily for a week.
keep muscles contracted for at least 10 seconds
A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? "It would be best just to get some adult diapers." "Let me refer you to a urologist who can help you." "Don't worry, this is a normal condition for older adults." "Let's explore structuring activities and toileting breaks."
lets explore structuring activities and toileting breaks
A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? loss of small amount of urine when intra-abdominal pressure rises need to void is perceived frequently, with short-lived ability to sustain control of flow loss of urine control because a toilet is not accessible loss of urine without any identifiable pattern or warning
loss of urine without any identifiable pattern or warning
A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? Calculating the flow rate of urinary output Monitoring the characteristics of the urinary output Assessing PVR using a bladder scanner Palpating the client's bladder region
monitoring the characteristics of the urinary output
A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved? Glomerulus Bowman's capsule Loop of Henle Nephron
nephron
A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a: cystocele. enuresis. overactive bladder. neurogenic bladder.
neurogenic bladder.
A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? Placing the client as N.P.O. status. Obtaining laboratory studies. Sitting the client up in a greater than a 40-degree angle. Notifying the health care provider of the assessment findings
notifying the health care provider of the assessment findings
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? Checking for blood return in the CVC Placing the client as N.P.O. status Notifying the health care provider of the assessment findings Obtaining laboratory studies
notifying the health care provider of the assessment findings
You are the clinic nurse assessing a new client that has come in to see a physician. The assessment data that you collect reveals that the client is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered? Average weight Obese Overweight Underweight
obese
An young adult female presents at the clinic with fatigue and long, heavy periods. Blood is drawn for laboratory testing, and findings include both low hemoglobin and hematocrit levels. What can these low levels indicate? Poor iron absorption Fluid deficit High-folate level Decreased calcium level
poor iron absorption
A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? Position the client in a supine position. Administer a diuretic, as ordered. Have the client rest for 15 minutes before the assessment. Assess the client's need for analgesia.
position the client in a supine position
A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking? Body mass index Waist circumference Mid-arm circumference Skinfold thickness
skinfold thickness
Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? Foley catheter suprapubic catheter indwelling urethral catheter straight catheter
straight catheter
An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? Urge Stress Overflow Functional
stress
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? reflex incontinence stress incontinence urge incontinence functional incontinence
stress incontinence
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? cloudy, foul odor light yellow, clear clear, colorless strongly aromatic, dark amber
strongly. aromatic, dark amber
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? The birth can cause perineal swelling. A neurogenic bladder results from local anesthesia. A urinary tract infection results from the birth process. Catheterization is necessary for 1 week.
the birth can cause perineal swelling
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? The client has an enlarged prostate. The diameter of the catheter is too large. The nurse failed to deflate the retention balloon after pretesting it for integrity. The client has an occult abscess in the urethra.
the client has an enlarged prostate
The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider? Respiratory rate Temperature Thrill and bruit Pedal pulses
thrill and bruit
The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include? Tighten the internal muscles used to prevent or interrupt urination. Keep muscles contracted for at least 30 seconds. Relax muscles for at least 1 minute between contractions. Perform these exercises 10 times daily for 1 month.
tighten the internal muscles used to prevent or interrupt urination
Use of an indwelling urinary catheter leads to the loss of bladder tone. True False
true
The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice? Specimen hat Large urine collection bag Bedpan Urinal
urinal
The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify? urinary tract infection (UTI) urinary retention urinary incontinence urinary suppression
urinary retention
When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient? Vitamin B Thiamine Iodine Niacin
vitamin B
The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client? "Void into the specimen hat in the toilet bowl." "Void a small amount, stop, and discard it." "Save all urine for the next 24 hours." "You will have a catheter put in to collect the urine."
void a small amount, stop, and discard it
The nurse assesses sunken eyes and poor skin turgor in a client. What should the nurse consider as a potential cause for these findings? vomiting high salt diet kidney failure heart problems
vomiting
A nurse has just determined a client's body mass index (BMI). Which measurement should the nurse add to the BMI to increase the predictive ability for health risk to the client? Mid-arm circumference Triceps skinfold measurement Waist circumference Mid-arm muscle circumference
waist circumference
What is the most common measurement used to determine abdominal visceral fat? Waist circumference. Body mass index. Subcutaneous fat determination. Triceps skinfold thickness.
waist circumference
Because BMI is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client with diabetes. who is 182.8 cm (6 ft) tall. with osteoarthritis. who is a bodybuilder.
who is a bodybuilder
