Quiz 3 review; Ch. 33, 34, 35
34. For a patient with a nasogastric tube who has a painful, distended abdomen, the first most appropriate action by the nurse is to: 1. remove the tube. 2. irrigate the tube. 3. pull the tube out farther. 4. notify the supervisor.
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41. A nurse is preparing to administer an enema to a 7-year-old child. When assembling the equipment, the nurse will prepare an enema of: 1. 100 to 250 mL of fluid. 2. 300 to 500 mL of fluid. 3. 600 to 800 mL of fluid. 4. 800 to 950 mL of fluid.
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43. A nurse evaluates that a patient has normal bowel sounds by auscultating all four quadrants and finding: 1. 4 sounds per minute. 2. 15 sounds per minute. 3. 40 sounds per minute. 4. no bowel sounds after 1 minute.
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45. A nurse is working with a patient who is a lacto vegetarian. The food that is selected as appropriate for this dietary pattern is: 1. fish. 2. milk. 3. eggs. 4. poultry.
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46. A patient states that he does not eat fish anymore. An appropriate follow-up question by the nurse is which of the following? 1. "Why don't you like fish?" 2. "What caused you to lose interest in fish?" 3. "Does fish make you feel ill in some way?" 4. "Aren't you aware that fish is a valuable source of nutrients?"
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47. Further follow-up is required if a patient informs the nurse that he regularly uses: 1. Fleet enemas. 2. tap water enemas. 3. castile soap enemas. 4. normal saline enemas.
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1. The nurse is teaching a patient about a healthy diet. Which nutrients would the nurse teach the patient to include? 1. Protein, carbohydrate, fat, vitamins, and minerals 2. Protein, carbohydrate, little or no fat, a water-soluble vitamin, and mineral supplements 3. Protein, carbohydrate, trans fats, vitamins, and minerals 4. Protein, carbohydrate, saturated fats, a fat-soluble vitamin, and mineral supplements
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10. What are the major concerns for the nurse caring for a patient receiving parenteral nutrition (PN)? 1. Infection and hyperglycemia 2. Hyponatremia and hypoglycemia 3. Diarrhea or constipation 4. Hypoxia and dehydration
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2. A patient's health care provider orders a post-void residual urine volume by either bladder scan or straight catheterization. The patient states an inability to void. What is your initial nursing intervention? 1. Implement measures to stimulate voiding. 2. Catheterize the patient and record the amount of urine obtained. 3. Measure bladder volume with the bladder scan and record the volume. 4. Notify the health care provider that the patient cannot void.
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3. During an enema the patient complains of cramping abdominal pain that he or she rates as a 6 out of 10. Which action should the nurse take first? 1. Stop the instillation 2. Slow down the rate of instillation 3. Obtain vital signs 4. Tell the patient to bear down as he or she would when having a bowel movement
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4. Which nursing action helps prevent trauma in a male patient with an indwelling urinary catheter? 1. Applying a catheter securement device 2. Washing the catheter with soap and water 3. Keeping the foreskin retracted while the catheter is in 4. Securing the drainage bag to patient's walker
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40. The nurse is documenting the appearance of the colostomy stoma. The term for a stoma that is above the abdominal skin level is: 1. budded. 2. flush. 3. retracted. 4. edematous.
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42. A nurse recognizes that the greatest challenge for skin care will be for a patient with a(n): 1. ileostomy. 2. sigmoid colostomy. 3. descending ostomy. 4. ileoanal pouch.
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43. A nurse is working with a patient who requires an increase in complete proteins in the diet. The nurse recommends: 1. milk. 2. cereals. 3. legumes. 4. vegetables.
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44. A nurse is talking with a community resident who has gone to the health fair. The resident tells the nurse that he takes a lot of extra vitamins every day. Because of the greater potential for toxicity, the resident is advised not to exceed the dietary guidelines for: 1. vitamin A. 2. vitamin B1. 3. vitamin B12. 4. folic acid.
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45. A nurse is caring for a patient with a Salem sump tube for gastric decompression. Which of the following actions by the nurse requires correction? 1. Clamping off the blue lumen or air vent 2. Using clean technique to insert the tube 3. Anchoring the tube to the patient's gown 4. Keeping the nares lubricated
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46. A nurse recognizes that the intake of mineral oil to promote bowel elimination interferes with the absorption of: 1. vitamin A. 2. vitamin B6. 3. vitamin C. 4. niacin.
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48. During a digital removal of a fecal impaction, a nurse notes that the patient has bradycardia. The nurse should: 1. provide oxygen. 2. discontinue the procedure. 3. turn the patient on the right side. 4. instruct the patient to take rapid, deep breaths.
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48. A nurse is preparing the enteral feeding for a patient who has a nasogastric tube in place. The most effective method that the nurse can use to check for placement of a nasogastric tube is to: 1. perform a pH analysis of aspirated secretions. 2. measure the visible tubing exiting from the nose. 3. inject air into the tube and auscultate over the stomach. 4. place the end of the tube into water and observe for bubbling.
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53. While completing an assessment during a home visit, a nurse discovers that the patient has a history of congestive heart failure and is taking digoxin 0.25 mg daily. Being aware that medications may influence the patient's dietary patterns, the nurse is alert to the patient experiencing: 1. anorexia. 2. gastric distress. 3. an alteration in taste. 4. an alteration in smell.
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56. For the family that cans food at home, there is a need for specific instruction about ways to prevent: 1. botulism. 2. E. coli. 3. salmonella. 4. listeriosis.
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56. For the patient who has had a continent urinary reservoir created, the nurse instructs the patient that there will be a need to: 1. catheterize the pouch 4 to 6 times/day. 2. eliminate urine through the intestine. 3. use the Valsalva maneuver to empty the pouch through the urethra. 4. restrict the intake of fluids.
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57. The individual with the highest percentage of water in the body is a(n): 1. infant. 2. obese patient. 3. lean patient. 4. older adult.
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58. A patient on the medical unit is scheduled to have a 24-hour urine collection to diagnose a urinary disorder. The nurse should: 1. note the start time on the container. 2. have the patient void while defecating. 3. start with the first voiding sample from the patient. 4. continue with the test if a specimen is flushed away
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6. Diarrhea may be a result of which of the following conditions in the intestinal tract? 1. Infection, inflammation, food intolerance 2. Loss of sphincter control, infection, decreased peristalsis 3. Inflammation, decreased peristalsis, fecal impaction 4. Food intolerance, fecal impaction, loss of sphincter control
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60. A nurse is instructing the family of a patient who is on an National Dysphagia Diet Task Force (NDDTF) dysphagia puree diet to include: 1. mashed potatoes. 2. moistened breads. 3. well-cooked noodles. 4. soft fruits.
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62. A realistic weight loss goal for the patient who is over- weight is: 1. 1 pound per week. 2. 3 pounds per week. 3. 5 pounds per week. 4. 7 pounds per week.
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63. A patient being seen at a urologist's office suffers from urge incontinence. The nurse anticipates that treatment for this difficulty will include: 1. biofeedback. 2. catheterization. 3. anti-muscarinic drug therapy. 4. electrical stimulation.
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77. A patient who is taking phenazopyridine needs to be instructed that a specific side effect of this medication is that: 1. the urine will turn orange. 2. there will be an increased urinary frequency. 3. back pain will be moderately severe. 4. occasional dizziness may be experienced.
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8. The urine flow has stopped in a patient's indwelling urinary catheter, and the nurse assesses tenderness and distention over the lower abdomen. What is your initial nursing action? 1. Check the drainage tubing for kinks. 2. Encourage patient to drink fluids. 3. Remove the catheter. 4. Notify the health care provider.
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49. A female patient who has gone to a family planning center is taking an oral contraceptive. This patient should increase vitamin B6 and niacin intake. The nurse recommends that the patient consume more: 1. tomatoes. 2. whole grains. 3. citrus fruits. 4. green, leafy vegetables.
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50. A patient tells the nurse that she is a vegan. Which of the following vitamin supplements is needed to promote health for this patient? 1. Niacin 2. Vitamin C 3. Thiamine 4. Vitamin B12
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4. Which information should the nurse teach a patient to prevent foodborne illness? (Select all that apply.) 1. Refrigerate foods at 40° F within 2 hours of cooking. 2. Cook meat, poultry, fish, and eggs until well done (180° F). 3. Do not use food past expiration date. 4. Foods may be safely thawed on the kitchen counter overnight. 5. Oak cutting boards provide a solid surface for chopping foods. 6. Wash fresh fruits and vegetables thoroughly.
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8. Which of the following symptoms are warning signs of possible colorectal cancer according to American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Unexplained abdominal or back pain 5. Muscle cramps 6. Incomplete emptying of the colon 7. Mucus in the stool
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9. What does a nurse teach a female patient recovering from a urinary tract infection about prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back.
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4. Which points would the nurse include when doing patient teaching for a patient with chronic complaints of constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Take laxatives twice a day. 4. Exercise for 30 minutes every day. 5. Schedule time to use the toilet at the same time every day. 6. Eat a high-carbohydrate, low-fat diet.
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1. The nurse should do which of the following when placing a bedpan under an immobilized patient? 1. Have another caregiver lift the patient's hips off the bed and slide the bedpan under the patient 2. Roll the patient on his or her side, place the bedpan against the buttocks, and roll the patient on his or her back while holding the bedpan in place under the buttocks 3. Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient 4. Raise the patient's bed to a sitting position and have two caregivers lift the patient while the nurse slides the bedpan under him or her
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3. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Daily cleansing the urinary meatus with antiseptic solution 2. Hanging the urinary drainage bag below the level with the bladder 3. Changing the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water
2
51. A nurse is assigned to make home visits to a number of pa- tients. Of the patients that the nurse visits, the patient with the greatest risk of a nutritional deficiency is the patient with: 1. decreased metabolic requirements. 2. an alteration in dietary schedule. 3. a body weight that is 5% over the ideal weight. 4. a weight loss of 3% within the past 6 months.
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54. The nurse is going to be catheterizing an average-size 9-year-old boy. The appropriate catheter size for this child is: 1. 5 to 6 FR. 2. 8 to 10 FR. 3. 12 to 14 FR. 4. 15 to 17 FR.
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59. One of a nurse's assigned patients is experiencing urgency urinary incontinence (UI). The nurse anticipates a medication that may be ordered for this difficulty is: 1. propantheline. 2. oxybutynin. 3. bethanechol. 4. phenylpropanolamine.
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6. An elderly woman with dementia is incontinent of urine. She ambulates with a cane, has poor short-term memory, and never alerts staff that she has an urge to void. The staff do not usually see her using the toilet. What is the best nursing intervention for this patient? 1. Offer her a bedpan every 2 hours. 2. Start a scheduled toileting program. 3. Recommend an indwelling catheter. 4. Start a bladder-retraining program.
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61. A nurse recognizes that a patient on a low cholesterol diet requires additional teaching if he indicates that he eats which of the following? 1. oatmeal. 2. pastries. 3. dried fruits. 4. green peppers.
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61. For a renal ultrasound, the patient is instructed to: 1. not eat or drink for 8 hours before. 2. have a full bladder. 3. complete bowel cleansing. 4. not do anything out of his/her routine, because there is no special preparation for this procedure.
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64. A nurse is visiting a patient in the home and notes that additional teaching is required if the patient is observed: 1. cooking poultry to 180° F. 2. thawing frozen foods at room temperature. 3. discarding all foods that may be spoiled. 4. cleaning the inside of the refrigerator with bleach.
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66. To determine the possibility of a renal problem, a patient is scheduled to have an intravenous pyelogram (IVP). Immediately after the procedure, a nurse will need to evaluate the patient's response and be alert to: 1. an infection in the urinary bladder. 2. an allergic reaction to the contrast material. 3. urinary suppression from injury to kidney tissues. 4. incontinence from paralysis of the urinary sphincter.
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66. Which one of the following foods is avoided by the patient on a gluten-free diet? 1. Cow's milk 2. Oatmeal 3. Canned fruit 4. Coffee
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69. A female patient has an order for urinary catheterization. A nursing student will be evaluated by the instructor on the insertion technique. The student is identified as implementing appropriate technique if: 1. the catheter is advanced 7 to 8 inches. 2. a new cotton ball or swab is used for each wipe when cleansing the urethral meatus. 3. the catheter is reinserted if it is accidentally placed in the vagina. 4. both hands are kept sterile throughout the procedure.
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73. A nurse recognizes that one of the specific purposes of intermittent catheterization is for: 1. prevention of obstruction. 2. assessment of residual urine. 3. urinary drainage during surgical procedures. 4. recording of output for comatose patients.
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75. The best way to remove urine from a patient's skin is for the nurse to use: 1. alcohol. 2. mild soap. 3. an antibacterial agent. 4. a hydrogen peroxide mix.
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78. A nurse anticipates that a treatment option for a patient with functional incontinence will include: 1. catheterization. 2. bladder training. 3. electrical stimulation. 4. hormone replacement.
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8. Which measure should the nurse take to ensure safety while the patient is receiving feeding via a nasally placed gastric feeding tube? 1. Administer medications together to reduce the amount of fluid you need to flush the tube 2. Ensure that the tube is well secured and that no more tube is external than when the tube was originally placed and determined to be in good position whenever you are with the patient and at least every 4 hours 3. Listen while a bolus of air is injected to ascertain placement before you administer medication into the tube 4. Consider that the amount of feeding and fluid that are administered for this patient must be adequate to meet his or her needs because they are the same amounts that you have been using for other patients
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50. The nurse is aware that a test for fecal ova and parasites requires: 1. performing the test 3 times while the patient is NPO. 2. keeping the sample at room temperature or warming. 3. using a chemical fixative for the sample. 4. saving the sample for 3 to 5 days.
3
53. The nurse recognizes that an intervention for a patient with stress incontinence is instruction regarding: 1. use of a mobility aid. 2. intermittent catheterization. 3. pelvic muscle exercises. 4. antimuscarinic medications.
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6. Which interventions by the nurse promote nutrition for a patient whose oral intake is less than required? (Select all that apply.) 1. Offering antinausea medication after meals 2. Suggesting substitutions, such as nutritious snacks, to enhance nutritional value 3. Encouraging frequent small meals 4. Telling the patient he will need for parenteral nutrition if he doesn't eat better
23
10. A healthy 50-year-old male has a history of prostate disease. Which nursing assessment question best indicates that he is not emptying his bladder completely and has overflow incontinence? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine?
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10. When a patient has fecal incontinence, which point is important for the nurse to instruct to all caregivers? 1. Cleanse the skin with antibacterial soap and apply baby powder. 2. Use diapers and heavy padding on the bed. 3. Cleanse the skin with a no-rinse cleanser and apply a barrier ointment. 4. Help the patient to toilet once every hour.
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3. Which factor related to nutrition does the nurse need to consider when planning care of patients in different age-groups and stages of life? 1. Pregnant patients have the same nutritional requirements as nonpregnant patients. 2. Adolescents no longer need calcium for bone growth. 3. Elderly patients may not need as many calories as younger patients. 4. Infants should remain on breast milk or formula only for the first year of life.
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35. A patient expresses a feeling of mild cramping during the administration of a saline enema. The nurse should first: 1. discontinue the procedure. 2. change the solution. 3. lower the bag to slow the infusion. 4. allow the solution to cool.
3
36. The patient begins to cough during the insertion of the nasogastric tube. The nurse should: 1. remove the tube. 2. lower the head of the bed 3. check the back of the throat. 4. advance the tube further.
3
38. For patients who have been prescribed extended bed rest, the prolonged immobility may result in reduced peristalsis and fecal impaction. A nurse is alert to one of the first signs of an impaction when the patient experiences: 1. headaches. 2. abdominal distention. 3. overflow diarrhea. 4. abdominal pain with guarding.
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49. In the teaching plan for a patient who will be having a fecal occult blood test, which of the following foods should be noted for producing a false negative result? 1. Fish 2. Pasta 3. Vitamin C 4. Whole grain bread
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5. An older-adult patient is admitted with a history of recent weight loss of 20 lbs over the last 6 months. The patient wears dentures, has lactose intolerance, and is allergic to shellfish. Which finding in the medical history indicates the patient is at high risk for poor nutrition? 1. Shellfish allergy 2. Lactose intolerance 3. 20-lb weight loss 4. Dentures
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5. What is the recommended catheter and balloon size for an indwelling catheter for an adult patient with urinary retention? 1. 10 Fr, 3 mL 2. 14 Fr, 30 mL 3. 16 Fr, 10 mL 4. 20 Fr, 10 mL
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5. When caring for a patient with a new colostomy on the first postoperative day, which of the following tasks would be appropriate to teach the patient? 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. What kind of diet he or she should be eating in the hospital
3
55. For the nursing diagnosis Functional Urinary Incontinence, the difficulty is related to the patient's: 1. inability to completely empty the bladder. 2. lack of sensation of a full bladder. 3. difficulty in getting out of the chair and going to the toilet. 4. pressure during coughing or sneezing.
3
55. Which of the following statements made by the parent of an infant indicates the need for additional teaching? 1. "I'll wait to give the baby regular cow's milk until he is a year old." 2. "I'll start with cereal as the first solid food that I give to the baby after about 4 months." 3. "I'll add a little honey to the baby's bottle to help him digest the formula." 4. "When he can have them, I'll wait a few days in between giving the baby any new foods."
3
57. The nurse is going to explain to new parents about toilet training. The parents are informed that early onset of a child's control of voluntary voiding does not occur until the age of: 1. 6 months old. 2. 12 months old. 3. 18 months old. 4. 4 years old.
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62. Prevention of infection is a patient outcome that is identified for a patient with a urinary alteration and an indwelling catheter. The nurse assists the patient to attain this outcome by: 1. emptying the drainage bag daily. 2. draining all urine after the patient ambulates. 3. performing perineal care q8h and prn. 4. opening the drainage system only at the connector points to obtain specimens.
3
63. To prevent the presence of E.coli in food, a nurse specifically instructs a patient and family to: 1. carefully can foods at home. 2. boil shellfish completely. 3. cook ground beef well. 4. keep dairy products refrigerated.
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65. Tube feedings are ordered for a patient with a nasogastric tube. Unless the agency specifies otherwise, the nurse should: 1. dilute the feedings with water. 2. infuse the feedings over the course of 1 to 2 hours. 3. begin with 150 to 250 mL at a time. 4. increase feedings by 100 to 150 mL per feeding every 8 hours.
3
67. A unit manager is evaluating the care that has been given to a patient by a new nursing staff member. The manager deter- mines that the staff member has implemented an appropriate technique for clean-voided urine specimen collection if: 1. fluids were restricted before the collection. 2. sterile gloves were applied for the procedure. 3. the specimen was collected after the initial stream of urine had passed. 4. the specimen was placed in a clean container and then placed in the utility room.
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7. When nutrition support is indicated for your patient, which of the following would be an appropriate factor for the use of parenteral nutrition (PN) instead of enteral tube feeding? 1. It has less serious complications. 2. It can be started immediately in an existing intravenous line. 3. It can be used when the gastrointestinal tract does not function adequately to absorb nutrients. 4. It should be used when the patient's advanced directive indicates that no aggressive measures such as a feeding tube are to be used.
3
72. For patients with diabetes mellitus, a nurse anticipates that the patients will experience: 1. dribbling. 2. hesitancy. 3. polyuria. 4. hematuria.
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74. A nurse notes that there is no urine in a drainage bag since it was emptied 11⁄2 hours ago. The nurse should first: 1. remove the catheter. 2. provide additional fluids. 3. check for kinks or bends in the tubing. 4. apply external pressure on the patient's bladder.
3
76. A nurse manager is observing a new nurse staff member provide care for a patient with a condom catheter. The man- ager determines that correction and additional instruction are required for the new employee if the staff nurse is observed: 1. draping the patient and exposing only the genitalia. 2. attaching the urinary drainage bag to the lower bed frame. 3. using adhesive tape to secure the catheter to the patient's penis. 4. clipping the hair at the base of the penile shaft.
3
9. The nurse is teaching the patient to obtain a specimen for fecal occult blood testing (FOBT) at home. Which is the correct way for the patient to collect the specimen? 1. Three fecal smears from one bowel movement 2. One fecal smear from an early-morning bowel movement 3. One fecal smear from three separate bowel movements 4. Three fecal smears when blood can be seen in the bowel movement
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2. A patient has not had a bowel movement for 5 days. Now the patient has small amounts of liquid stool seepage and complains of "rectal pressure." Based on this scenario, which problem should the nurse suspect? 1. An intestinal obstruction 2. Irritation of the intestinal mucosa 3. Gastroenteritis 4. A fecal impaction
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2. In reviewing a patient's chart, the nurse notes that the patient's serum albumin level is 2.5 g/dL and the BMI is 35. In analyzing the laboratory values, the nurse identifies which problem for the patient? 1. This patient is underweight. 2. This patient is malnourished. 3. This patient needs a nitrogen balance study. 4. This patient is obese.
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37. A nurse observes a nursing assistant carrying out bowel retraining with a patient in the extended care facility. The nurse identifies that the assistant implements an incorrect procedure when: 1. allowing the patient adequate time in the bathroom. 2. taking the patient to the bathroom at regular times throughout the day. 3. pulling the curtain around the patient while on the commode. 4. restricting fluids with breakfast and lunch meals.
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39. A patient has been admitted to an acute care unit with a diagnosis of biliary disease. When assessing the patient's feces, the nurse expects that they will be: 1. bloody. 2. pus filled. 3. black and tarry. 4. white or clay colored.
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44. A nurse instructs a patient who is taking an iron supple- ment that his stool may be: 1. red and liquid. 2. pale and frothy. 3. mucus filled. 4. black and tarry.
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47. A nurse is preparing to insert a nasogastric tube for enteral feedings. The nurse recognizes that this intervention is used when the patient: 1. has a gag reflex. 2. is not able to chew foods. 3. is slow to eliminate food. 4. is not able to ingest foods.
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52. After surgery, a patient is having her dietary intake advanced. After a period of NPO, the patient is placed on a clear liquid diet. What food does the nurse request for the patient? 1. Milk 2. Soup 3. Custard 4. Popsicles
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54. A patient on the unit has an enteral tube in place for feedings. When the nurse enters the room, the patient says that he is experiencing cramps and nausea. The nurse should: 1. cool the formula. 2. remove the tube. 3. use a more concentrated formula. 4. decrease the administration rate.
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58. A patient with a gastrostomy has an excessive residual volume of 200 mL. The nurse should: 1. request an order for a chest x-ray. 2. alter the type of feeding being given. 3. request an order for an antidiarrheal agent. 4. return the contents to the stomach.
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59. A nurse is monitoring a patient's laboratory reports. Which of the following, if decreased, is indicative of anemia? 1. BUN level 2. Creatinine level 3. Albumin level 4. Hemoglobin level
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60. Several patients in a long-term care unit have indwelling urinary catheters in place. A nurse is delegating catheter care to the nursing assistant. The nurse includes instruction in: 1. using lotion on the perineal area. 2. disinfecting the first 2 to 3 inches of the catheter every 2 hours. 3. ensuring that the drainage bag is secured to the side rail. 4. cleansing about 4 inches along the length of the catheter, proximal to distal.
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64. Anursenotesthatthereisanorderonapatient'srecordfora sterile urine specimen. The patient has an indwelling urinary catheter. The nurse will proceed to obtain this specimen by: 1. withdrawing the urine from a urinometer. 2. opening the drainage bag and removing urine. 3. disconnecting the catheter from the drainage tubing. 4. using a syringe to withdraw urine from the catheter port.
4
65. A patient had a laparoscopic procedure in the morning and is having difficulty voiding later that day. Before initiating invasive measures, the nurse intervenes by: 1. administering a cholinergic agent. 2. applying firm pressure over the perineal area. 3. increasing the patient's daily fluid intake to 3000 mL. 4. rinsing the perineal area with warm water.
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67. The patient is receiving continuous enteral nutrition via a nasogastric tube and begins to vomit. The nurse should: 1. slow down the feeding. 2. remove the tube. 3. aspirate remaining gastric content. 4. place the patient in side-lying position.
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68. A patient at the urology clinic is diagnosed with reflex incontinence. This problem was identified by the patient's statement of experiencing: 1. a constant dribbling of urine. 2. an urge to void and not enough time to reach the bathroom. 3. an uncontrollable loss of urine when coughing or sneezing. 4. no urge to void and being unaware of bladder fullness.
4
68. During the insertion of a nasogastric tube, the unit nurse manager is observing the new nurse graduate. Correction is required when the new nurse: 1. has the patient flex the head after the tube passes the nasopharynx. 2. rotates the tube 180 degrees during the insertion. 3. encourages the patient to swallow as the tube moves along. 4. advances the tube during patient inspiration.
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70. A patient is diagnosed with prostate enlargement. The nurse is alert to a specific indication of this problem when finding that the patient has: 1. chills. 2. cloudy urine. 3. polyuria. 4. bladder distention.
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71. Stress incontinence is associated with: 1. irritation of the bladder. 2. neurological trauma. 3. alcohol or caffeine ingestion. 4. coughing or sneezing.
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9. Which point is important for the nurse to include in the plan of care to monitor the patient's tolerance to enteral tube feeding? 1. Strict guidelines for residual volumes 2. Serum albumin level 3. Lack of feeding tube misplacement 4. Abdominal assessment and monitoring of bowel status
4
1. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.
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7. Place the steps for changing an ostomy pouch in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch into place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
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A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with A. Abnormal defecation. B. Constipation. C. Fecal impaction. D. Fecal incontinence.
b
To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because A. The presence of food stimulates peristalsis. B. Mass colonic peristalsis occurs at this time. C. Irregularity helps to develop a habitual pattern. D. Neglecting the urge to defecate can cause diarrhea.
b
A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse's response is the A. Bladder. B. Kidney. C. Nephron. D. Ureter.
c
A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct quantities of nutrients. Which statement reflects that she understands the dietary guidelines? A. "I am not concerned with what I am eating." B. "I am taking vitamin doses based on TV." C. "I am taking a daily MVI." D. "I am making eating choices according to the recommended dietary allowances and intakes."
d
A health care provider may suspect that a patient is experiencing urinary retention when the patient has A. Large amounts of voided cloudy urine. B. Pain in the suprapubic region. C. Spasms and difficulty during urination. D. Small amounts of urine voided 2 to 3 times per hour.
d
