Concepts Unit 3 - Elimination
A nurse caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take. 1 - Perform a tape test 2 - Collect stool specimen for culture 3 - Test the stool for occult blood 4 - Ensure IV fluids are initiated
1 - Perform a tape test
A nurse is providing teaching to a client about using leuprolide to treat endometriosis. Which of the following instructions should the nurse include? 1 - Perform weight-bearing activities. 2 - Wear sunscreen or protective clothing 3 - Take the drug with food to increase absorption. 4 - Avoid drinking grapefruit juice.
1 - Perform weight-bearing activities.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take? 1 - Position the client supine 2 - Have the client bear down during removal 3 - Cleanse the perineal area with an antiseptic 4 - Deflate the balloon halfway and then pull out the catheter.
1 - Position the client supine
A nurse is teaching a client who has a new prescription for transdermal testosterone gel to treat delayed puberty. Which of the following instructions should the nurse include? (Select all) 1 - "Apply the gel to the scrotum." 2 - "Cover the area of application with clothing." 3 - "Wash your hands after applying the gel." 4 - "Do not shower for several hours after applying the gel." 5 - "Apply the gel to the gums above an upper incisor."
2 - "Cover the area of application with clothing." 3 - "Wash your hands after applying the gel." 4 - "Do not shower for several hours after applying the gel."
The charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene? 1 - "It will be easier to use your non-dominant hand to spread the labia." 2 - "Use the provided towelette to cleanse the area by moving in a back-and-forth motion." 3- "Start the flow of urine before passing the container under the stream to collect the specimen." 4 - "Remove the specimen container before stopping the stream of urine.:
2 - "Use the provided towelette to cleanse the area by moving in a back-and-forth motion."
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following information should the nurse include in the teaching? 1 - "You can expect fecal output within 24 hours." 2 - "You may experience a small amount of bleeding around the stoma." 3 - "You will need to increase your dietary intake of raw vegetables." 4 - "You can expect the stoma to be purplish in color for the first week."
2 - "You may experience a small amount of bleeding around the stoma."
A nurse is caring for a child who has enuresis. The nurse should monitor for which of the following as a complication of enuresis? 1 - UTI 2 - Altered body image 3 - Urosepsis 4 - Progressive kidney disease
2 - Altered body image
A nurse is reinforcing teaching with the a parent of a child who has a UTI. Which of the following should the nurse include? (Select all) 1 - Wear nylon underpants 2 - Avoid bubble baths 3 - Empty the bladder completely with each void 4 - Report recurrence of urinary frequency 5 - Wipe perineal area back to front
2 - Avoid bubble baths 3 - Empty the bladder completely with each void 4 - Report recurrence of urinary frequency
A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (Select all) 1 - Limit total daily fluid intake 2 - Decrease or avoid caffeine 3 - Take calcium supplements 4 - Avoid drinking alcohol 5 - Use the Crede maneuver
2 - Decrease or avoid caffeine 4 - Avoid drinking alcohol
A nurse is reinforcing teaching with a client who has a urinary tract infection (UTI). Which of the following risk factors should the nurse include in the teaching? 1 - COPD 2 - Diabetes mellitus 3 - Anema 4 - Osteoporosis
2 - Diabetes mellitus
A nurse is assessing a client who has a new prescription of oxybutynin to treat neurogenic bladder. Which of the following assessment findings should the nurse identify as an adverse effect of the drug? (Select all) 1 - Diaphoresis 2 - Dilated pupils 3 - Dizziness 4 - Distended bladder 5 - Fever
2 - Dilated pupils 3 - Dizziness 4 - Distended bladder 5 - Fever
A nurse is providing teaching to a client about sildenafil to treat erectile dysfunction. Which of the following instructions should the nurse include? 1 - Take the drug with a glass of grapefruit juice 2 - Do not take the drug with high-fat foods. 3 - Increase intake of foods rich in vitamin K 4 - Avoid aged cheeses and red wine.
2 - Do not take the drug with high-fat foods.
A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing the supplies, which of the following steps should the nurse perform next? 1 - Cleanse the meatus 2 - Don sterile gloves 3 - Cleanse the labia 4 - Lubricate the catheter.
2 - Don sterile gloves
A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? 1 - Decrease intake of calorie-dense food 2 - Drink canned protein supplements 3 - Increase intake of high fiber foods 4 - Take a bulk-forming laxative daily.
2 - Drink canned protein supplements
A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? 1 - Change the ostomy pouch daily 2 - Empty the ostomy pouch when it is 2/3 full 3 - Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma 4 - Apply lotion to the peristomal skin when changing the ostomy pouch
2 - Empty the ostomy pouch when it is 2/3 full
A nurse is assisting with the care of a client who just returned to the unit following a partial colectomy. Which of the following actions should the nurse plan to take first? 1 - Remind the client and family of restrictions for oral intake. 2 - Ensure the client is wearing bilateral anti-embolism stockings 3 - Position the indwelling urinary catheter tubing for optimal drainage 4 - Mark the level of drainage on the NG tube collection container.
2 - Ensure the client is wearing bilateral anti-embolism stockings
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? 1 - Macaroni and cheese 2 - Fresh fruit and whole wheat toast 3 - Bread pudding and yogurt 4 - Roast chicken and white rice
2 - Fresh fruit and whole wheat toast
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all) 1 - Establish a schedule of urinating prior to meal times 2 - Have the client record urination times 3 - Gradually increase the urination intervals 4 - Remind the client to hold urine the next scheduled urination time 5 - Provide a sterile container for urine.
2 - Have the client record urination times 3 - Gradually increase the urination intervals 4 - Remind the client to hold urine the next scheduled urination time
A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? 1 - Weight the client weekly 2 - Irrigate the catheter as prescribed 3 - Instruct the client to report an urge to urinate 4 - Intrust the client to bear down as if to have a bowel movement every hour.
2 - Irrigate the catheter as prescribed
A nurse is collecting data from an infant who has a suspected UTI. Which of the following findings should the nurse expect? (Select all) 1 - Increase in hunger 2 - Irritability 3 - Decrease in urination 4 - Vomiting 5 - Fever
2 - Irritability 4 - Vomiting 5 - Fever
A nurse is reinforcing teaching to the parents of a toddler who has salmonella. Which of the following information should the nurse include in the teaching? (Select all) 1 - Incubation period is nonspecific 2 - It is a bacterial infection 3 - Bloody diarrhea is common 4- Transmission can be from house pets 5 - Antibiotics are used for treatment
2 - It is a bacterial infection 3 - Bloody diarrhea is common 4- Transmission can be from house pets
A nurse is caring for a client who has not voided for 8 hr following surgery. Which of the following actions should the nurse take first? 1 - Offer the client fluids 2 - Perform a bladder scan 3 - Insert an indwelling urinary catheter 4 - Provide assistance to bathroom.
2 - Perform a bladder scan
A nurse is caring for an infant who is postoperative following cleft lip and palate repair. Which of the following actions should the nurse take? 1 - Keep the infant NPO for the first 24 hr following surgery 2 - Place elbow restraints on the infant 3 - Offer the infant a pacifier containing sucrose 4 - Inspect the incision site inside the mouth with a tongue blade
2 - Place elbow restraints on the infant
A nurse is checking urinalysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection? 1 - Positive for hyaline casts 2 - Positive for leukocyte esterase 3 - Positive for ketones 4 - Positive for crystals
2 - Positive for leukocyte esterase
A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? 1 - Encourage a high-fiber, low-protein, low calorie diet 2 - Prepare the family for surgery 3 - Place an NG tube for decompression 4 - Initiate bed rest
2 - Prepare the family for surgery
A nurse is assessing a client who has a new prescription for the combination oral contraceptive ethinyl estrodiol and drospirenone. Which of the following findings should the nurse identify as a contraindication to use of this medication? 1 - Drinks a glass of wine each night 2 - Smokes half a pack of cigarettes a day 3 - Runs marathons regularly 4 - Drives school bus.
2 - Smokes half a pack of cigarettes a day
A nurse is collecting data from a child who has urinary tract infection. Which of the following findings should the nurse expect? (Select all) 1 - Night sweats 2 - Swelling of the face 3 - Pallor 4 - Blood in the urine 5 - Fatigue
2 - Swelling of the face 3 - Pallor 4 - Blood in the urine 5 - Fatigue
A nurse is reviewing the medical record for an infant who has obstructive uropathy. Which of the following findings should the nurse expect? 1 - Female sex 2 - Urinary tract infection 3 - Dilute urine 4 - Prenatal excess of amniotic fluid
2 - Urinary tract infection
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take? 1 - Collect urine from a catheter's port 2 - Use a sterile specimen container 3 - Use sterile water to inflate the balloon 4 - Instruct the client to clean from front to back with an antiseptic solution.
2 - Use a sterile specimen container
A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply) 1 - Add the amount of bladder irrigation to the total output 2 - Use sterile technique when preparing the irrigation solution 3 - Make sure the drainage tubing is patent and without obstruction 4 - Contact the surgeon if the client reports a continual need to void 5 - Notify the surgeon if the urine is bright red or has large clots.
2 - Use sterile technique when preparing the irrigation solution 3 - Make sure the drainage tubing is patent and without obstruction 5 - Notify the surgeon if the urine is bright red or has large clots.
A nurse is caring for a male client who has hyperthyroidism and is not responding to treatment. The nurse should identify that hyperthyroidism is a contraindication for which of the following drugs. 1 - Sildenafil 2- Bethanechol 3 - Tamsulosin 4 - Finasteride
2- Bethanechol
A nurse is reinforcing discharge teaching to a client who will be performing intermittent self-catheterizations. Which of the following statements should the nurse include in the teaching? 1 - Use sterile techniques during the insertion procedure 2 - Limit fluids throughout the day 3 - Advance the catheter 5 cm (2 in) after urine begins to flow 4 - Lubricating the catheter tip prior to its insertion is not necessary.
3 - Advance the catheter 5 cm (2 in) after urine begins to flow
A nurse is collecting data from a client who has been taking prednisone following an exacerbation of inflammatory bowel disease. The nurse should identify which of the following findings as the priority? 1 - Client reports difficulty sleeping. 2 - The client's urine is positive for glucose 3 - Client reports having an elevated body temperature 4 - Client reports gaining 4 lb. in the last 6 months
3 - Client reports having an elevated body temperature
A nurse is collecting data from a client who is 12 hr postoperative following a colectomy and colostomy placement. Which of the following findings should the nurse report to the provider? 1 - Slight bleeding of the stoma site 2 - Edematous stoma 3 - Purplish colored stoma 4 - No stool noted in the collection bag
3 - Purplish colored stoma Deep purple in color indicates obstruction of blood flow to the stoma and is a medical emergency 1 - slight bleeding is expected 2 - postoperative stoma may have an edematous appearance 4 - will not produce any stool for 2 - 4 days
An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior? 1 - Remind the client to tell the nurse when he has to urinate 2 - Use adult diapers to prevent frequent clothing changes 3 - Take the client to the bathroom on an every-2-hour schedule 4 - Request a prescription for an indwelling urinary catheter.
3 - Take the client to the bathroom on an every-2-hour schedule
A nurse is collecting data from a client while changing his ileostomy pouch. Which of the following data should the nurse report immediately? 1 - The client last changed the ostomy pouch 10 days ago. 2 - The ostomy is draining constantly 3 - The stoma is pale in color 4 - The skin around the stoma is red
3 - The stoma is pale in color
A nurse is monitoring a client who is 12 hr postoperative following a colectomy. Which of the following findings should the nurse report to the provider? 1 - Bowel sounds 10/min 2 - Serum potassium 3.7 g/dL 3 - Urine output 48 mL/2 hr 4 - Heart rate 90/min
3 - Urine output 48 mL/2 hr
A nurse is caring for a client who has a new prescription for conjugated equine estrogen. The nurse should instruct the client to report which of the following indications of a serious adverse reaction? 1 - Hot flashes 2 - Urinary tract infection 3 - Vaginal bleeding 4 - Bone pain
3 - Vaginal bleeding
A nurse is preparing to administer finasteride to a client who has benign prostatic hypertrophy (BPH). Which of the following precautions should the nurse plan to take when administering this drug? 1 - Refrain from crushing the tablet 2 - Withhold the medication if the client doesn't eat 3 - Wear gloves when handling the tablet 4 - Monitor heart rate prior to administration.
3 - Wear gloves when handling the tablet
A nurse is teaching a client who has a new prescription for a testosterone transdermal patch. Which of the following statement made by the client indicates an understanding of the teaching? 1 - "I should have pancreatic function tests obtained while taking this drug." 2 - "I should have my white blood cell count checked annually." 3 - "I should take off the patch to shower." 4 - "I should apply the medication to a different site each time."
4 - "I should apply the medication to a different site each time."
A nurse is caring for a client who is taking comination oral contraceptive ethinyl estradiol and drospirenone and is about to begin taking rifampin to treat TB. Which of the following instructions should the nurse give the client due to a possible drug interaction? 1 - "Increase the rifampin dose." 2 - "Increase the oral contraceptive dose." 3 - "Wait 2 hours between taking each drug." 4 - "Use additional birth control methods."
4 - "Use additional birth control methods."
A nurse is assisting with the plan of care for a client who has a three-way urethral catheter connected to continuous bladder irrigation following a suprapubic and transurethral resection of the prostate. Which intervention should the nurse include in the plan of care? 1 - Limit fluid intake for the first 24 hr after surgery 2 - Notify the provider if the client feels the urge to void 3 - Use sterile water to provide intermittent bladder irrigation every 4 hr 4 - Adjust the flow rate of the irrigation fluid so that the urine is light pink.
4 - Adjust the flow rate of the irrigation fluid so that the urine is light pink.
A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention by the nurse? 1 - Offer a warm sitz bath 2 - Recommend drinking cranberry juice 3 - Encourage increase fluids. 4 - Administer an antibiotic
4 - Administer an antibiotic
A nurse should question the use of conjugated equine estrogen by a client who has a history of which of the following? 1 - Osteoporosis 2 - Peptic ulcer disease 3 - Rheumatoid arthritis 4 - Blood clots
4 - Blood clots
A nurse is reinforcing teaching with a newly hired assistive personnel (AP) who is assisting with the care of a client who has an indwelling urinary catheter. Which of the following instructions should the nurse give to the AP? 1 - Secure the client's catheter tubing to the bed 2 - Store the catheter bag at the level of the client's waist. 3 - Use sterile technique to obtain a urine specimen from the catheter. 4 - Close the tubing clamp when transferring a client from the bed to a chair.
4 - Close the tubing clamp when transferring a client from the bed to a chair. Close clamp when a chance of raising the collecting bag over the client's bladder.
A nurse is caring for a client who received prochlorperazine 4 hr ago. The client reports spasms of the muscles in his face. The nurse should anticipate a prescription for which of the following medications 1 - Fomepizole 2 - Naloxone 3 - Phytonadione 4 - Diphenhydramine
4 - Diphenhydramine
A nurse is contribution to the plan of care for a child who has urinary tract infection. Which of the following should the nurse recommend? 1 - Adminiser an antidiuretic 2 - Restrict fluids 3 - Evaluate the child's self-esteem 4 - Encourage frequent voiding
4 - Encourage frequent voiding
A nurse is collecting data on a client who is two days postoperative following creation of an ileal conduit. The nurse should report which of the following findings? 1 - Mild edema of the stoma 2 - Urine in the drainage appliance 3 - Redness of the stoma 4 - Feces in the drainage appliance
4 - Feces in the drainage appliance
Ileostomy
-Creation of an artificial opening into the ileum -When disease, congenital defects, or trauma require bypassing the entire colon.
A nurse is collecting data from a client who has been taking oflozacin for an upper respiratory infection. Which of the following statements should the nurse report to the provider? 1 - "I have been limiting my time outdoors." 2 - "I have had foul-smelling diarrhea." 3 - "I kept taking the medication even though my symptoms stopped." 4 - "I have been taking loratadine for my allergies."
2 - "I have had foul-smelling diarrhea."
A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an appropriate action for the nurse to take? 1 - Offer chicken broth 2 - Initiate oral rehydration therapy 3 - Start hypertonic IV solution 4 - Keep the child NPO until the diarrhea subsides
2 - Initiate oral rehydration therapy
The nurse should plan intervention to combat constipation in a pt 1 - being treated for diabetes mellitus 2 - who has a routine order for Metamucil 3 - Who just completed barium studies of the bowel 4 - with orders to ambulate with assistance
3 - Who just completed barium studies of the bowel
The nurse is caring for a client postoperative repair of a bowel obstruction. The nurse's priority of care is: 1 - Promoting weight loss 2 - Encouraging mobility 3 - Monitoring intake and output 4 - Auscultating bowel sounds
4 - Auscultating bowel sounds
The nurse working in the Emergency Department assists with the care of a 12-year-old diagnosed with appendicitis. The parents ask the nurse why something isn't being done to reduce the child's pain. The nurse's best response informs them that: 1 - Appendicitis is not very painful, so powerful narcotics are not needed. 2 - The child will not obtain pain relief until the appendix is removed 3 - Analgesics cannot be given prior to surgery, to prevent toxicity 4 - Eliminating pain prevents monitoring for rupture of the appendix
4 - Eliminating pain prevents monitoring for rupture of the appendix
Urostomy
Creation of an opening in the urinary tract, normally to divert urine flow away from a diseased bladder
The nurse caring for a severely dehydrated patient who has a Foley catheter in place assesses the patient to confirm adequate kidney perfusion by the hourly urine output of A - 15 mL B - 20 mL C - 25 mL D - 30 mL
D - 30 mL
Colostomy
The surgical creation of an artificial excretory opening between the colon and the body surface Elimination of fecal matter
Computed tomography
a procedure that uses a beam of radiation to allow three-dimensional visualization of abdominal structures
Flat plate of the abdomen
an anterior-posterior view of the abdomen
Upper GI series (barium and swallow)
an x-ray examination of the esophagus, stomach, duodenum, & jejunum using oral barium to contours of organs
Lower GI endoscopy
direct visualization of the distal sigmoid colon, rectum, & anal canal using a rigid or flexible endoscope
Upper GI endoscopy
direct visualization of the stomach, esophagus, & duodenum, using endoscope
Lower GI series (barium enema)
radiograph used to visualize the position, movements, & filling of the colon
A pt has been ordered to have a 24 hour urine collection as part of a diagnostic work up. The action taken to perform this procedure correctly is to 1 - Continue the collection if the pt accidentally voids directly into the toilet 2 - Obtain a container and put it in a warm water bath in the bathroom 3 - Have the patient void at the beginning of the collection and throw it away 4 - Have the pt void for the last time a few hours before the collection ends
3 - Have the patient void at the beginning of the collection and throw it away
A nurse is reinforcing teaching with a client who has a new prescription for nitrofurantoin. Which of the following information should the nurse include? Select all 1 - Observe for bruising on the skin 2 - Take the medication with milk or meals 3 - Expect brown discoloration of urine 4 - Crush the medication if it is difficult to swallow 5 - Expect insomnia when taking it
1 - Observe for bruising on the skin 2 - Take the medication with milk or meals 3 - Expect brown discoloration of urine
A nurse is reviewing a medication information sheet about ciprofloxacin with a client. Which of the following information about adverse reactions should the nurse include? (Select all) 1 - Observe for pain and swelling of the Achilles tendon 2 - Watch for a vaginal yeast infection 3 - Expect excessive nighttime perspiration 4 - Inspect the mouth for cottage cheese-like lesions 5 - Take the medication with a dairy product
1 - Observe for pain and swelling of the Achilles tendon 2 - Watch for a vaginal yeast infection 4 - Inspect the mouth for cottage cheese-like lesions
The nurse is caring for a client admitted to the hospital with a diagnosis of acute gastroenteritis and a fever. Which of the following findings has the highest priority? 1 - Potassium 2.5 mEq/L 2 - Urine specific gravity 1.035 3 - Weight loss 4% of total body weight 4 - Blood glucose 150 mg/dL
1 - Potassium 2.5 mEq/L
The nurse receives a call from an adult who reports recent development of diarrhea with five liquid stools in the past 24 hours. Which of the following additional symptoms would cause the nurse to suggest the client seek immediate/emergent medical attention? (Select all) 1 - Weight loss of 1 pound in the past week. 2 - Blood in the stool 3 - Severe abdominal cramping 4 - Fever 5 - Oral intake of 3 L of fluid in 25 hours 6 - Blood pressure 138/72 mm Hg
2 - Blood in the stool 3 - Severe abdominal cramping 4 - Fever
The nurse is caring for several clients complaining of constipation. A digital rectal examination can be safely performed on the client with a diagnosis of 1 - Increased intracranial pressure 2 - Hiatal hernia repair 3 - Myocardial infarction 4 - Transurethral resection of the prostate gland
2 - Hiatal hernia repair
The nurse is reviewing prescribed medications for a client with a UTI and notes that phexazopyridine (Pyridium) is to be administered. Which of the following can the nurse expect the client to experience from this medication? 1 - Burning during urination 2 - Reddish-orange colored urine 3 - Lethargy 4 - Visual disturbances
2 - Reddish-orange colored urine
A nurse instructing a female pt on obtaining a clean catch urine specimen should stress 1 - to spread the labia apart and clan the center area first 2 - to catch the middle portion of urine after voiding a small amount into the toilet 3 - to carefully collect the urine in the container as soon as the urine stream starts 4- to full the urine cup to the brim to ensure an adequate sample
2 - to catch the middle portion of urine after voiding a small amount into the toilet
The nurse is instructing the female client how to collect a clean-catch urine specimen, and determines the client understood the instructions when she states: 1 - "I will wait to collect the last few drops of urine near the end of my stream." 2 - "I will make one swipe form back to front with each of these three antiseptic wipes." 3 - "I will be careful not to touch the inside of the container or lid." 4 - "I will fill the container as full as possible."
3 - "I will be careful not to touch the inside of the container or lid."
The nurse is reinforcing teaching to a female adult client regarding avoiding urinary tract infections (UTI's). Which of the following client statements indicated the need for further teaching? 1 - "I will avoid using perfumed bath soaps that can cause irritation and tissue breakdown." 2 - "I will make an effort to empty my bladder regularly and completely." 3 - "I will clean my perineal area form back to front after urinating." 4 - "I will increase my intake of water daily."
3 - "I will clean my perineal area form back to front after urinating."
A nurse is documenting the removal of a urinary drainage catheter from an assigned pt. If the catheter is removed at 9:00 am, the nurse recognizes that the pt is due to void by 1 - 11:00 am 2 - 12 noon 3 - 5:00 pm 4 - 9:00 pm
3 - 5:00 pm (8 hours)
The nurse is aware that in the older adult, a urinary infection may cause the pt to 1 - Experience a high temp 2 - Have foul urine and diarrhea 3 - Become disoriented and confused 4 - Become irritable
3 - Become disoriented and confused
The nurse is preparing the client for a barium enema to be performed tomorrow, and instructs the client to: 1 - Perform a cleansing enema the morning of the procedure 2 - Eat a high-fiber diet for two days prior to the procedure 3 - Take a laxative the night before the procedure 4 - NPO after 6 p.m. the night before the procedure
3 - Take a laxative the night before the procedure
A nurse is reviewing discharge teaching with a client who has a new prescription for trimethoprim-sulfamethoxazole. Which of the following information should the nurse include? 1 - Take the medication even if pregnant 2 - Maintain a fluid restriction while taking it 3 - Take it on an empty stomach 4 - Stop taking it when manifestations subside
3 - Take it on an empty stomach
The nurse is providing care for a client receiving ciprofloxacin (Cipro) for the treatment of an uncomplicated UTI. Which of the following should the nurse recognize as the most reliable indicator of therapeutic effect? 1 - Urine is clear and odorless 2 - Client notes increasing pain in lower leg ankle area 3 - Client reports decreased in urgency and painful urination 4 - Urinalysis shows decreased pyuria and bacteriuria from prior results.
4 - Urinalysis shows decreased pyuria and bacteriuria from prior results.
When the pt who has an order to be out of bed complains of feeling to weak to walk to the bathroom, the nurse assist the pt with urination eliminating by 1 - acquiring a walker so that the pt can go to the bathroom 2 - using a fractured bedpan and keep the pt flat - cast 3 - obtaining a raised toilet seat 4 - placing a commode at the bedside
4 - placing a commode at the bedside
The nurse has assessed that a pt stool has changed form brown to dark black and sticky. The nurse suspects 1 - Blockage of the bile duct 2 - blockage of the pancreatic duct 3 - recent excessive intake of milk products 4 - presence of occult blood
4 - presence of occult blood Occult blood can't see with your eyes - hidden
A nurse is reinforcing teaching with a client who has recurrent urinary tract infections (UTI) about prevention measures. Which of the following client statements indicated the need for further teaching? 1 - "I will need to wipe my perineal area from back to front after urination." 2 - "I will need to empty my bladder after having sexual intercourse." 3 - "I should avoid taking bubble baths." 4 - "I need to drink at least 8 full glasses of liquid each day."
1 - "I will need to wipe my perineal area from back to front after urination."
A nurse in a clinic is reinforcing teaching with a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? 1 - "I will plan to limit fiber in my diet." 2 - "I will restrict fluid intake during meals." 3 - "I will switch to black tea instead of drinking coffee." 4 - "I will try to eat three moderate to large meals a day."
1 - "I will plan to limit fiber in my diet."
A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make? 1 - Blood 2 - Lipids 3 - Bacteria 4 - Bile
1 - Blood
A nurse is collecting data from a preschooler who has a rotavirus infection. Which of the following are expected manifestations? (Select all) 1 - Fever 2 - Vomiting 3 - Watery stools 4 - Bloody stools 5 - Confusion
1 - Fever 2 - Vomiting 3 - Watery stools
A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include (Select all) 1 - Relief of urinary retention 2 - Convenience for the nursing staff or the client's family 3 - Measurement of residual urine after urination 4 - Routine acquisition of a urine specimen 5 - Presence of an open perineal wound.
1 - Relief of urinary retention 3 - Measurement of residual urine after urination 5 - Presence of an open perineal wound.
A nurse is reinforcing teaching with a group of parents about E. coli. Which of the following information should the nurse include in the teaching? (Select all) 1 - Severe abdominal cramping occurs 2 - Bloody diarrhea is the first manifestation 3 - It can lead to hemolytic uremic syndrome 4 - It is a food-borne pathogen 5 - Antibiotics are given for treatment.
1 - Severe abdominal cramping occurs 3 - It can lead to hemolytic uremic syndrome 4 - It is a food-borne pathogen
A nurse is caring for a client who has diabetes mellitus and nausea due to gastroparesis. The nurse should anticipate a prescription for which of the following medications? 1 - Lubiprostone 2 - Metoclypramide 3 - Bisacodyl 4 - Loperamide
2 - Metoclypramide
A nurse is reinforcing teaching with a client who has a new prescription for sulfasalazine. Which of the following instructions should the nurse include in the teaching? 1 - "Take the medication 2 hr after eating." 2 - "Discontinue this medication if your skin turns yellow-orange." 3 - "Notify the provider if you experience a sore throat." 4 - "Expect your stools to turn black."
3 - "Notify the provider if you experience a sore throat." *Report any manifestations of infections.
A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. 1 - Open the innermost flap toward the body 2 - Use the inner surface of the package as a sterile field 3 - Use inner surface of package as a sterile field 4 - Open the side flaps 5 - Place the sterile package on the work surface 6 - Open the outermost flap away from the body
5, 6
A charge nurse is assisting a newly-licensed nurse to insert an indwelling urinary catheter for a male client. Which of the following actions requires the charge nurse to intervene? 1 - Lubricates the first 2.5 to 5 cm (1 to 2 in) of the catheter tubing 2 - Lubricates the first 15 to 17.5 cm (6 to 7 in) of the catheter 3 - Secures the tubing to the client's upper thigh 4 - Secures the tubing to the client's lower abdomen.
1 - Lubricates the first 2.5 to 5 cm (1 to 2 in) of the catheter tubing Female - 2.5 - 5 cm Male - 15 to 17.5 cm
A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first? 1 - Clean the perineum from front to back 2 - Lubricate the catheter. 3 - Explain to the client that she will feel temporary discomfort 4 - Arrange the sterile items on the sterile field.
3 - Explain to the client that she will feel temporary discomfort
A nurse is caring for a client who received human menopausal gonadotropin (hMG). Which of the following findings should the nurse expect? 1 - Prolactin secreation 2 - Estrogen release 3 - Follicular maturation 4 - Oxytocin secretion
3 - Follicular maturation
A nurse is teaching a client about conjugate estrogen and medroxyprogesterone. Which of the following instructions should the nurse include? 1 - Monitor for rectal bleeding 2 - Avoid drinking alcoholic beverages 3 - Have blood pressure checked regularly 4 - Sit ip for 30 min after taking the drug.
3 - Have blood pressure checked regularly
A nurse is planning to insert an indwelling urinary catheter for an adult female client. Which of the following actions should the nurse plan to take? 1 - Use an 8-Fr size catheter 2 - Insert the catheter using clean technique 3 - Lubricate the catheter 2.5 to 5 cm (1-2 in) 4 - Provide routine catheter care with povidone iodine.
3 - Lubricate the catheter 2.5 to 5 cm (1-2 in)
A nurse is caring for a client who is about to begin clomiphene therapy to treat infertility. The nurse should monitor the client for which of the following adverse effects? 1 - Breast cancer 2 - Deep-vein thrombosis 3 - Ovarian hyperstimulation syndrome 4 - Restless leg syndrome
3 - Ovarian hyperstimulation syndrome
After administering terbutaline to a client to inhibit preterm labor, the nurse should assess which of the following. 1 - Peripheral pulses 2 - Temperature 3 - Vision 4 - Heart rate
4 - Heart rate
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take. 1 - Have the client hold his breath briefly and bear down 2 - Discontinue the fluid instillation 3 - Remind the client that cramping is common at this time. 4 - Lower the enema fluid container.
4 - Lower the enema fluid container.
A nurse is caring for a client who is about to begin taking cabergoline to treat infertility. The nurse should explain to the client the need to monitor which of the following laboratory values? 1 - Potassium 2 - Glucose 3 - BUN and creatinine 4 - Prolactin level
4 - Prolactin level
A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take? 1 - Use the left hand to cleanse the urinary meatus 2 - Use the right hand to insert the catheter 3 - Stand on the client's right side 4 - Raise the bed to a comfortable working height
4 - Raise the bed to a comfortable working height
A nurse is caring for a client who will preform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? 1 - Eating more protein is optimal prior to testing 2 - One stool specimen is sufficient for testing 3 - A red color change indicates a positive test 4 - The specimen cannot be contaminated with urine
4 - The specimen cannot be contaminated with urine
A nurse is reviewing information with a female client who has frequent urinary tract infections. Which of the following information should the nurse include? (Select all) 1 - Avoid sitting in a web bathing suit 2 - Wipe the perineal area back to front following elimination 3 - Empty the bladder when there is an urge to void 4 - Wear synthetic fabric underwear 5 - Take a shower daily
1 - Avoid sitting in a web bathing suit 3 - Empty the bladder when there is an urge to void 5 - Take a shower daily
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? 1 - Check to see whether the catheter is patent. 2 - Reassure the client that it is not possible for her to urinate 3 - Recatheterize the bladder with a larger-gauge catheter 4 - Collect a urine specimen for analysis
1 - Check to see whether the catheter is patent./kinked
A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take? 1 - Discard the first voiding 2 - Keep the urine in a single container at room temperature 3 - Ask the client to urinate and pour the urine into a specimen container. 4 - Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
1 - Discard the first voiding
A provider has prescribed a dinoprostone vaginal insert to promote cervical ripening in a client who is at 40 weeks of gestation. When administering dinoprostone, which of the following actions should the nurse take? (Select all) 1 - Encourage the client to urinate prior to insertion 2 - Remove the pouch when active labor begins 3 - Monitor for uterine hyperstimulation 4 - Encourage the client to walk after insertion 5 - Monitor the client's temperature.
1 - Encourage the client to urinate prior to insertion 2 - Remove the pouch when active labor begins 3 - Monitor for uterine hyperstimulation 5 - Monitor the client's temperature.
A nurse is reviewing factors that increase the risk of UTI's with a client who has recurrent UTI's. Which of the following factors should the nurse include? (Select all) 1 - Frequent sexual intercourse 2 - Lowering of testosterone levels 3 - Wiping from front to back 4 - Location of the urethra in relation to the anus 5 - Frequent catheterization
1 - Frequent sexual intercourse 4 - Location of the urethra in relation to the anus 5 - Frequent catheterization
A nurse is caring for a client who is about to begin taking finasteride to treat benign prostatic hypertrophy. The nurse should explain to the client the need to monitor which of the following laboratory values? 1 - Prostate-specific antigen (PSA) 2 - BUN 3 - Creatine phosphokinase (CPK) 4 - ALT
1 - Prostate-specific antigen (PSA)
A nurse is caring for a client who has a new prescription for transdermal conjugated estrogen and medroxyprogesterone to treat postmenopausal symptoms. The nurse should explain to the client that this drug combination includes which of the following therapeutic effects? (Select all) 1 - Reduces the risk of ovarian cancer 2 - Relieves hot flashes 3 - Prevents osteoporosis 4 - Reduces the risk of breast cancer 5 - Reduces the risk of thromboembolism
1 - Reduces the risk of ovarian cancer 2 - Relieves hot flashes 3 - Prevents osteoporosis
A nurse is reinforcing instructions about the use of laxatives with a client who has heart failure. The client should avoid which of the following laxatives? 1 - Sodium phosphate 2 - Psyllium 3 - Bisacodyl 4 - Polyethylene glycol
1 - Sodium phosphate
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should monitor the client for which of the following expected outcomes after catheter removal? 1 - Temporary urinary retention 2 - Urinary frequency for several days 3 - Blood-tinged urine 4 - Highly concentrated urine.
1 - Temporary urinary retention
A nurse is collecting data on a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should recognize which of the following findings is the priority? 1 - The client has bright red urine in his urinary catheter 2 - The client reports a continuous urge to void 3 - The client has small blood clots in his urinary catheter 4 - The client reports burning around the urinary catheter.
1 - The client has bright red urine in his urinary catheter
A nurse is collecting data from a male infant who has an epispadias. Which of the following findings should the nurse expect? 1 - Urethral opening on the dorsal surface of the penis 2 - Exposed bladder through the suprapubic area 3 - Ventral curvature of the penis 4 - Foreskin that does not retract
1 - Urethral opening on the dorsal surface of the penis
A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following? 1 - Urinary tract infection 2 - Urinary incontinence 3 - Urinary frequency 4 - Urinary retention
1 - Urinary tract infection
A nurse is teaching a client about receiving leuprolide to treat endometriosis. The nurse should instruct the client to expect which of the following side effects? 1 - Vaginal dryness 2 - Hypertension 3 - Blurred vision 4 - Orthostatic hypotenstion
1 - Vaginal dryness
A nurse is caring for a client who has benign prostatic hypertrophy and is taking tamsulosin. The nurse should question the use of the drug if the client also has which of the following? 1 - A seizure disorder for which he take carbamazepine 2 - Erectile dysfunction for which he takes sildenafil 3 - Diabetes mellitus for which he takes glyburide 4 - Angle-closure glaucoma for which he takes pilocarpine.
2 - Erectile dysfunction for which he takes sildenafil
A nurse is reviewing the serum laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following lab tests should the nurse expect to be elevated? (Select all) 1 - Hematocrit 2 - Erythrocyte sedimentation rate 3 - WBC 4 - Folic acid 5 - Albumin
2 - Erythrocyte sedimentation rate 3 - WBC
A nurse is caring for an infant who has a hydrocele. Which of the following actions should the nurse take? 1 - Preparing the child for surgery 2 - Explain to the parents that the issue can self-resolve 3 - Retract the foreskin and cleanse several times daily 4 - Refer the family for genetic counseling
2 - Explain to the parents that the issue can self-resolve
A nurse is collecting data from a child who has Mechel's diverticulum. Which of the following manifestations should the nurse expect? (Select all) 1 - Abdominal pain 2 - Fever 3 - Mucus, bloody stools 4 - Vomiting 5 - Rapid, shallow breathing
1 - Abdominal pain 3 - Mucus, bloody stools 2, 4 & 5 - Appendicitis
A nurse is reinforcing information about probiotic supplements with a client who is taking an antibiotic to treat a bacterial infection. Which of the following information should the nurse include? (Select all) 1 - "Probiotics are micro-organisms that inhibit the GI tract." 2 - "Probiotics treat Clostridium difficile infections." 3 - "Probiotics treat benign prostatic hyperplasia." 4 - "Expect some bloating while taking probiotic supplements." 5 - "Take your antibiotic at the same time you take your probiotic supplement."
1 - "Probiotics are micro-organisms that inhibit the GI tract." 2 - "Probiotics treat Clostridium difficile infections." 4 - "Expect some bloating while taking probiotic supplements."
A nurse is caring for several clients. Which of the following clients are at risk for developing pyelonephritis? (Select all) 1 - A client who is at 32 weeks of gestation 2 - A client who has kidney calculi 3 - A client who has a urine pH of 4.2 4 - A client who has a neurogenic bladder 5 - A client who has diabetes mellitus
1 - A client who is at 32 weeks of gestation 2 - A client who has kidney calculi 4 - A client who has a neurogenic bladder 5 - A client who has diabetes mellitus
A nurse is providing safety education to a client who is scheduled to being treatment with tamsulosin for benign prostatic hypertrophy (BPH). Which of the following instructions should the nurse include in the teaching? 1 -Change positions slowly 2 - Crush the medication 3 - Take the medication on an empty stomach 4 - Report increased urinary output immediately.
1 -Change positions slowly
A nurse is caring for a newborn who has ambiguous genitalia. Which of the following actions should the nurse take? 1 - Prepare the child for DNA analysis 2 - Refer to the specific sex when talking about the newborn 3 - Gather supplies for an immediate circumcision 4 - Advise the parents to avoid rooming-in until reconstructive surgery is complete
1 - Prepare the child for DNA analysis
A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? (Select all) 1 - Projectile vomiting 2 - Dry mucus membranes 3 - Currant jelly stools 4 - Sausage-shaped abdominal mass 5 - Constant hunger
1 - Projectile vomiting 2 - Dry mucus membranes 5 - Constant hunger
A nurse is caring for a client who has had diarrhea for 4 days. When assessing a client, the nurse should expect which of the following findings? (Select all) 1 - Bradycardia 2 - Hypotension 3 - Elevated temperature 4 - Poor skin turgor 5- Peripheral edema
2 - Hypotension 3 - Elevated temperature 4 - Poor skin turgor
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all) 1 - Warm the enema solution prior to instillation 2 - Position the client on the left side with the right leg flexed forward 3 - Lubricate the rectal tube or nozzle 4 - Slowly insert the rectal tube about 5 cm (2in) 5 - Hang the enema container 61 cm (24 in) about the client's anus
1 - Warm the enema solution prior to instillation 2 - Position the client on the left side with the right leg flexed forward 3 - Lubricate the rectal tube or nozzle
A nurse is contributing to the plan of care for a client who has chronic pyelonephritis. Which of the following actions should the nurse recommend? (Select all) 1 - Assist with a referral for nutrition counseling 2 - Encourage daily fluid intake to 1 L 3 - Palpate the costovertebral angle 4 - Monitor urinary output 5 - Administer antibiotics
1 - Assist with a referral for nutrition counseling 3 - Palpate the costovertebral angle 4 - Monitor urinary output 5 - Administer antibiotics
A nurse is providing teaching to a client who is taking bethanechol for urinary retention Which of the following instructions should the nurse include? (Select all) 1 - Avoid driving and activities that require alertness 2 - Increase fluid intake 3 - Take the drug with food 4 - Stay close to a bathroom after taking the drug 5 - Increase weight-bearing activities.
1 - Avoid driving and activities that require alertness 2 - Increase fluid intake 4 - Stay close to a bathroom after taking the drug
A nurse is collecting data from an older adult client who is receiving ondansetron IV, has a history of diabetes mellitus and cardiac myopathy, and is receiving chemotherapy to treat cancer. For which of the following adverse effects of ondansetron should the nurse monitor? (Select all) 1 - Headache 2 - Diarrhea 3 - Shortened PR interval 4 - Hyperglycemia 5 - Prolonged QT interval
1 - Headache 2 - Diarrhea 5 - Prolonged QT interval
A nurse is reviewing a client's medication history and notes an allergy to sulfonamides. This allergy is a contraindication for taking which of the following medications? (Select all) 1 - Hydrochlorothiazide 2 - Metoprolol 3 - Acetaminophen 4 - Glipizide 5 - Furosemide
1 - Hydrochlorothiazide 4 - Glipizide 5 - Furosemide
A nurse should question the use of ethinyl estradiol drospirenone by a client who has renal disease due to the increase risk of which of the following? 1 - Hyperkalemia 2 - Hyponatremia 3 - Hypoglycemia 4 - Respiratory alkalosis.
1 - Hyperkalemia
A nurse is reinforcing teaching with the parents of an infant about gastrointestinal reflux disease. Which of the following interventions should the nurse include in the instructions (Select all) 1 - Offer frequent feedings 2 - Thicken formula with rice cereal 3 - Use a bottle with a one-way valve 4 - Position the infant upright after feedings 5 - Use a wide-base nipple for feedings
1 - Offer frequent feedings 2 - Thicken formula with rice cereal 4 - Position the infant upright after feedings 3 & 5 - cleft lip
A nurse is caring for a client who missed a dose of her oral contraceptive. Which of the following instructions should the nurse give the client? 1 - Take a pregnancy test 2 - Double up on pills for remainder of the pack 3 - Take the missed dose as soon as possible 4 - Stop the oral contraceptive and use a different contraceptive.
3 - Take the missed dose as soon as possible
