Fundamentals EXAM 2 combined
After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output?
1320 mL
The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? Select all that apply. A: SpO2 levels B: Amount of sputum production C: Change in respiratory rate and pattern D: Pain in lower calf area
A,B,C A: SpO2 levels B: Amount of sputum production C: Change in respiratory rate and pattern
During assessment of the client with urinary incontinence, the nurse is most likely to asses for which of the following? Select all that apply. A: Perineal skin irritation B: Fluid intake of less than 1,500 mL/day C: History of antihistamine intake D: History of frequent urinary tract infections E: A fecal impaction
A,B,D,E A: Perineal skin irritation B: Fluid intake of less than 1,500 mL/day D: History of frequent urinary tract infections E: A fecal impaction
Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply. A: Bowel Incontinence B: Risk for Deficient Fluid Volume C: Disturbed Body Image D: Social Isolation E: Risk for Impaired Skin Integrity
A,C,D,E A: Bowel Incontinence C: Disturbed Body Image D: Social Isolation E: Risk for Impaired Skin Integrity
The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which of the following responses by participants indicates a correct understanding of the material? Select all that apply. A: "The client is willing to look at the stoma." B: "The patient uses spray deodorant several times an hour to mask odor." C: "The client makes neutral or positive statements about the ostomy." D: "The client agrees to take prescribed antidepressants." E: "The client expresses interest in learning self-care."
A,C,E A: "The client is willing to look at the stoma." C: "The client makes neutral or positive statements about the ostomy." E: "The client expresses interest in learning self-care."
Which of the following medications listed in a patient's medication history possibly causes gastrointestinal bleeding? Select all that apply. A. Aspirin B. Cathartics C. Antidiarrheal opiate agents D. Nonsteroidal antiinflammatory drugs (NSAIDs)
A,D A. Aspirin D. Nonsteroidal antiinflammatory drugs (NSAIDs)
A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: Select all that apply. A. Infection. B. Retention. C. Stagnant urine. D. Reflux of urine.
A,D A. Infection. D. Reflux of urine.
The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.) A. Note any allergies. B. Monitor intake and output. C. Provide for perineal hygiene. D. Assess vital signs. E. Encourage fluids after the procedure.
A,E A. Note any allergies. E. Encourage fluids after the procedure.
Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to: A. Ask the patient to void. B. Wash the patient's perineum. C. Secure a sterile, specimen container. D. Plan to collect the first specimen of the day.
A. Ask the patient to void.
Since removal of the patient's Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first? A. Check for bladder distention B. Encourage fluid intake C. Obtain an order to recatheterize the patient D. Document the amount of each voiding for 24 hours
A. Check for bladder distention
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: A. Cystitis. B. Hematuria. C. Pyelonephritis. D. Dysuria.
A. Cystitis.
A patient is admitted for lower gastrointestinal (GI) bleeding. What color of stool does the nurse anticipate the patient to have? A. Red B. Black C. Green D. Orange
A. Red
A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? A. Suggest he stand at the bedside B. Stay with the patient C. Give him the urinal to use in bed D. Tell him that, if he doesn't urinate, he will be catheterized
A. Suggest he stand at the bedside
A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which of the following diets? A: A diet lacking in fruits and vegetables B: A diet lacking in glucose and water C: A diet lacking in meat and poultry products D: A diet consisting of whole grains, seeds, and nuts
A: A diet lacking in fruits and vegetables
The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has A: Anemia. B: An infection. C: A fractured rib. D: A tumor of the medulla.
A: Anemia.
A physician orders a retention enema for a client to destroy intestinal parasites. Which of the following enemas would be indicated for this client? A: Anthelmintic enema B: Oil retention enema C: Carminative enema D: Nutritive enema
A: Anthelmintic enema
You are educating a new colostomy client on gas-producing foods. Which of the following are gas-producing foods the client may choose to avoid? A: Brussels sprouts B: Rice C: Green peppers D: Lettuce
A: Brussels sprouts
A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? A: Cleansing enema B: Retention enema C: Return-flow enema D: Carminative enema
A: Cleansing enema
Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? A: Constipation B: Diarrhea C: Incontinence D: Hemorrhoids
A: Constipation
A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color? A: Dark pink and moist. B: Off-white or pale pink. C: Red and dry. D: Dark or purple-blue.
A: Dark pink and moist.
A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? A: Fever increases metabolic demands, requiring increased oxygen need. B: Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C: Carbon dioxide production increases as result of hyperventilation. D: Carbon dioxide production decreases as a result of hypoventilation.
A: Fever increases metabolic demands, requiring increased oxygen need.
While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. What stool characteristics are expected in breast-fed infants? A: Golden yellow and loose B: Yellow-brown and pasty C: Dark brown and firm D: Green and mucusy
A: Golden yellow and loose
The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? A: Leaves the catheter in place and gets a new sterile catheter. B: Leaves the catheter in place and asks another nurse to attempt the procedure. C: Removes the catheter and redirects it to the urinary meatus. D: Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
A: Leaves the catheter in place and gets a new sterile catheter.
A client's last bowel movement was four days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the patient in anticipation of administering a cleansing enema? A: Left side-lying B: Right side-lying C: Prone D: Supine
A: Left side-lying
The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A: Nasal cannula B: Venturi mask C: Simple face mask without inflated reservoir bag D: Plastic face mask with inflated reservoir bag
A: Nasal cannula
A nurse attempts to administer a nutritive retention enema to a patient who is dehydrated and finds that the patient cannot retain the enema for the prescribed amount of time. Which of the following would be a recommended intervention for this patient? A: Place the patient on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees. B: Place the patient in a sitting position on the toilet and lower the enema solution. C: Stop the enema and reposition the rectal tube or remove it to check for any fecal contents. D: Do not attempt to re-administer the enema because part of the solution has already been absorbed; notify the physician.
A: Place the patient on a bedpan in supine position while receiving the enema and elevate the head of the bed 30 degrees.
You are reviewing a patient's laboratory work before administering a large-volume enema. Which of the following laboratory results indicate that a nurse should confer with the primary care provider before administering the enema? A: Platelet count 18,000/mm3 B: Serum albumin 3.1 g/dL C: Arterial pH 5.2 D. WBC count 15,200/mm3
A: Platelet count 18,000/mm3
The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A: Raise the head of the bed to 45 degrees. B: Take his oxygen saturation with a pulse oximeter. C: Take his blood pressure and respiratory rate. D: Notify the health care provider of his shortness of breath.
A: Raise the head of the bed to 45 degrees.
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A: Record the amount and continue to monitor drainage B: Notify the health care provider C: Strip the chest tube starting at the chest D: Increase the suction by 10 mm Hg
A: Record the amount and continue to monitor drainage
A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? A: Sharp pleuritic pain that worsens on inspiration B: Crackles over lung bases of affected lung C: Tracheal deviation toward the affected lung D: Increased diaphragmatic excursion on side of rib fractures
A: Sharp pleuritic pain that worsens on inspiration
The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action? A: Tells the client to raise two fingers to indicate pain or distress. B: Changes the twill tape holding the tracheostomy in place. C: Cleans the incision site. D: Checks the tightness of the ties and knot.
A: Tells the client to raise two fingers to indicate pain or distress.
Elimination changes that result from inability of the bladder to empty properly may cause which of the following? Select all that apply. A. Incontinence B. Frequency C. Urgency D. Urinary retention E. Urinary tract infection
ALL OF THE ABOVE
The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply. A: Mixes the reagent with the stool sample before applying to the card B: Collects a sample from two different areas of the stool specimen. C: Assesses for a blue color change. D: Asks a colleague to verify the pink color results. E: Asks the client if he has taken Vitamin C in the past few days.
B, C, E B: Collects a sample from two different areas of the stool specimen. C: Assesses for a blue color change. E: Asks the client if he has taken Vitamin C in the past few days.
A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. A: Limit fluids to avoid the burning sensation on urination. B: Review symptoms of UTI with the client. C: Wipe the perineal area from back to front. D: Wear cotton underclothes. E: Take baths rather than showers.
B,D B: Review symptoms of UTI with the client. D: Wear cotton underclothes.
The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply. A: Collect the specimen in the evening. B: Send the specimen immediately to the lab. C: Ask the client to spit into the sputum container. D: Offer mouth care before and after collection of the sputum specimen. E: Collect a specimen for 3 consecutive days.
B,D,E B: Send the specimen immediately to the lab. D: Offer mouth care before and after collection of the sputum specimen. E: Collect a specimen for 3 consecutive days.
Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. A: Voids each time there is an urge. B: Practices slow, deep breathing until the urge decreases. C: Uses adult diapers, for "just in case" D: Drinks citrus juices and carbonated beverages. E: Performs pelvic muscle exercises.
B,E B: Practices slow, deep breathing until the urge decreases. E: Performs pelvic muscle exercises.
The nurse notes that the patient's Foley catheter bag has been empty for 4 hours. The priority action would be to: A. Irrigate the Foley. B. Check for kinks in the tubing. C. Notify the health care provider. D. Assess the patient's intake.
B. Check for kinks in the tubing.
The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider? A. Malnutrition B. Dehydration C. Skin breakdown D. Incontinence
B. Dehydration
Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? A: "I need to drink one and a half to two quarts of liquids each day." B: "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." C: "If my bowel pattern changes on its own, I should call you." D: "Eating my meals at regular times is likely to result in regular bowel movements."
B: "I need to take a laxative such as Milk of Magnesia if I don't have a BM every day."
Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective? A: "I should breathe out as fast and hard as possible into the device." B: "I should inhale slowly and steadily to keep the balls up." C: "I should use the device three times a day, after meals." D: "The entire device should be washed thoroughly in sudsy water once a week."
B: "I should inhale slowly and steadily to keep the balls up."
A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? A: Prepare to irrigate the colostomy. B: After assessing the stoma and surrounding skin, notify the surgeon. C: Assess bowel sounds and administer anti mimetic. D. Administer a bulk-forming laxative, and encourage increased fluids and exercise.
B: After assessing the stoma and surrounding skin, notify the surgeon.
During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing which of the following? A: Percussion B: Auscultation C: Light palpation D: Deep palpation
B: Auscultation
When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to A: Brown B: Blue C: Red D: Green
B: Blue
Which action represents the appropriate nursing management of a client wearing a condom catheter? A: Ensure that the tip of the penis fits snugly against the end of the condom. B: Check the penis for adequate circulation 30 minutes after applying. C: Change the condom every 8 hours. E: Tape the collecting tube to the lower abdomen.
B: Check the penis for adequate circulation 30 minutes after applying.
A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A: Stimulates hyperventilation, causing respiratory alkalosis B: Forms a strong bond with hemoglobin, creating a functional anemia. C: Stimulates hypoventilation, causing respiratory acidosis D: Causes alveoli to overinflate, leading to atelectasis
B: Forms a strong bond with hemoglobin, creating a functional anemia.
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A: Antibiotics B: Frequent change of position C: Oxygen humidification D: Chest physiotherapy
B: Frequent change of position
The nurse would call the primary care provider immediately for which laboratory result? A: Hgb = 16 g/dL for a male client B: Hct = 22% for a female client C: WBC = 9 x 10 ^3/mL^3 D: Platelets = 300 x 10^3/mL^3
B: Hct = 22% for a female client
The client has a urinary health problem. Which procedure is performed using indirect visualization? A: Intravenous pyelography (IVP) B: Kidneys, ureter, bladder (KUB) C: Retrograde pyelography D: Cystoscopy
B: Kidneys, ureter, bladder (KUB)
The nurse will need to asses the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? A: ileal conduit B: Kock pouch C: Neobladder D: Vesicostomy
B: Kock pouch
The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be A: Mucus filled B: Liquid consistency C: Soft semi-formed D: Bloody
B: Liquid consistency
A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed? A: Irritates local tissue B: Lubricates and softens stool C: Distends rectum and moistens stool D: Distends rectum and irritates local tissue
B: Lubricates and softens stool
While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate? A: Assist the client to ambulate back to bed. B: Reconnect the tube to the water seal. C: Assess the client's lung sounds with a stethoscope. D: Have the client cough forcibly several times.
B: Reconnect the tube to the water seal.
Which goal is most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? A: The client will wear a medical alert bracelet for antibiotic allergy. B: The client will return to his or her previous fecal elimination pattern. C: The client verbalizes the need to take an antidiarrheal medication prn. D: The client will increase intake of insoluble fiber such as grains, rice, and cereals.
B: The client will return to his or her previous fecal elimination pattern.
Which of the following factors is related to developmental changes in bowel habits for older adult clients? A: Milk products cause constipation in clients with lactose intolerance B: Weakened pelvic muscles lead to constipation C: Older adults should peel fruits before eating D: Increase in dietary fiber can decrease peristalsis
B: Weakened pelvic muscles lead to constipation
Nurses discourage patients from straining on defecation primarily because it causes: Select all that apply. A. Pain. B. Impaction. C. Hemorrhoids. D. Dysrhythmias.
C,D C. Hemorrhoids. D. Dysrhythmias.
The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states: A. "I will perform my Kegel exercises every day." B. "I joined weight watchers." C. "I drink two glasses of wine with dinner." D. "I have tried urinating every 3 hours."
C. "I drink two glasses of wine with dinner."
The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by: A. 1400. B. 1600 C. 1700. D. 2300.
C. 1700.
When assessing a 55-year-old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT): A. If patient reports rectal bleeding. B. When there is a family history of polyps. C. As part of a routine examination for colon cancer. D. If a palpable mass is detected on digital examination.
C. As part of a routine examination for colon cancer.
The patient is incontinent, and a condom catheter is placed. The nurse should take which action? A. Secure the condom with adhesive tape B. Change the condom every 48 hours C. Assess the patient for skin irritation D. Use sterile technique for placement
C. Assess the patient for skin irritation
During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with: A. Food allergy. B. Irritable bowel. C. Lactose intolerance. D. Increased peristalsis.
C. Lactose intolerance.
The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to: A. Minimize the risk of a bowel obstruction. B. Ensure drainage of the intestines. C. Prevent gastric mucosal damage. D. Promote resting the gut.
C. Prevent gastric mucosal damage.
The nurse is caring for a patient with a colostomy. Which intervention is most important? A. Cleansing the stoma with hot water B. Inserting a deodorant tablet in the stoma bag C. Selecting a bag with an appropriate-size stoma opening D. Wearing sterile gloves while caring for the stoma
C. Selecting a bag with an appropriate-size stoma opening
The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to: A. Use the double-voiding technique. B. Perform Kegel exercises. C. Use Credé's method. D. Keep a voiding diary.
C. Use Credé's method.
The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient? A. Describe your bowel movements. B. How often do you have a bowel movement? C. When was the last time you moved your bowels? D. Do you routinely use stool softeners, laxatives, or enemas?
C. When was the last time you moved your bowels?
Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? A: "I will keep the collecting bag below the level of the bladder at all times." B: "Intake of cranberry juice may help decrease the risk of infection." C: "Soaking in a warm tub bath may ease the irritation associated with the catheter." D: "I should use clean technique when emptying the collecting bag."
C: "Soaking in a warm tub bath may ease the irritation associated with the catheter."
Which of the following clients is most likely to require interventions in order to maintain regular bowel patterns? A: A client who has a history of atrial fibrillation requiring daily anticoagulants B: A woman 59 years of age who has recently begun hormone replacement therapy C: A client whose neuropathic pain requires multiple doses of opioids each day D: A client with hypertension who takes a diuretic and adrenergic blocker each morning
C: A client whose neuropathic pain requires multiple doses of opioids each day
An older adult woman who is incontinent of stool following a cerebrovascular accident will have which of the following nursing diagnoses? A: Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency B: Fecal retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis C: Bowel incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate D: Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence
C: Bowel incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate
A student nurse studying human anatomy knows that the following is a structure of the large intestine: A: Jejunum B: Ileum C: Cecum D: Duodenum
C: Cecum
Which focus is the nurse most likely to teach for a client with a flaccid bladder? A: Habit training - attempt voicing at specific time periods. B: Bladder training - delay voiding according to a preschedule timetable C: Crede's maneuver - apply gentle manual pressure to the lower abdomen. D: Kegel exercises - contract the pelvic muscles.
C: Crede's maneuver - apply gentle manual pressure to the lower abdomen.
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A: Coughing up thick sputum only occasionally B: Coughing up thin, watery sputum easily after nebulization C: Decreased independent ability to cough D: Lung sounds clear only after coughing
C: Decreased independent ability to cough
The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? A: Allow the low intermittent suction to continue during the assessment of bowel sounds. B: Disconnect the nasogastric tube from the suction for one hour prior to the assessment of bowel sounds. C: Disconnect the nasogastric tube from suction during the assessment of bowel sounds. D: Apply continuous suction to the nasogastric tube during assessment of bowel sounds.
C: Disconnect the nasogastric tube from suction during the assessment of bowel sounds.
To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the following? A: Coughing exercises 1 hour before meals and deep breathing 1 hour after meals. B: Forceful coughing as many times as tolerated C: Huff coughing every 2 hours or as needed. D: Diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day.
C: Huff coughing every 2 hours or as needed.
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? A: Postural drainage B: Chest percussion C: Incentive spirometer D: Suctioning
C: Incentive spirometer
A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? A: Abdominal tenderness B: Areas of distention C: Increased bowel sounds D: Muscular resistance
C: Increased bowel sounds
Which of the following medications causes constipation? A: Dulcolax B: Magnesium antacids C: Iron supplements D: Aspirin
C: Iron supplements
Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively? A: Dyspnea B: Hyperpnea C: Orthopnea D: Acapnea
C: Orthopnea
A 78 year old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important? A: Instruct the client to empty his bladder and save this voiding to start the collection. B: Instruct the client to use sterile individual containers to collect the urine. C: Post a sign stating "Save All Urine" in the bathroom. D: Keep the urine specimen in the refrigerator.
C: Post a sign stating "Save All Urine" in the bathroom.
The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? A: Soapsuds B: Retention C: Return flow D: Oil retention
C: Return flow
Which action by the nurse represents proper nasopharyngeal/nasotracheal suction technique? A: Lubricate the suction catheter with petroleum jelly before and between insertions. B: Apply suction intermittently while inserting the suction catheter. C: Rotate the catheter while applying suction. D: Hyperoxygenate with 100% oxygen for 30 minutes before and after suctioning.
C: Rotate the catheter while applying suction.
Which of the following is most likely to validate that a client is experiencing intestinal bleeding? A: Large quantities of fat mixed with pale yellow liquid stool B: Brown, formed stool C: Semisoft, tar-colored stool D: Narrow, pencil-shaped stool
C: Semisoft, tar-colored stool
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? A: The stoma extends 1/2 in. above the abdomen. B: The skin under the appliance looks red briefly after removing the appliance. C: The stoma color is a deep red-purple. D: An ascending colostomy delivers liquid feces.
C: The stoma color is a deep red-purple.
A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is: A. 150 to 200 mL. B. 200 to 400 mL. C. 400 to 750 mL. D. 750 to 1000 mL.
D. 750 to 1000 mL.
The nurse recognizes which patient needs to use a fracture pan for a bowel movement? A. The patient who is obese B. The patient experiencing confusion C. The patient on bed rest D. A patient recovering from hip surgery
D. A patient recovering from hip surgery
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness
D. Decreased activity tolerance and increased breathlessness
An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to: A. Help him stand to void. B. Place a condom catheter. C. Have him practice Credé's method. D. Initiate Kegel exercises.
D. Initiate Kegel exercises.
To minimize the patient experiencing nocturia, the nurse would teach him or her to: A. Perform perineal hygiene after urinating. B. Set up a toileting schedule. C. Double void. D. Limit fluids before bedtime.
D. Limit fluids before bedtime.
A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first? A. Administers pain medication B. Slows down the rate of instillation C. Tells the patient to breathe slowly and relax D. Stops the instillation and obtains vital signs
D. Stops the instillation and obtains vital signs
The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first? A. Encourage fluid intake B. Administer pain medication C. Catheterize the patient D. Turn on the bathroom faucet as he tries to void
D. Turn on the bathroom faucet as he tries to void
Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? A: "Suctioning the patient requires sterile technique." B: "I'll apply suction while rotating and withdrawing the suction catheter." C: "I'll suction the mouth after I suction the endotracheal tube." D: "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
D: "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A: "I'll make sure that I rest between activities so I don't get so short of breath." B: "I'll rest for 30 minutes before I eat my meal." C: "If I have trouble breathing at night, I'll use two to three pillows to prop up." D: "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
D: "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A: Alcoholism and hypertension B: Obesity and diabetes C: Stress-related illnesses D: Cardiopulmonary disease and lung cancer
D: Cardiopulmonary disease and lung cancer
A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client's condition? A: Hypoxia B: Hypoxemia C: Dyspnea D: Cyanosis
D: Cyanosis
Which of the following symptoms are known side effects of antibiotics? A: Constipation B: Fecal impaction C: Abdominal bloating D: Diarrhea
D: Diarrhea
Which of the following statements best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? A: Nurses find the procedure distasteful and difficult to perform. B: It often causes rebound diarrhea and electrolyte loss. C: Most clients will not consent to have digital removal of stool. D: Digital removal of stool may cause parasympathetic stimulation.
D: Digital removal of stool may cause parasympathetic stimulation.
A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? A: Sonorous wheezes in the left lower lung B: Rhonchi midsternum C: Crackles only in apex of lungs D: Inspiratory crackles in lung bases
D: Inspiratory crackles in lung bases
A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? A: Oil retention B: Return flow C: High, large volume D: Low, small volume
D: Low, small volume
During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify? A: Risk of constipation B: Constipation C: Bowel incontinence D: Perceived constipation
D: Perceived constipation
A nurse is caring for a middle-aged client with fecal incontinence at her house. The client's friends have come to visit her, but the client avoids meeting them. Which of the following nursing diagnoses should the nurse identify? A: Toileting self-care deficit B: Risk for infection C: Severe diarrhea D: Situational low self-esteem
D: Situational low self-esteem
The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? A: The bladder distends and its capacity increases. B: Older adults ignore the need to void. C: Urine becomes more concentrated. D: The amount of urine retained after voiding increases.
D: The amount of urine retained after voiding increases.
During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? A: Stress Urinary Incontinence B: Reflex Urinary Incontinence C: Functional Urinary Incontinence D: Urge Urinary Incontinence
D: Urge Urinary Incontinence
