FUNDAMENTALS EXAM 3 PRACTICE QUESTIONS

While preparing the client for a colonoscopy, the nurse's responsibilities include: A. Explaining the risks and benefits of the exam B. Instructing the client about the bowel preparation prior to the test C. Instructing the client about medication that will be used to sedate the client D. Explaining the results of the exam

B. Instructing the client about the bowel preparation prior to the test

A patient who underwent surgery for removal of a pituitary tumor develops a condition in which the kidneys are unable to conserve water and the quantity of urine voided increases. Which urine specific gravity would the nurse expect to find in the patient with this disorder? 1) 1.001 2) 1.010 3) 1.025 4) 1.030

1) 1.001 Rationale: The patient with diabetes insipidus would have a low specific gravity, such as 1.001. This indicates dilute urine that results from poor concentrating ability of the kidneys.Normal urine specific gravity ranges from 1.010 to 1.025.A specific gravity of 1.030 indicates concentrated urine or deficient fluid volume (dehydration).

What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro blood vessels to renal cortex 3) Formation of urate crystals 4) Increased renal mass

1) Decreased glomerular filtration rate Rationale: Glomerular filtration rate is the amount of filtrate formed by the kidneys in 1 minute.Renal blood flow progressively decreases with aging primarily because of reduced blood supply through the micro-blood vessels of the kidney. A decrease in glomerular filtration is the most important functional deficit caused by aging.Urate crystals are somewhat common in the newborn period. They might indicate that the infant is dehydrated. In older people, they result from too much uric acid in the blood, although this is not related to aging.Renal mass (weight) decreases over time, starting around age 30 to 40.

When inserting an indwelling urinary catheter in a male patient, the nurse cleanses the penis with an antiseptic wash. Which step should she take next? 1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. 2) Ask the patient to bear down as though trying to void. 3) Slowly insert the end of the catheter into the urinary meatus. 4) Insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows.

1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. Rationale: The steps of the procedure for inserting an indwelling urinary catheter are as follows: The nurse should gently insert the tip of the prefilled syringe into the urethra and instill the lubricant. Then the nurse should ask the patient to bear down as though trying to void, as she slowly inserts the end of the catheter into the meatus. She should continue to insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows. When urine appears, she should advance the catheter 1 to 2 inches (2.5 to 5 cm) more. She should hold the catheter securely with her dominant hand while the urine flows. After urine flows, she should stabilize the catheter's position in the urethra and use the other hand to pick up the saline-filled syringe and inflate the catheter balloon.

A patient is admitted with pyelonephritis. Which anatomic structure is affected by this disorder? 1) Kidneys 2) Bladder 3) Urethra 4) Prostate gland

1) Kidneys Rationale: Pyelonephritis is an infection of the kidneys.Cystitis is an infection involving the bladder.An infection of the urethra is known as urethritis.Prostatitis is an infection involving the prostate gland.

A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.) 1) palpating the bladder height. 2) obtaining a clean-catch urine specimen. 3) performing a bladder scan. 4) asking the patient about his recent voiding history. 5) encouraging the patient to consume cranberry juice daily. 6) inserting a straight catheter to measure residual urine.

1) Palpating the bladder height. 3) Performing a bladder scan. 4) Asking the patient about his recent voiding history. Rationale: The nurse should palpate the bladder for distention.A bladder scan will yield a more accurate measurement of the postvoid residual urine. A detailed history of the client's recent voiding patterns will assist the nurse in determining the appropriate nursing diagnosis and developing a plan of care.A clean-catch urine specimen may be necessary if further assessment shows the potential of a urinary tract infection.Cranberry juice is sometimes used to in an effort to prevent urinary tract infection, although there is conflicting research to support this action.Inserting a straight catheter to measure residual urine is an invasive procedure with the risk of introducing microorganisms into the bladder and is usually unnecessary if the nurse has access to a portable bladder scanner.

Which urinary system structure is largely responsible for storing urine? 1) Kidney 2) Bladder 3) Ureters 4) Nephrons

2) Bladder Rationale: The urinary bladder is a sac-like organ that receives urine from the ureters and stores it until discharged from the body.The kidneys filter metabolic wastes, toxins, excess ions, and water from the bloodstream and excrete them as urine.The ureters transport urine.The nephrons form urine.

Which medication will the primary care provider will most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin

2) Furosemide Rationale: Furosemide (Lasix) is a loop diuretic that increases urine elimination. It works by limiting the reabsorption of water in the renal tubules.Digoxin (Lanoxin) increases the force of contraction by the heart. It is also prescribed for treatment of heart failure.Lovastatin (Mevacor) is a cholesterol-lowering agent.Atorvastatin (Lipitor) is a cholesterol-lowering drug. Although high cholesterol is a leading factor for heart disease, the medication is used to reduce cholesterol in the blood—not to promote diuresis to reduce the demand on the heart and backflow into the lungs.

The nurse is obtaining the history of a newly admitted patient. Which element in the history places the patient at risk for urinary tract infection? 1) Hypertension 2) Hypothyroidism 3) Diabetes mellitus 4) Hormonal contraceptive use

3) Diabetes mellitus Rationale: Diabetes mellitus places the patient at risk for urinary tract infection because glucose in the urine provides a medium favorable for bacterial growth.Hypertension, hypothyroidism, and hormonal contraceptive use are not directly related to an increased risk for urinary tract infection.

The parent of a 7-year-old son brings the child to the pediatric care provider to discuss her child's nighttime bedwetting. She reports he has never achieved consistent dryness at night. What is the nurse's best response to the mother's concern? 1) "We'll start medication right away to control it." 2) "Family history is not associated with bedwetting." 3) "We will look for a urinary tract infection." 4) "Wait it out. Your son will likely outgrow it."

4) "Wait it out. Your son will likely outgrow it." Rationale: Based on the history, the nurse understands the condition is nocturnal enuresis because the child has not yet achieved dryness at night at an age when continence would be expected. Nocturnal enuresis is most common among boys. Ninety-five percent of children outgrow it by age 10.Nighttime bedwetting runs in families. So if one parent experienced nocturnal enuresis as a child, then the chances that the child will also have trouble with achieving continence at night will be likely.Pharmacological intervention can be useful for older children, particularly when the child is not sleeping at home. However, prior to age 8 or 10, medication is not indicated.Frequency and urgency and burning are signs of a urinary tract infection. These symptoms are most noticeable during the day (not night). Nocturnal enuresis occurs without the person realizing that he emptied the bladder.

Which blood level is commonly tested to help assess kidney function? 1) Hemoglobin 2) Potassium 3) Sodium 4) Creatinine

4) Creatinine Rationale: The nurse would examine laboratory results for blood urea nitrogen and creatinine to assess kidney function.Hemoglobin, potassium, and sodium levels can be affected by kidney disease, but they do not directly assess kidney function.

The nurse is teaching an older female patient how to manage stress incontinence at home. She instructs her to contract her pelvic floor muscles for at least 10 seconds followed by a brief period of relaxation. What is this intervention called? 1) Prompted voiding 2) Crede technique 3) Valsalva maneuver 4) Kegel exercises

4) Kegel exercises Rationale: Kegel exercises strengthen the pelvic floor muscles that support the uterus, bladder, and bowel. Doing Kegel exercises regularly can reduce urinary incontinence. These exercises involve tightening and relaxing the muscles around the vaginal area.Prompted voiding is a part of a bladder-training program in which the person learns to void based on a schedule, rather than to empty the bladder.The Crede technique is applying manual pressure with your hands to the top portion of the bladder to initiate a urine flow.The Valsalva is the maneuver in which a person tries to exhale forcibly with a closed glottis (the windpipe) so that no air exits through the mouth or nose, for example, in strenuous coughing, straining during a bowel movement, or lifting a heavy weight.

During removal of a fecal impaction, which of the following could occur Because of vaginal stimulation? A) Bradycardia B)Atelectasid C) Tachycardia D) Cardiac tamponade

A) BradycardiaRemoving a fecal impaction manually may result in stimulation of the vaginal nerve and resulting bradycardia

Which of the following is a true statement about the effects of medication on bowel illumination? A) Diarrhea commonly occurs with amoxicillin clavulanate use B) Anticoagulants cause a white discoloration of the stool C) Narcotic analgesics increased Gastrointestinal mobility D) Iron salts in pair digestion and cause a green store

A) Diarrhea commonly occurs with amoxicillin clavulanate use Anticoagulants may result in the store having a pink to red to black appearance, whereas iron salts also cause a black stool. Narcotic analgesics decrease gastric mobility.

A barium Enema should be done before an upper gastrointestinal series because of which of the following? A) Retained barium may cloud the colon B) barium Can cause lower Gastrointestinal bleeding C) The physicians orders are in that sequence D)barium Is absorbed readily in the lower intestine

A) Retained barium may cloud the colon The barium And I'm should always perceive the upper gastrointestinal series because retained barium from the latter may take several days to pass through the gastrointestinal tract and may cloud anatomic detail on the barium enema studies

Which class of laxative acts by causing the stool to absorb water and swell? A)Bulk-forming B)Emollient C)Lubricant D)Stimulant

A)Bulk-forming Emollients Lubricate the stool; Lubricants soften the stool, making it easier to pass: and Stimulants promotes peristalsis by irritating the intestinal mucosa or stimulating nerve ending in the intestinal wall

Which of the following are included in the nursing plan of care to prevent adverse effects when caring for patients with a nasogastric tube in place for gastric decompression's? Select all that apply. A) Irrigation with Saline B) Measure the length of exposed tube C) Measure the pH of the aspirated tube contents D) Administer frequent oral hygiene

A,B,C,D After checking placement, NGT should be Irrigated with 30 to 60 mL of normal saline to maintain patency. The frequency is determined by facility policy, medical order, and nursing judgment. The length of the exposed tubes should be measured after insertion and routinely thereafter, as part of the assessment to verify placement and ensure the tube has not dislodged. Measuring the pH of aspirated two contents is one way to validate to placement in the intestinal tract. The other methods is to visually Assess aspirate to confirm gastric contents. Patients with NGTs Often experience discomfort related to irritation to nasal and throat mucosa And drying of the mucous membranes. Frequent oral hygiene should be administered as well as applying lubricant to the lips

Following a gastroscopy, a client asks for something to eat. The nurse correctly responds: A. "I will first check your gag reflex." B. "I will first listen for bowel sounds." C. "I will first have you cough and deep-breathe." D. "I will first listen to your lungs."

A. "I will first check your gag reflex."

A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Which type of client would this type of procedure would benefit from this procedure? A. An abdominal trauma victim B. A renal failure client C. A client with kidney stones D. An individual suffering from a urinary tract infection

A. An abdominal trauma victim Rationale: The abdominal trauma victim is the only appropriate answer here. The remaining problems can be treated with less traumatic care measures.

The nurse is requested to perform teaching to a client in the Emergency Department related to the diagnosis of a urinary tract infection. An intervention to be followed by the client includes: A. Avoid tight-fitting pants or clothing B. Drink six glasses of water per day C. Type of soap when bathing has no significance in this area. D. Voiding pattern in the course of the day has no significance with this problem.

A. Avoid tight-fitting pants or clothing Rationale: Tight-fitting clothing creates irritation to the urethra and prevents ventilation of the perineal area. It is recommended that eight glasses of water be drunk to flush out the urinary system. Avoid harsh soaps, bubble bath, powders, and sprays in the perineal area, because they can have an irritating effect on the urethra, encouraging inflammation and a bacterial infection. Practice frequent voiding (q 2-3 hours) to flush bacteria out other the urethra and prevent organisms from ascending into the bladder.

A client who has an indwelling catheter reports I need to urinate. Which of the following interventions should the nurse perform? A. Check to see whether the catheter is patent B. Reassure the client that it is not possible for her to urinate C. Re-catheterize the bladder with a larger gauge catheter D. Collect a urine specimen for analysis

A. Check to see whether the catheter is patent A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate. Reassuring the client that is not possible to urinate is a non-therapeutic response because it diminishes the client's concern (opt2). There are less invasive approaches the nurse can take before replacing the catheter (opt3). Although it may become necessary to collect a urine specimen, there is a simpler approach the nurse can take to assess and possibly resolve the client's problem (opt4).

A provider prescribes a 24 hour urine collection for a client. Which of the following actions should the nurse take? A. Discard the first voiding B. Keep all voidings in a container at room temperature C. Ask the client to urinate and pour the urine into a specimen container D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container

A. Discard the first voiding The nurse should discard the first voiding of the 24 hour urine specimen, and note the time. The nurse should collect all voidings after that and keep them in a refrigerated container (opt2). For a urinalysis, the nurse should ask the client to urinate and pour the urine into a specimen container (opt3). For a culture, the nurse should ask the client to urinate first into the toilet, then stop midstream, and finish urinating in the specimen container (opt4).

A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections with a group of assistive personnel. Which of the following should be included in the review? Select all that apply. A. Having sexual intercourse on a frequent basis B. Lowering of testosterone levels C. Wiping from front to back D. The location of the vagina in relation to the anus E. Undergoing frequent catheterization

A. Having sexual intercourse on a frequent basis D. The location of the vagina in relation to the anus E. Undergoing frequent catheterization Having sexual intercourse on a frequent basis is a factor that increases the risk of UTI in both males and females. The close proximity of the female urethra to the anus is a factor that increases the risk of UTIs. Undergoing frequent catheterization and the use of indwelling catheters are risk factors for UTIs. The decrease in estrogen levels during menopause increases a woman's susceptibility to UTIs (opt2). Wiping from front to back decreases a woman's risk of UTIs (opt3).

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 The catheter in the vagina is contaminated and can't be reused.If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn't indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus (opt2).

Thinking back to the patient in Question 1, what type of stool would you expect the stoma to be excreting? Recap: Question 1 = On assessment of a patient with a colostomy, you note the stoma is located on the right area of the abdomen. Due to its location, this is known as what type of colostomy? Answer: Ascending Colostomy A. Liquid stool B. Lose to partly formed stool C. Similar to normal stool D. Semi-solid stool

A. Liquid stool Stool from an ascending colostomy will be liquid. Stool from a Transverse Colostomy: lose to partly formed stool, Descending/Sigmoid: similar to normal solid consistency. An ileostomy will always excrete liquid stool.

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. A. Perineal skin irritation B. Fluid intake of less than 1,500 mL/d C. History of antihistamine intake D. Hx of UTI E. A fecal impaction

A. Perineal skin irritation B. Fluid intake of less than 1,500 mL/d D. Hx of UTI E. A fecal impaction The perineum may become irritated by the frequent contact with urine (Opt1). Normal fluid intake is at least 1,500 mL/d and clients often decrease their intake to try to minimize urine leakage (Opt.2). UTIs can contribute to incontinence (Opt4). A fecal impaction can compress the urethra, which results in sm. amts of urine leakage (Opt5). Antihistamines can cause urinary retention rather than urinary incontinence (Opt3).

During assessment of the client with urinary incontinence, the nurse is most likely to assess 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. Perineal skin irritation B. Fluid intake of less than 1,500 mL/day D. History of frequent urinary tract infections E. A fecal impaction Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1,500 mL/day and clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3).

A patient has a double-barrel colostomy of the transverse colon. You note on assessment two stomas, a proximal and distal stoma. What type of stool do you expect to drain from the proximal and distal stomas? A. Proximal: lose to partly formed stool; Distal: mucous B. Proximal: liquid stool; Distal: mucous C. Proximal: mucous; Distal: lose to partly formed stool D. Proximal & Distal: lose to partly formed stool

A. Proximal: lose to partly formed stool; Distal: mucous The proximal will drain stool while the distal will NOT. The distal will drain mucous. Since it is a double-barrel colostomy of the transverse colon, you can expect the stool to be lose to partly formed.

The nurse is counseling a young mother who complains of having stress incontinence continuing for three months after her pregnancy. It has been recommended that she practice pelvic muscle exercises to strengthen her bladder muscles. What action would the nurse recommend to this client in order to perform this activity correctly? A. Stopping urination midstream B. Standing tall and stretching out her arms and touching her toes C. Emptying her bladder completely D. Moving her bowels

A. Stopping urination midstream Rationale: Stopping the flow of urination midstream focuses on the muscle used to control this activity. The remaining answers do not affect this muscle in the same manner.

A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen? A. Use a sterile specimen container. B. Collect urine from the catheter port. C. Inflate the balloon with 10 mL of sterile water. D. Have the patient void before collecting the specimen.

A. Use a sterile specimen container. A culture attempts to identify the microorganisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against the isolated micro organisms. A sterile specimen container is used to prevent contamination of the specimen by micro organisms outside the body (exogenous). The urine from straight catheter flows directly into the specimen container. Collecting a urine specimen from a catheter port is necessary when the patient has a urinary retention catheter (opt2). A straight catheter has a single lumen for draining urine from the bladder. A straight catheter does not remain in the bladder and therefore does not have a 2nd lumen for water to be inserted into a balloon (opt3). This may result in no urine left in the bladder for the straight catheter to collect. A minimum of 3 mL of urine is necessary for a specimen for urine culture and sensitivity (opt4).

During an assessment, the nurse learns that the client has a history of liver disease. Which diagnostic tests might be indicated for this client?Select all that apply. A. Alanine aminotransferase (ALT) B. Myoglobin C. Cholesterol D. Ammonia E. Brain natriuretic peptide or B-Type natriuretic peptide (BNP)

A.Alanine aminotransferase (ALT) D. Ammonia ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver.The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease.

If the patient was instructed to avoid foods that may have a laxative effect, the nurse would advise the patient to avoid which of the following foods? A) Chinese B) Alcohol C) Eggs D) Pasta

B) Alcohol All the foods listed as such alcohol have a constipating effect

Your patient complains of an excessive flatulence. When reviewing your patients dietary intake, which foods, if eaten regularly, would you identify as possibly responsible? A) Meat B) Cauliflower C) Potatoes D) Ice cream

B) Cauliflower Cauliflower is a gas producing food that relates in flatulence

Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this? A) They will cause a fecal impaction B) They will cause chronic constipation C) They change the pH of the Gastrointestinal track D) They inhibit the intestinal enzymes

B) They will cause chronic constipation Habitual use of laxatives is the most common cause of chronic constipation

Mr. T is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test by explaining that it allows which of the following? A) Visual examination of the esophagus and stomach B) Visual examination of the large intestine C) Radiographic examination of the large intestine D) Fluoroscopic examination of the small intestine

B) Visual examination of the large intestineAn esophagogastroduodenoscopy Allows visual examination of the esophagus and stomach. The radiographic examination of the large intestine refers to a barium enema, and a fluoroscopic Examination of the small intestines refers to an upper gastrointestinal series

A certified nursing assistant is collecting a 24-hour urine specimen from a client. Which statement by the assistant indicates that the specimen collection will need to be restarted? A. "I used a container from the lab that has a preservative in it." B. "The client voided in it right away, and I wrote the time on the container." C. "I have the container in a plastic bucket with ice in it." D. "I told the client that every single urination must be put in the container. If one is missed, call one of us."

B. "The client voided in it right away, and I wrote the time on the container."

A client is to obtain a clean-catch urine specimen. Which statement by the client demonstrates a lack of understanding regarding the procedure? A. "I should use all of the towelettes in the kit and use each only once." B. "Urinate into the cup as soon as I start to go." C. "I don't have to fill the cup. Just get an ounce or two." D. "Put the cover on right away, without touching the inside of the cover or the cup."

B. "Urinate into the cup as soon as I start to go."

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 min after applying C. Change the condom every 8 hours D. Tape the collecting tube to the lower abdomen.

B. Check the penis for adequate circulation 30 min after applying The penis and condom should be checked 1/2 hour after application to ensure that it's not too tight. A 1 in. space should be left btw the penis and the end of the condom (Opt1). The condom is changed every 24h (opt3) and the tubing is taped to the leg or attached to a leg bag. An indwelling catheter is taped to the lower abdomen or upper thigh (opt4).

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. D. Tape the collecting tubing to the lower abdomen.

B. Check the penis for adequate circulation 30 minutes after applying. Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight. A 1-in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bag (option 4). An indwelling catheter is taped to the lower abdomen or upper thigh.

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. 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. Rationale: The nurse should obtain the stool specimen from two different areas of the stool.The nurse should observe for a blue color change, which is indicative of a positive result.The nurse should assess for the ingestion of vitamin C by the client because it is contraindicated for 3 days prior to taking the specimen. Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification.

A nurse in a provider's office is assessing a client who reports losing control of urine when ever 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 are appropriate for helping to control or eliminate the clients incontinence? Select all that apply. A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Increase the intake of calcium supplements D. Avoid the intake of alcohol E. Use Crede maneuver

B. Decrease or avoid caffeine D. Avoid the intake of alcohol Caffeine and alcohol are bladder irritants and can worsen stress incontinence. Alcohol is a bladder irritant and can worsen stress incontinence. Because stress incontinence results from weak pelvic muscles and other structures, limiting fluid will not resolve the problem (opt1). Calcium has no effect on stress incontinence (opt3). The Crede maneuver helps manage reflex incontinence, not stress incontinence (opt5).

A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter? A. Urinal B. Graduate C. Large syringe D. Urine collection bag

B. Graduate A graduate is a collection container with volume markings usually at 25 mL increments that promote accurate measurements of urine volume. Although urinals have volume markings on the side, usually they occur in 100 mL increments that do not promote accurate measurements (opt1). Option 3 is impractical. A large syringe is used to obtain a sterile specimen from a retention catheter (Foley catheter). A urine collection bag is flexible and balloons outward as urine collects. In addition, the volume markings are at 100 mL increments that do not promote accurate measurements (opt4).

A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? Select all that apply. A. Establish a schedule of voiding prior to meal times B. Have the client record voiding times C. Gradually increase the voiding intervals D. Reminded client to hold urine until next scheduled voiding time E. Provide a sterile container for voiding

B. Have the client record voiding times C. Gradually increase the voiding intervals D. Reminded client to hold urine until next scheduled voiding time Ask the client to keep track of voiding times is an appropriate nursing action. Gradually increasing the voiding interval is an appropriate nursing action. The client should be reminded to hold urine until the next scheduled voiding time. Bladder training involves voiding at scheduled in frequent intervals and gradually increasing these intervals to four hours. Mealtimes are not regular, and the intervals may be longer than every four hours (opt1). A sterile container is not used in a bladder training program (opt5).

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 10³/mL³ D. Platelets = 300 x 10³/mL³

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) A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cytoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization.

The nurse will need to assess 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 Rationale: The ileal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3).

The nurse will need to assess 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 ileal conduit and vesicostomy (opt1,4) are in continent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (opt3).

A primary care provider is going to perform a thoracentesis. The nurse's role will include which action? A. Place the client supine in the Trendelenburg position. B. Position the client in a seated position with elbows on the overbed table. C. Instruct the UAP to measure vital signs. D. Administer an opioid analgesic.

B. Position the client in a seated position with elbows on the overbed table.

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. Practices slow, deep breathing until the urge decreases E. Performs pelvic muscle exercises It is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Some clients may need diapers; this is not the best indicator of a successful program (opt3). Citrus juices may irritate the bladder (opt4). Carbonated beverages increase diuresis and the risk of incontinence (opt4).

A female client has a urinary tract infection. Which teaching points by the nurse should 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. Review symptoms of UTI with the client D. Wear cotton underclothes Option two validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (opt4). Increased fluids decrease concentration and irritation (opt1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (opt3). Showers reduce exposure of area to bacteria (opt5).

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. Review symptoms of UTI with the client. D. Wear cotton underclothes. Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of area to bacteria (option 5).

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 laboratory. 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. Send the specimen immediately to the laboratory. D. Offer mouth care before and after collection of the sputum specimen. E. Collect a specimen for 3 consecutive days

A patient is 8 hours post-opt from an colostomy placement. Which finding requires immediate nursing action? A. The stoma is swollen and large. B. The stoma is black. C. The stoma is not draining any stool. D. The patient states the site is tender.

B. The stoma is black. An assessment finding of a stoma being black is not a normal finding but represents compromised circulation to the stoma. It requires immediate physician notification. The stoma should look red and be shiny/moist. It is normal for a stoma to be swollen and large after surgery (this will subside after a few months), and it is normal for the site to be tender due to the surgery (this will subside as well) and for the stoma to not be draining any stool yet. It can take approximately 2 day before stool drains from a colostomy.

A patient's urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment? A. Urinary retention B. Urinary tract infection C. Ketone bodies in the urine D. High urinary calcium level

B. Urinary tract infection The urine appears concentrated (amber)and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria). These clinical manifestations do not reflect urinary retention. Urinary retention is evidenced by supra pubic distention and lack of voiding or small, frequent voiding (overflow incontinence) (opt1). These clinical manifestations do not reflect Ketone bodies in the urine. A reagent strip dipped in urine will measure the presence of Ketone bodies (opt3). These clinical manifestations do not reflect excessive calcium in the urine. Urine calcium levels are measured by assessing a 24 hour urine specimen (opt4).

Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention Enema by doing which of the following? A) Administering a large volume solution 500 to 1000 ml B) Mixing milk and molasses and equal parts for an enema C) Instructing the patient to retain the enema for at least 30 seconds D) Administering the enema while the patient is sitting on a toilet

C) Instructing the patient to retain the enema for at least 30 seconds The usual amount of solution administered with a retention Enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema That helps to expel flats, As does the Harrison flush procedure

When explaining the action of a hyper tonic solution enema, the nurse incorporates which of the following as the basis for action? A) bowel mucosa irritations B) Diffusion of water out of colon C) Osmosis of water into colon D) Softening of fecal contents

C) Osmosis of water into colon Hypertonic solutions draw water into the colon a By osmosis that's stimulating the defecation reflex. Orrills solutions soften fecal contents, and soup solutions distend the intestines and irritate the bowel mucosa

Which statement indicates a need for further teaching of a 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 tech. when emptying the collecting bag"

C. "Soaking in a warm tub bath may ease the irritation associated with the catheter" Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (opt1). Intake of cranberry juice creates an environment nonconducive to infection (opt2). Clean technique is appropriate for touching the exterior portions of the system (opt4).

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." Rationale: Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (option 1). Intake of cranberry juice creates an environment nonconducive to infection (option 2). Clean technique is appropriate for touching the exterior portions of the system (option 4).

When assisting with a bone marrow biopsy, the nurse should take which action? A. Assist the client to a right side-lying position after the procedure. B. Observe for signs of dyspnea, pallor, and coughing. C. Assess for bleeding and hematoma formation for several days after the procedure. D. Stand in front of the client and support the back of the neck and knees.

C. Assess for bleeding and hematoma formation for several days after the procedure. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? A. Habit training: attempt voiding at specific time periods B. Bladder training: delay voiding according to a pre-schedule 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 Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination, the process is initiated manually. Options one, two, and four: to promote continence bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? A. Habit training: attempt voiding at specific time periods. B. Bladder training: delay voiding according to a preschedule timetable. C. Credé's maneuver: apply gentle manual pressure to the lower abdomen. D. Kegel exercises: contract the pelvic muscles.

C. Credé's maneuver: apply gentle manual pressure to the lower abdomen. Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles.

The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information? A. Fasting blood glucose B. Capillary blood specimen C. Glycosylated hemoglobin D. GGT (gamma-glutamyl transferase)

C. Glycosylated hemoglobin A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options 1 and 2 will provide information about the current blood glucose not the past history. Option 4 is used to assess for liver disease.

A patient, who had a colostomy placed yesterday, calls on the call light to say their surgical dressing "fell off". You will re-apply what type of dressing over the stoma? A. Wet to dressing B. No dressing is needed. You will keep it open to air. C. Petroleum gauze dressing D. Telfa gauze

C. Petroleum gauze dressing A petroleum gauze dressing will be kept in place (or a sterile dry dressing) until a pouch system is in place.

A nurse cares for a client following a liver biopsy. Which nursing care plan reflects proper care? A. Position in a dorsal recumbent position, with one pillow under the head B. Bed rest for 24 hours, with a pressure dressing over the biopsy site C. Position to a right side-lying position, with a pillow under the biopsy site D. Neurological checks of lower extremities every hour

C. Position to a right side-lying position, with a pillow under the biopsy site

A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs? A. Encouraging the use of bladder training exercises B. Providing assistance with toileting every four hours C. Positioning a bedside commode near the bed D. Teaching the avoidance of fluid after 5 PM

C. Positioning a bedside commode near the bed The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on the commode uses gravity to empty the bladder fully and thus prevent urinary stasis. Although option 1 should be done, it is not the priority. Option 2 may be too often or not often enough for the patient. Care should be individualized for the patient. Fluids may be decreased during the last two hours before bedtime, but they should not be avoided completely after 5 PM (opt4). Some fluid intake is necessary for adequate renal perfusion.

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. Option 3 is the most important nursing measure. This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the first voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterile, and one container is needed—not individual containers. Option 4 is inappropriate because some 24-hour urine collections do not require refrigeration.

A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation? A. Coughing B. Mobility deficits C. Prostate enlargement D. Urinary tract infection

C. Prostate enlargement An enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25-60mL) of urine to escape (overflow incontinence). Coughing, which raises the intro abdominal pressure, is related to stress incontinence, not overflow incontinence (opt1). Mobility deficits, such as spinal cord injuries, are related to reflex incontinence, not overflow incontinence (opt2). Urinary tract infections are related to urge incontinence, not overflow incontinence (opt4).

A client comes to the primary care provider's office with the complaints of urinating all the time, pain on urination, small amounts of urine being passed when voiding, and a foul smell to the urine. A urine specimen has been sent for analysis. Based on the signs and symptoms expressed by the client, which of the following health problems would be anticipated? A. Acute renal failure B. Renal stone C. Urinary tract infection D. Chronic renal failure

C. Urinary tract infection Rationale: The noted signs and symptoms help to identify the problem of urinary tract infection. The signs and symptoms noted are not common with the other diseases listed.

You're providing teaching to a patient with an ileostomy on how to change their pouch drainage system. Which statement is INCORRECT about how to change a pouching system for an ostomy? A. Empty the pouch when it is 1/3 to 1/2 full. B. Change the pouching system every 3-5 days. C. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 2/3 inch larger than the stoma. D. Keep the skin around the stoma clean and dry at all times.

C. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 2/3 inch larger than the stoma. This statement is INCORRECT. When measuring the stoma for skin barrier placement, be sure the opening of the skin barrier is a 1/8 inch larger than the stoma.....not 2/3 inch.

The nurse is having difficulty obtaining a capillary blood sample from a client's finger to measure blood glucose using a blood glucose monitor. Which procedure will increase the blood flow to the area to ensure an adequate specimen? A. Raise the hand on a pillow to increase venous flow. B. Pierce the skin with the lancet in the middle of the finger pad. C. Wrap the finger in a warm cloth for 30--60 seconds. D. Pierce the skin at a 45-degree angle.

C. Wrap the finger in a warm cloth for 30--60 seconds.

Which of the following is an appropriate nursing action to promote regular bowel habits? A) Encourage the patient to avoid moving his bowels until a certain time of day B) Encourage the patient to avoid excess fluid intake and too much fiber C) Avoid strenuous exercise to limit stress on the abdominal muscles and impair peristalsis D) Assisting the patient to a normal position as possible to defecate

D) Assisting the patient to a normal position as possible to defecate Sitting upright on a toilet or commode promotes defecation. If the patient must use a bedpan, raise the head of the bed 30 to 45°. Patient should be encouraged to move their bowels at their usual time of the day. However, the patient should not be encouraged to put off defecation if the urge arises before or after their usual time. Patient should be encouraged to consume 2000 to 3000 mL of fluid, preferably water, and increase fiber, to promote regular defecation. Regular exercise improves gastrointestinal activities and aids in defecation

As the nurse prepares to assist Mrs. P with her newly created Ileostomy, She is aware of which of the following? A) An appliance will not be required on the continual basis B) The size of the stoma stabilizes within two weeks C) Irrigation is necessary for regulationD) Fecal drainage will be liquid

D) Fecal drainage will be liquid And appliance is usually required on a continual basis because the fecal drainage is liquid. Stomas size usually stabilizes within 4 to 6 weeks, and Ileostomy Irrigation is not necessary because fecal matter is liquid

On assessment of a patient with a colostomy, you note the stoma is located on the right area of the abdomen. Due to its location, this is known as what type of colostomy? A. Descending Colostomy B. Transverse C. Ileostomy D. Ascending Colostomy

D. Ascending Colostomy

The goal of nursing care of the client with an indwelling catheter and continuous drainage is largely directed at preventing infection of the urinary tract and encouraging urinary flow through the drainage system. Which of the following interventions encouraged by nurses working with these clients would not be appropriate in meeting this goal? A. Having the client drink up to 3000mL per day B. Encouraging the client to eat foods that increase the acid in the urine C. Routine hygienic care D. Changing indwelling catheters every 72 hours.

D. Changing indwelling catheters every 72 hours. Rationale: Retention catheters are removed after their purpose is achieved; routine changing of the catheter or drainage system is not recommended. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection. Eating foods that increase the acid in urine helps to reduce the risk of urinary tract infections and stone formation. Hygiene care related to catheters is set by hospital policy.

A client is admitted with gastrointestinal bleeding. One of the earliest and most important blood tests completed will be: A. Electrolyte Panel B. Arterial Blood Gases C. Liver Panel D. Complete Blood Count

D. Complete Blood Count

Urinary incontinence is not a normal part of aging. An intervention used by nurses to assist clients to regain or maintain continence with individuals suffering from this problem would not include: A. Bladder training B. Habit training C. Prompted voiding D. Fluid restriction

D. Fluid restriction Rationale: Fluids would be encouraged, to allow the kidneys to be flushed and urine to be formed. Bladder training requires that the client postpone voiding, resist or inhinbit the sensation of urgency, and void according to a timetable, rather than according to an urge. Habit training is also referred to timed or scheduled voiding. There is no attempt to motivate the client to delay voiding if the urge occurs. Prompted voiding supplements habit training by encouraging the client to try to use the toilet and reminding the client when to void.

A client reports an iodine allergy. This information is most significant if the client is scheduled for which exam? A. Lung Scan B. Computed Tomography C. Magnetic Resonance Imaging D. Intravenous Pyelogram

D. Intravenous Pyelogram

Describe, in order, how food travels from the stomach to the rectum: A. It exits the stomach into: the cecum to the jejunum to the ileum, then into the duodenum, descending colon, transverse colon, ascending colon, sigmoid colon, and rectum. B. It exits the stomach into: the duodenum to the ileum to the jejunum, then into the cecum, ascending colon, sigmoid colon, descending colon, transverse colon, and rectum. C. It exits the stomach into: the ileum to the jejunum to the duodenum, then into the cecum, sigmoid colon, transverse colon, descending colon, ascending colon, and rectum. D. It exits the stomach into: the duodenum to the jejunum to the ileum, then into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.

D. It exits the stomach into: the duodenum to the jejunum to the ileum, then into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.

A client has a streptococcal throat infection. The White Blood Cell count is elevated. When looking at the differential, the nurse expects which type of white blood cell to be elevated? A.Eosinophils B. Monocytes C. Lymphocytes D. Neutrophils

D. Neutrophils

Which nursing assessment in the home care environment for clients with urinary elimination problems is inappropriate? A. Client self-care abilities B. Distance and barriers to accessing the bathroom C. Need/use of ambulatory aids as required D. No dietary restrictions needed

D. No dietary restrictions needed Rationale: Dietary guides related to fiber and fluid balance are given to clients with this problem. The remaining actions are noted in the assessment guide, and are appropriate measures to use with clients.

Which noninvasive procedure provides information about the physiology or function of an organ? A. Angiography B. Computerized tomography (CT) C. Magnetic resonance imaging (MRI) D. Positron emission tomography (PET)

D. Positron emission tomography (PET) Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ.

A practice guideline for nurses to use in preventing catheter-associated urinary infection includes which of the instructions listed below? A. Maintain clean technique when inserting the catheter into the client. B. Disconnect the catheter and drainage tubing once a shift to rinse the unit in cleaning the device. C. Since you are wearing gloves, it is not necessary to wash your hands. D. Prevent contamination of the catheter with feces in the incontinent client.

D. Prevent contamination of the catheter with feces in the incontinent client. Rationale: Keeping the perineal area free of feces eliminates the possible spread of any bacteria that may colonize in the feces and travel up the catheter to the bladder. Sterile or aseptic technique is used when inserting Foley catheters into clients to prevent the spread of infection with the process. Catheter tubing should not be disconnected once put into use. Connections are usually taped to help secure their seal. Wearing gloves with this procedure is part of the practice of Universal Precautions utilized when health care workers come in contact with most tubes and body fluids.

A client is to have a thoracentesis in order to aspirate pleural fluid for biopsy. In order to prepare the client for the procedure, the nurse best positions the client in which manner? A. Lying in a lateral position with the affected lung down and back, curved into a fetal position. The head is supported with a pillow. The arms are positioned comfortably away from the chest wall. B. Lying in a 10-degree reverse Trendelenburg position with the arms over the head. Small pillows allowed under the head and arms. C. Sitting in a Fowler's position with the arms abducted and supported by pillows placed on each side of the body. The head is lying flat against the mattress. D. Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow

D. Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow

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 The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (Option 4). Older adults don't ignore the urge to void and may have difficulty getting to the toilet in time (Option 2). The kidney becomes less able to concentrate urine with age (Option3).

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. Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3).

Urinary catheterization is carried out for clients only when absolutely necessary. Which of the following candidates/situations would not warrant the need for this procedure? A. A client having abdominal surgery B. A client who is completely paralyzed C. A client in need of decompression of the bladder D. To collect a random urine specimen for evaluation

D. To collect a random urine specimen for evaluation Rationale: Collection of a random urine specimen is not routinely obtained by use of the process of catheterization. The other candidates/situations are appropriate uses of this technique.

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 Rationale: The key phrase is "the urge to void." Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function.

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 The key phrase is "the urge to void" option one occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option two occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option three is involuntary loss of urine related to impaired function.

An appropriate health goal for clients with urinary elimination problems would include: A. Ignoring normalization of voiding pattern. B. That the patient has the ability to void is the most important aspect of care. C. Encouraging the client to follow measures to show a larger than normal urine output to flush to kidneys D. Always assisting the client with toileting activities in order to monitor amount E. Preventing associated risks, such as infections and fluid and electrolyte imbalances.

E. Preventing associated risks, such as infections and fluid and electrolyte imbalances. Rationale: Preventing associated risks related to urinary disease is the only appropriate goal noted.

True or False: An ileostomy is a surgical opening created to bring the large intestine to the surface of the abdomen.

False An ileostomy is a surgical opening created to bring the SMALL (not large) intestine to the surface of the abdomen.

True or False: The ileocecal (aka ileocolic) valve is the connection between the ileum of the small intestine and the large intestine

True

When seating a patient in bed to use a bed pan, situate the head of the bed between ____ and ____ degrees. a. 30; 90 b. 30; 45 c. 45; 90 d. 45; 55 e. 30; 55

b

What color stool indicate upper gastrointestinal bleeding, such as from a peptic ulcer.

black

The primary organ of bowel elimination is... a. Small intestine b. Rectum c. Large intestine d. Stomach

c

What is the term used to describe the technique of "bearing down" when passing a bowel movement? a. Hemorrhoids b. Defecation c. Valsalva maneuver d. Bowel elmination

c

When preserving a specimen en-route to the laboratory, the most efficient method is: a. Preservatives b. Heat c. Refrigeration d. Freezing

c

The ____ is the first part of the large intestine.

cecum

Bright-red blood in stool is an indicator of __________ bleeding, such as from _________ or polyps. a. Upper gastrointestinal; peptic ulcer b. Lower gastrointestinal; peptic ulcer c. Upper gastrointestinal; hemorrhoids d. Lower gastrointestinal; hemorrhoids e. Upper gastrointestinal; hernia

d

Medication with the potential to cause gastrointestinal bleeding (e.g. anticoagulants, aspirin, etc) may cause the stool to appear: a. Black b. Red c. Pink d. All of the above e. None of the above

d

______ in stool is blood that his hidden in the specimen or cannot be seen on gross examination. Can be detected with simple screening tests.

occult blood