Foundations Test #2 PREPU

A nurse is carrying out a prescription to remove an indwelling catheter. Which explanation should the nurse use with the client prior to removing an indwelling catheter?

"I am going to remove the catheter after withdrawing the fluid from the balloon."

A client is to be discharged home with an indwelling catheter. The client asks, "How will I be able to move around and carry this bag?" Which statement by the nurse will teach the client about the appropriate use of a leg bag?

"I can show you how to use a leg bag when you are up and walking about."

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?

"I make sure to limit how much I drink so that I don't have accidents."

A school nurse is educating a class of female middle school students on how to promote urinary system health. Which statement by one of the girls indicates understanding?

"I will wipe from front to back after going to the toilet."

The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter?

"Let me talk to your health care provider about a condom catheter."

The nurse is caring for a client who scored 3 on the Hendrich II Fall Risk Model. Which intervention is appropriate? Select all that apply.

- Implement normal fall prevention measures. - Document the finding in the electronic health record (EHR).

A nurse is making a home visit for a client with several home safety concerns. On which safety concept(s) would the nurse advise the client? Select all that apply.

- Remove extension cords from open spaces. - Check the batteries in all smoke detectors. - Ensure appropriate lighting in hallways and entrances to the home. - Remove throw rugs from high traffic areas.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

1. Clean each labial fold, then the area directly over the meatus. 2. Insert the lubricated catheter into the urethra. 3. Advance the catheter until there is a return of urine. 4. Inflate the balloon with the correct amount of sterile saline. 5. Discard used supplies.

A nurse is administering the Hendrich Fall Risk Tool to a client. What is the cutoff Final Risk Score for the client to not be considered at risk for falling?

5

Preliminary laboratory results of a client's urine culture suggest that the sample was contaminated. A clean-catch specimen has consequently been recommended. Why is a clean-catch specimen preferable to a randomly voided specimen?

A clean-catch specimen is more accurate because it is collected after the initial urine stream has cleansed the urinary structures.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

A hair dryer is placed next to the sink.

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

After the initial stream is initiated, collect the sample.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

Apply an allergy-alert identification bracelet on the client.

The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take?

Ask the client why he or she does not want a catheter.

When educating parents about the safety of preschool-aged children, which is most important for the nurse to include in the presentation?

At home chemicals should be kept in a locked cabinet.

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?

Check electronic health record for medical order.

A nurse hears a client call and finds that the client's room has caught fire due to an electrical short circuit. The nurse evacuates the room and raises an alarm. Which of the following types of extinguishers should the nurse use in this situation?

Class C

A nurse is providing an in-service program for staff on fire safety and is reviewing the types of fire extinguishers available. Which class of fire extinguisher would the nurse describe as appropriate for use on an electrical fire?

Class C

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Encourage fluid intake

A 79-year-old client with a history of osteoporosis experienced a fall while attempting to walk independently to the hospital washroom to urinate. How can the nurse best prevent a repeat of this incident?

Encourage the client to ring the call bell when the client has the urge to void.

A client has presented to the emergency department after splashing a chemical in the eyes. When managing the injury, what should be included in the plan of care?

Flush the eyes with water for 10 minutes.

One of the leading causes of death in the United States is drowning. How can the nurse assist in lowering this statistic?

Implement drowning prevention strategies.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds.

A nurse is assigned to care for a 10-month-old boy. Which activity should be the priority for the nurse?

Protect the toddler from injury.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

Refrain from using extension cords.

There is a fire in the trashcan in the client's room. What is the nurse's first priority?

Remove the client from the room.

A client who had an open hysterectomy 2 days ago is ambulating around the unit four times daily. The health care provider has not yet written a prescription to discontinue the client's urinary catheter. What is the appropriate nursing action?

Request a prescription for catheter discontinuation from the health care provider.

An elderly client has a diagnosis of vascular dementia and has been found wandering the hospital unit at numerous times during the day and night. The nurse should assign what priority nursing diagnosis to this client's behavior?

Risk for Falls

What generalization can be made about safety in client care?

Safety is a paramount concern underlying all nursing care.

The nurse is teaching the caregiver of an infant about safety. Which teaching will the nurse include?

Supervise your child on the changing table.

Use of an indwelling urinary catheter leads to the loss of bladder tone.

True

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

Trying to balance too many activities can result in sleep deprivation.

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

Wash hands thoroughly after removing gloves with a pH-balanced soap.

A nurse is delegating the collection of urinary output to an unlicensed assistive personnel (UAP). What should the nurse tell the UAP to do while measuring the urine?

Wear gloves when handling a client's urine.

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

The nurse is caring for a client who has been repetitively pulling at IV lines and the urinary catheter. After other methods of diverting the client's behaviors fail, the health care provider orders chemical restraints. Which treatment does the nurse anticipate?

administration of an antipsychotic agent to alter the client's behavior

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning

A 75-year-old man was admitted to the hospital for altered mental status. He had been in his usual state of good health until this morning when a nurse at the long-term care facility where he lives noticed that he was confused. Shortly after being admitted to the hospital, he became combative and had to be restrained. His bed linens have to be changed frequently because of urinary incontinence. Which nursing diagnosis best describes this client's condition?

functional incontinence

A client has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate?

increased output of dilute urine