NUR204 exam 5

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When a patient with heartburn takes antacids, for which problem is he especially at risk? 1) Diarrhea 2) Constipation 3) Stomach ulceration 4) Flatulence

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

Which of the following individuals may be more prone to episodes of urinary incontinence? Select all that apply. a. Women b. Men c. School-aged children d. Older adults e. Pregnant women

a d e

Which symptom is a potential adverse effect of sleep medications? Select all that apply. One, some, or all responses may be correct. a. Vomiting b. Sleep-driving c. Dehydration d. Allergic reactions e. Severe facial swelling

b d e

Which sleep cycle is characterized by vivid and colorful dreaming? a. Rapid eye movement (REM) b. Non-rapid eye movement 3 (NREM 3) c. NREM 2 d. NREM 1

Normal flora contained in the colon aid digestion and produce which nutrients? Select all that apply. 1) Vitamin A 2) Vitamin B 3) Vitamin C 4) Vitamin K 5) Iron 6) Zinc

2 4

The nurse recognizes which goal to be appropriate for the nursing diagnosis of Anxiety? 1. The patient will attend a weekly support group. 2. The patient will discuss possible coping strategies during weekly office visits. 3. The patient will report increased ability to concentrate on care instructions before discharge. 4. The patient's family will use respite care once a week for the next month

Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAIDs

T or F. The nurse should call the physician immediately if a patient's urostomy stoma is red in color.

17. A nurse is scheduling ordered diagnostic studies for a patient. Which of the following tests would be performed first? A) fecal occult blood test B) barium study C) endoscopic exam D) upper gastrointestinal series

The nurse providing education to a patient in the sleep lab understands that the most common type of sleep apnea is caused by which of these factors? a. Airway collapse b. Lack of exercise c. Dietary factors d. Medication use

Which intervention would prevent urinary stasis and formation of renal calculi in an immobile client? a. Increasing oral fluid intake to 2 to 3 L/day b. Maintaining bed rest after discharge c. Limiting fluid intake to 1 L/day d. Voiding at least every hour

Which sleep disorder is a dyssomnia? Select all that apply. One, some, or all responses may be correct. a. Narcolepsy b. Hypersomnia c. Somnambulism d. Sleep deprivation e. Nocturnal enuresis

a b d

46. The nurse suspects that the patient has a bladder infection on the basis of the patient exhibiting a. nausea b. hematuria. c. flank pain. d. incontinence.

26. A nurse is caring for a patient with a colostomy. What type of stools would she expect to find in the colostomy bag? A) liquid B) watery C) formed D) none

Which diagnostic procedure requires the clinic nurse to instruct a client to discard the morning first-voided urine, then collect a fresh urine specimen and transport it to the laboratory within 1 hour of collection? a. Residual urine b. Concentration test c. Urine cytology d. Protein level

Which intervention would be most appropriate for the nurse to include in the care plan for a patient who is experiencing constipation and increased heart and respiratory rates? a. Time management b. Decreased grain intake c. Relaxation therapy d. Regimented exercise

Which finding in the older adult client is associated with a urinary tract infection (UTI)? Select all that apply. One, some, or all responses may be correct. a. Dysuria b. Urgency c. Confusion d. Incontinence e. Slight rise in temperature

c d e

38. Which of the following information provided by the patient's bed partner is most associated with sleep apnea? a. Restlessness b. Talking during sleep c. Somnambulism d. Excessive snoring

The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patient's abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds

To which of the following patients would it be considered acceptable to administer an enema without the nurse needing to question the order? a. A patient who is going to have abdominal surgery b. Patient with increased intracranial pressure c. A patient with glaucoma d. Patient with inflammatory bowel disease

Which patient condition does the nurse infer after noticing that the stoma is dry and black with no sign of bleeding while assessing the stoma of a patient with an ostomy? a. Necrotic stoma b. Normal stoma c. Fungal infection d. Allergic reaction

Which condition would be evaluated for in a patient who reports passing black, tarry stools? Select all that apply. One, some, or all responses may be correct. a. Iron ingestion b. Dentition c. Gastrointestinal (Gl) bleeding d. Spastic constipation e. Malabsorption of fat

a c

Which complication is the nurse trying to prevent by instructing a patient to increase fluid intake after a series of lower gastrointestinal scans? a. Diarrhea b. Constipation c. Flatulence d. Incontinence

Which statement made by a coworker administering an enema requires further teaching by the registered nurse who is reviewing the procedure? a. "I should explain the procedure to the patient." b. "I should fill the enema bag with a cool solution." c. "I should lubricate the tip of the tubing 3 inches." d. "I should put the patient in a left side-lying position."

Which medication listed in a patient's medication history may cause gastrointestinal bleeding? a. Cathartic b. Antidiarrheal opiate agent c. Nonsteroidal antiinflammatory drug (NSAID) d. Opioid

44. An assessment is completed by the nurse, and a nursing diagnosis/hypothesis for the oriented adult female patient is identified as experiencing Stress incontinence, which is associated with decreased pelvic muscle tone. An appropriate nursing interven- tion/action based on this assessment is to a. apply adult diapers. b. catheterize the patient. c. administer urecholine. d. teach Keel exercises.

Two adult siblings are caring for their ill mother, who requires 24-hour care. She needs assistance with feeding, bathing, and toileting. One of the siblings takes time to exercise after work, whereas the other goes directly to the mother's home before and after work each day. The nurse recognizes that people may react differently to the same stressors depending on which factors? (Select all that apply.) a. Individual coping skills b. Type of identified stressor c. Amount of perceived stress d. Personal appraisal of the stressor e. Hair color, gender, and skin type

a b c d

25. What are the expected characteristics of urine? Select the four findings that are expected. a. Pale yellow color. b. Clear c. Fruity odor. d. pH = 6 e. Protein present f. No glucose g. Specific gravity 1.00

a b d f

Which condition can be diagnosed with multiple sleep latency tests? a. Bruxism b. Narcolepsy c. Somnambulism d. Obstructive sleep apnea

Mrs. Sanchez is awaiting surgery for a right hip fracture. The physician suspects that Mrs. Sanchez has a urinary tract infection. The nurse anticipates that the physician will order which of the following? A. Freshly voided urine specimen in the morning B. Clean-catch specimen C. Sterile urine specimen D. 24-hour urine collection

The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowler's position 2) Left side-lying position 3) Supine, with the head of the bed lowered flat 4) Supine, with the head of bed raised to 30 degrees

A nurse has a sleep disorder due to working on rotating shifts. Which physiologic symptoms are observed in the nurse? Select all that apply. One, some, or all responses may be correct. a. Fatigue b. Increased reflexes c. Difficulty concentrating d. Decreased neuromuscular coordination e. Increased visual alertness

a c d

Which type of stress did Hans Selye describe as a form of stress that is essential for the normal growth and development of an individual? a. Physiologic b. Motivational c. Sociocultural d. Psychological

17. The nurse is alert to patients who may be predisposed to obstructive sleep apnea, including those individu- als with which of the following risk factor(s)? Select all that apply. a. Heart disease. b. Renal disease. c. Nasal polyps d. Obesity . e. Arthritis f. Alcohol use

c d f

4. Select the four physiologic signs that are found with the fight-or-flight response. a. Bradycardia b. Pupil dilation c. Increased blood pressure d. Palpitations e. Decreased gastric motility I. Bradypnea

b c d e

For which reason would a Salem sump be the correct tool when comparing nasogastric tubes used for gastric decompression? a. It minimizes the risk for a bowel obstruction. b. It ensures drainage of the intestines. c. It has two lumens. d. It has one lumen.

35. For a patient who is currently taking a diuretic, the nurse should inform the patient that he or she may experience a. nocturia. b. nightmares. c. reduced REM sleep. d. increased daytime sleepiness.

55. For the patient with an ileostomy, the critical element is a. skin care. b. odor control. c. stoma irrigation. d. infection prevention.

Which nursing intervention is helpful to a patient suffering from a stomachache who was diagnosed with stomach cancer when the nurse finds that the patient is sad and feels hopeless about his health and the future? Select all that apply. One, some, or all responses may be correct. a. Help the patient set important goals. b. Spend time with the patient and teach coping strategies. c. Assess the potential for committing suicide. d. Encourage the patient to listen to music of his choice. e. Assess the potential for presence of psychosis.

a b c

Which condition can be caused by straining on defecation and is a reason why this is discouraged by nurses? Select all that apply. One, some, or all responses may be correct. a. Pain b. Impaction c. Hemorrhoids d. Dysrhythmias e. Dry stool

c d

Indicate which of the following is (are) expected with a cystoscopy. Select all that apply. a. A biopsy may be performed. b. The patient is NO for 8 to 12 hours before. c. The test will take 1 to 2 hours. d. An urge to void may be felt. - e. Bladder puncture occurs frequently.. f. Urine may be pink-tinged for several days after the procedure.

a b d f

Which condition is indicated by abdominal pain and hyperactive bowel sounds in a patient? a. Fecal impaction b. Onset of diarrhea c. Constipation d. Paralytic ileus

Which of the following subjective data gathered from the client would indicate a risk for constipation? A. Use of vitamin C and caffeine B. Taking Maalox often for heartburn C. Drinking 1,500 mL of water during the day D. Eating yogurt for breakfast and taking a magnesium supplement:

Which information would the nurse give when caring for a patient with abdominal pain before a scheduled lower gastrointestinal (GI) series? Select all that apply. One, some, or all responses may be correct. a. The procedure will help in the examination of the lower Gl tract. b. The patient will have a restricted diet before the procedure. c. No metallic objects are allowed during the procedure. d. Light sedation is required for the procedure. e. The patient needs to change position to allow for different views of the colon.

a b c e

Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? a. Restrict the client's fluid intake. b. Regularly offer the client a urinal. c. Apply incontinence pants. d. Insert an indwelling urinary catheter.

Which is the recommended length of insertion of the enema tube in a child of 3 years? a. 1 to 2.5 cm b. 5 to 7.5 cm c. 7.5 to 10 cm d. 2.5 to 3.7 cm

Which nursing intervention would help prevent cardiac complications after finding that a patient complaining of constipation has a history of a myocardial infarction and is taking antianginal drugs? a. Obtain and record daily weights from the patient. b. Instruct the patient not to strain while defecating. c. Explain how to ignore the urge to defecate. d. Encourage the patient to consume lukewarm liquids.

From the following, choose the correct equipment to bring to the bedside to administer the commercially prepared Fleet enema. (Select all that apply.) a. Tubing with a rectal tip b. Waterproof bed pad c. Clean disposable gloves d. Water-soluble lubricant e. Commercially prepared enema product f. Toilet paper and/or basin with warm water, washcloth, and towel g. Enema bag h. Sterile gloves

b c d e f

42. Identify the correct sequence for replacing an ostomy pouch, one-piece system. a. Center opening over stoma and secure in place. b. Perform hand hygiene and apply new clean gloves. c. Fill in leaks with barrier paste and allow to dry. d. Remove the backing or apply stoma adhesive, allow to dry. e. Gently tug on pouch to ensure it is secure. f. Assess the seal.

b d a f c e

Which instruction would the nurse give when caring for a patient with belching and flatulence to relieve discomfort and pain? Select all that apply. One, some, or all responses may be correct. a. "Do not rock back and forth." b. "Walk on a regular basis." c. "Include more cabbage in your diet." d. "Stay away from onions." e. "Avoid carbonated drinks."

b d e

10. Which of the following statements is (are) accurate regarding sleep? Select all that apply. a. Humans spend one-half of their lives sleeping, b. Adults normally fall asleep within 10 minutes. c. There are usually five sleep stages. d. NREM sleep alternates with REM sleep in about 5-minute intervals. e. Pain can adversely affect the quality of sleep. f. Individuals who are awakened from sleep will begin their cycle again with the first stage of NREM sleep.

b e f

25. A patient tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the patient? A) "Just give it a few more days and you should be fine." B) "Well, that shouldn't happen. Let me recommend a good laxative for you." C) "When you increase fiber in your diet, you also need to increase liquids." D) "I will tell the doctor you are having problems; maybe he can help."

36. As a result of recent studies regarding sudden infant death syndrome and infant safety during sleep, the nurse instructs the parents to a. cover the infant loosely with a blanket. b. provide a stuffed toy for comfort. c. place the infant on her back. d. use small pillows in the crib.

56. For patients with hypercalcemia, the nurse should implement measures to prevent a. gastric upset. b. malabsorption. c. constipation. d. fluid secretion.

A patient on sedative-hypnotic therapy reports to the nurse, "I don't think these drugs are working on me anymore; I'm having trouble sleeping again." After assessing the patient, the nurse finds that the patient has developed drug tolerance to these medications. Which suggestion might the nurse offer the patient to improve sleep? a. "Drink tea before bedtime." b. "Exercise before bedtime." c. "Drink warm milk before bedtime." d. "Eat a heavy meal before bedtime."

The nurse listens for bowel sounds before administering an enema. The patient asks, "Why are you listening to my abdomen?" The nurse's accurate response is: a. To determine the presence of bowel sounds, which indicates you will be able to hold the solution b. To determine which position I should place you in for administration of the enema c. To determine the presence of bowel sounds which indicates the intestines are working d. To determine the amount of enema solution needed

The nurse provides education to a client with a new colostomy about when to irrigate the colostomy. Which client statement indicates correct understanding of the teaching? a. "After it gets done healing in a few weeks, I will begin irrigating it just before going to bed each day." b. "It will need to be irrigated each morning before I can eat any food." c. "I will irrigate it during the late morning, the same time as I had a bowel movement every day before my surgery." d. "I will wait to start irrigating it until after I have gotten familiar with the bag and the change in lifestyle.

Which goal is the nurse trying to achieve with continuous bladder irrigations (CBI) of a client who has undergone a suprapubic prostatectomy for cancer of the prostate? a. Stimulate continuous formation of urine. b. Facilitate the measurement of urinary output. c. Prevent the development of clots in the bladder. d. Provide continuous pressure on the prostatic fossa.

Which system is responsible for the fight-or-flight response? a. Renin-angiotensin system b. Respiratory system c. Sympathetic nervous system d. Parasympathetic nervous system

Which test result would confirm the diagnosis of benign prostatic hyperplasia (BPH)? a. Digital rectal examination b. Serum phosphatase level c. Biopsy of prostatic tissue d. Massage of prostatic fluid

25. Identify the factor(s) that will promote bowel elimination. Select all that apply. a. Lack of privacy . b. Immobility. c. Squatting d. Calcium supplements e. Anesthesia f. Emotional stress

c f

14. A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last when conducting an abdominal assessment? A) it is the most painful assessment method B) it is the most embarrassing assessment method C) to allow time for the examiner's hands to warm D) it disturbs normal peristalsis and bowel motility

3. What term is used to describe intestinal gas? A) feces B) stool C) peristalsis D) flatuence

37. While working with patients who are experiencing a significant degree of stress, the nurse is aware that a priority assessment area is which of the following? a. The patient's primary activities of daily living needs b. What else is happening in the patient's life c. How the stress has influenced the patient's activi- ties of daily living d. Whether the patient is thinking about harming themself or others

51. For the patient with diarrhea, the nurse recommends which of the following? a. Fresh vegetables b. Milk products c. Cold sodas d. Lean meats

57. The appropriate amount of fluid to prepare for an enema to be given to an average size adult is which of the following? a. 250 to 350 mL b. 300 to 500 mL c. 500 to 750 mL d. 750 to 1000 mL

The nurse is teaching a patient about the difference between mild anxiety and moderate anxiety. Which statement by the patient indicates a need for further education? a. "Mild anxiety can help me remember things." b. "Moderate anxiety will narrow my focus." c. "Mild anxiety will help me be creative." d. "Moderate anxiety will increase my perception."

The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice? a. Hot dog on a bun b. Grilled chicken c. Tuna sandwich on white bread d. Spinach salad with dressing

The nurse notes that there has only been 100 mL of urine output from his patient's Foley catheter in 6 hours. The nurse should first do which of the following? A. Instruct the patient to drink two glasses of water. B. Call the doctor immediately. C. Irrigate the Foley catheter with 30 mL of sterile saline. D. Assess the catheter tubing and the patient's abdomen

Which intended result is the primary purpose of a soft, high-fiber diet immediately following a myocardial infarction (MI)? a. Easy digestion b. Lower cholesterol levels c. Bowel health to decrease flatulence d. A high-bulk, soft stool to minimize Valsalva maneuver

Which intervention is implemented by the nurse caring for a patient with a colostomy? a. Cleansing the stoma with hot water b. Inserting a deodorant tablet in the stoma bag c. Wearing sterile gloves while caring for the stoma d. Selecting a bag with an appropriate-sized stoma opening

Which medication turns urine reddish-orange in color? a. Amoxicillin b. Ciprofloxacin c. Nitrofurantoin d. Phenazopyridine

While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, from the stoma that is located in the upper right quadrant of the abdomen. What type of ostomy does the patient have? a. Descending colostomy b. Ureterostomy c. Ileostomy d. Ascending colostomy

The nurse instructs the patient that the health care provider has ordered an enema. The patient states, An enema! I'm not constipated. What are other possible reasons for the order? (Select all that apply.) a. Preparation for a diagnostic procedure b. To increase fluid intake c. To prevent laxative misuse d. To administer a medication e. Preparation for surgery

a d e

Which purpose is served by a stool culture? Select all that apply. One, some, or all responses may be correct. a. To detect parasites b. To detect blood in the stool c. To identify internal hemorrhoids d. To help determine the cause of diarrhea e. To verify that a previous pathogenic bacterial infection has been resolved

a d e

Which instruction would the nurse include when teaching a client with multiple sclerosis (MS) about managing urinary retention? Select all that apply. One, some, or all responses may be correct. a. Using the Credé maneuver b. Using an indwelling catheter c. Using anticholinergic medications d. Monitoring and restricting fluid intake to 800 mL daily e. Monitoring for and reporting signs of urinary tract infection

a e

Which neurotransmitter levels are elevated during non-rapid eye movement (NREM) sleep? Select all that apply. One, some, or all responses may be correct. a. Serotonin b. Melatonin c. Acetylcholine d. Norepinephrine e. Gamma aminobutyric acid (GABA)

a e

13. A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? A) "Auscultated abdomen for bowel sounds, bowel not functioning." B) "All four abdominal quadrants auscultated. Inaudible bowel sounds." C) "Bowel sounds auscultated. Patient has no bowel sounds." D) "Patient may have bowel sounds, but they can't be heard."

22. A patient is on bedrest, and an enema has been ordered. In what position should the nurse position the patient? A) Fowler's B) Sims C) Prone D) Sitting

30. Which of the following is associated with a patient who has hypersomnia? a. Sleeping less than 6 hours a night b. Having trouble waking up in the morning c. Falling asleep during a conversation d. Having difficulty falling asleep

56. The nurse is working with a patient who has an incontinent urinary diversion. Included in the plan of care for this patient is instruction that a. special clothing is necessary. b. careful skin care is a priority. c. a stoma bag will only need to be worn at night. d. a strict reduction in physical activity will be planned.

60. A sample is obtained from the patient for a routine urinalysis. After reviewing the results of the test, the nurse notes that an expected finding of the urinalysis iS a. pH 8.0. b. specific gravity 1.018. c. protein amounts to 12 mg/100 mL. d. white blood cells (WBCs) of 5 to 8 per low-power field casts.

61. A small-volume enema that is used to provide relief from gastric distention and stimulate peristalsis is a(n) a. hypertonic enema. b. carminative enema. c. oil retention enema. d. medication enema.

A high cleansing enema is prescribed for a client. Which is the maximum height at which the container of fluid would be held by the nurse when administering this enema? a. 30 cm (12 inches) b. 46 cm (18 inches) c. 51 cm (20 inches) d. 66 cm (26 inches)

A nurse is working a night shift after several months of working day shift. What action does the nurse take to protect patient safety? a. Take a meal break at midnight. b. Plan critical tasks for early in the shift. c. Ask another nurse to administer all medications. d. Turn up lights on the unit to maintain alertness.

Which factor does the nurse suspect as the cause of blurred vision in a patient with constipation who reports straining during defecation? a. A decrease in intrathoracic pressure b. An increase in intraocular pressure c. An increase in arterial blood pressure d. A decrease in intracranial pressure

54. The patient receiving a tube feeding develops diar- rhea. The nurse should a. adjust the rate of the infusion. b. change the container every 8 hours. c. request that psyllium be added to the feeding. d. monitor the output, recognizing that this is an expected occurrence.

Which manifestation would the nurse expect during a home visit to an elderly patient wl expresses embarrassment about experiencing flatulence? Select all that apply. One, som or all responses may be correct. a. Discomfort from buildup of gas pressure b. Pain c. Abdominal distention d. Loose, watery stools e. Involuntary passage of stools

a b c

The nurse is providing education to patients at a gastrointestinal clinic. One of the topics is to promote good bowel health. Which of the following should the nurse include in this education? (Select all that apply.) a. Active range of motion daily. b. Take loperamide daily. c. Walk 10 to 15 minutes a day. d. Follow a high-fiber diet. e. Utilize a bedpan for a minimum of 20 minutes. f. Encourage foods such as cabbage or beans. g. Utilize daily laxative. h. Maintain a positive attitude.

a c d h

Which duty would the registered nurse delegate to an unlicensed assistive personnel (UAP) when preparing a care plan for a patient who has undergone formation of an ostomy? Select all that apply. One, some, or all responses may be correct. a. Applying an ostomy deodorant b. Formulating the dietary plan for the patient c. Changing the drainage bag of a new ostomy d. Reporting the output volume and consistency e. Observing the patient for sores and wounds

a d e

A young woman comes to the Emergency Department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis? A) routine urinalysis B) chest x-ray C) stool sample D) sputum sample

Which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissue surrounding the urethra? a. Prostatitis b. Paraphimosis c. Prostate cancer d. Benign prostatic hyperplasia (BPH)

Which short-term goal would be most appropriate for a patient with the nursing diagnosis Anxiety with supporting data, including upcoming diagnostic tests, expressions of concern, and pacing around the room? a. Patient will discuss specific aspects of concern. b. Nurse will administer prescribed antianxiety medication. c. Patient will understand diagnostic test procedures. d. Nurse will describe test procedures in detail to allay concerns.

Which manifestation is a characteristic of constipation? Select all that apply. One, some, or all responses may be correct. a. Abdominal pressure b. Abdominal distention c. Stoma budding d. Loose feces e. Abdominal cramping

a b e

Which statements by a patient would indicate the use of effective coping strategies? (Select all that apply.) a. "Each month, my wife and I attend a support group for parents of children with autism." b. "Talking with my spiritual adviser may challenge my thinking on how best to handle this situation." c. "I've invited my son to join me for drinks at the bar each night on his way home from work so that we can spend more time together." d. "We are looking into joining the new health club facility in our neighborhood." e. "After working all day, I eat dinner in front of the television while my family sits at the kitchen table."

a b d

An obese patient is diagnosed with obstructive sleep apnea. Which conservative approach is included in the treatment plan of the patient? Select all that apply. One, some, or all responses may be correct. a. Limiting alcohol consumption b. Motivating the patient to lose weight c. Recommending that the patient take sedatives d. Recommending that the patient take herbal medicines e. Avoiding the consumption of stimulants before going to bed

a b e

Which nursing intervention would help an older adult who is receiving hospice care to cope with feelings related to death and dying? Select all that apply. One, some, or all responses may be correct. a. Teaching the patient how to use guided imagery b. Encouraging the family to visit the patient frequently c. Taking the patient's vital signs every time the nurse visits d. Teaching the patient how to manage pain and take pain medications e. Helping the patient put significant photographs in a scrapbook for the family

a b e

38. The patient demonstrates unrealistic levels of worry and tension without an identifiable cause. This is termed a. social anxiety disorder. b. generalized anxiety disorder. c. obsessive-compulsive disorder. d. posttraumatic stress disorder.

Which statement made by the nurse explaining the procedure for a series of lower gastrointestinal scans to a patient with a colonic ulcer indicates the need for additional teaching? a. "You will change positions frequently during the scan." b. "Maintain a liquid diet for 2 days before the test." c. "Limit fluid intake for several days after the test." d. "An enema will be administered before the procedure."

Which information would the nurse provide when caring for a patient who is scheduled for a colonoscopy? Select all that apply. One, some, or all responses may be correct. a. A local anesthetic will be administered before the test. b. The patient will take a laxative after the test. c. The patient should not drive for 12 hours after the test. d. The patient should refrain from liquids with red or purple dye before the test. e. The patient should follow a clear liquid diet for 1 to 3 days before the test.

c d e

Which of the following would be considered a normal finding after the administration and evacuation of an enema? a. Abdominal distention is absent b. High pitched, hyperactive bowel sounds are present c. The patient complains of a firm and painful abdomen d. The patient passes approximately 50 mL of bright red blood

The nurse is caring for a patient who has undergone an ostomy procedure in the large intestine to create an opening in the upper right abdomen. Upon discharge, the nurse instructs the patient to wear the drainage appliances all the time. Which type of ostomy formation has the patient undergone? a. lleostomy b. Sigmoid colostomy c. Transverse colostomy d. Descending colostomy

cd. Urinary elimination may be altered with different pata- physiological conditions. For the patient with diabete Méfitus, the nurse anticipates that an initial urinary sign or symptom will be which of the following? a. Urgency b. Polyuria C. Dysuria d. Hematuria

The nurse is caring for a patient who states they have not been able to sleep while in the hospital. Which action would be a priority to implement? a. Administer a sleeping medication with the evening meal. b. Restrict visitors for the patient in the evening. c. Decrease noise around the patient during the night. d. Offer a hot drink of regular tea at bedtime.

Which instruction would the nurse include regarding an ileal conduit when providing a client's discharge teaching? a. "Maintain fluid intake of at least 2 L daily." b. "Abstain from beer and other alcohol consumption." c. "Avoid getting soap and water on the peristomal skin." d. "Notify the primary health care provider if the stoma size decreases."

The nurse is caring for a newborn and instructs the parents, "Place your baby on her back for sleeping." Which condition does the nurse want to prevent in the newborn? a. Bruxism b. Narcolepsy c. Sleep apnea d. Sudden infant death syndrome

Which nursing action during a focused urinary assessment would the nurse use to collect subjective client data? Select all that apply. One, some, or all responses may be correct. a. Inquire about painful urination. b. Ask the client about changes in characteristics of urination. c. Assess the levels of blood urea nitrogen and creatinine. d. Palpate the abdomen for bladder distention or masses. e. Inspect the urinary meatus for inflammation or discharge.

a b

Which of the following would be inappropriate to delegate to NAP? a. Recording the amount of ostomy output b. Administering a tap water enema c. Pouching a newly established ostomy d. Administering a fleet type enema, commercially prepared

Which condition would the nurse suspect if the client reports passing urine involuntarily while coughing? a. Enuresis b. Pneumaturia c. Urinary retention d. Stress incontinence

53. In an assessment of a patient with overflow inconti- nence, the nurse expects to find that the patient has a. a constant dribbling of urine. b. no urge to void and an unawareness of bladder fill- ins. C. an uncontrollable loss of urine when coughing or sneezing. d. an immediate urge to void but not enough time to reach the bathroom.

Which defense mechanism is being used by a patient who is having difficulty managing his diabetes mellitus and responds to the news that his hemoglobin Alc (a measure of blood sugar control over the past 90 days) has increased by saying, "The hemoglobin Alc is wrong. My blood sugar levels have been excellent for the last 6 months."? a. Denial b. Conversion c. Dissociation d. Displacement

Which evidenced-based nursing intervention links to reducing catheter associated urinary tract infections (CAUTIs) in clients requiring long-term indwelling catheters? a. Perform catheter care twice a day. b. Replace the catheter on a routine basis. c. Administer cranberry tablets three times a day. d. Administer prophylactic antibiotics twice a day for the duration of the catheter placement.

When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? (Select all that apply.) a. Taking the urinary tract analgesic phenazopyridine b. A diet that includes a large number of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake f. Dehydration g. Infection

a b c d f g

Which precaution would the nurse implement while assisting a bedridden patient to use a bedpan? Select all that apply. One, some, or all responses may be correct. a. Applies barrier cream to the patient's skin b. Places a waterproof pad on top of the patient's bed c. Leaves the bedpan in place for 12 to 14 minutes d. Cleans the bedpan with a disinfectant twice a week e. Raises the head of the bed before placing the bedpan

a b e

17. Which of the following are accurate statements regarding stress? Select all that apply. a. Most stressors for older adults involve loss and grieving. b. Young adults experience more interpersonal stressors. c. Children are able to deal with multiple stressors for a long time. d. Culture has little impact on the response to stress. e. The arrival of a sibling can become a stressor for a child. f. Cognitive changes can influence an individual's ability to cope.

a b e f

. The nurse has been assigned the same patients for the past 4 days. Two of the patients demand a great deal of attention, and the nurse feels anxious and angry about being given this assignment again. What action would demonstrate the most effective way for the nurse to cope with the patient care assignment? a. Share complaints about the assignment with the nurse manager. b. Prioritize the patients' needs and identify a specific time period to care for each patient. c. Talk with the patients and explain that they cannot expect so much personal attention. d. Trade assignments with another nurse who is unaware of the concerns regarding the patient assignment.

32. During the end-of-shift report, the nurse notes that a postoperative patient had been nervous and preoccu pied during the evening, and that no family members had visited. To determine the amount of anxiety that the patient is experiencing, the nurse should ask a. "How serious do you think your illness is?" b. "You seem worried about something. Would it help to talk about it?" "Would you like for me to call a family member to come support you?" d. "Would you like to go down the hall and talk with another patient who had the same surgery?»

47. A 6-month-old infant has severe diarrhea. The major problem associated with severe diarrhea, especially for this age group, is a. pain in the abdominal area. b. electrolyte and fluid loss. c. presence of excessive flatus. d. irritation of the perineal and rectal area.

The nurse provides postoperative teaching about colostomy care to a client who underwent surgery for cancer of the colon. The education would include which instruction related to skin care around the stoma? a. Apply liberal amounts of Vaseline for 3 inches (7.6 cm) around the stoma. b. Wash the area with soap and water and then apply a protective ointment. c. Pour saline over the stoma, and rub the area to remove hard fecal matter. d. Rinse the area with peroxide before applying fresh gauze bandages.

Which action would the nurse take first when assessing a patient who is malnourished and has severe abdominal pain? a. Ask the patient to relax during palpation. b. Examine the patient's oral cavity. c. Use deep palpation to examine underlying organs. d. Ask the patient to lie in a supine position.

Which information would the nurse provide about what the client can expect after surgery for a transurethral resection of the prostate? a. "Urinary control may be permanently lost to some degree." b. "An indwelling urinary catheter is required for at least a day." c. "Your ability to perform sexually will be impaired permanently" d. "Burning on urination will last while the cystostomy tube is in place."

Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. Tell the patient to void and pour the urine into a labeled specimen container. b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container. c. Instruct the patient to discard the first void and collect the next void for the specimen. d. Have the patient keep all voided urine for 24 hours in a chilled, opaque collection container.

The student nurse studying bowel elimination learns that the following statements accurately describe the process of peristalsis. Select all that apply. A) The sympathetic nervous system stimulates movement. B) The autonomic nervous system innervates the muscles of the colon. C) Peristalsis occurs every 3 to 12 minutes. D) Mass peristaltic sweeps occur one to four times each 24-hour period in most people. E) Mass peristalsis often occurs after food has been ingested. F) One-third to one-half of ingested food waste is normally excreted in the stool within 48 hours

b c d e

How can the patient prevent UTIs? Select all that apply. a. Take bubble baths. b. Wear cotton underwear. c. Cleanse the perineum from front to back.. d. Drink at least 64 oz of water/day. e. Urinate as infrequently as possible. f. Cleanse the genital area before and after intercourse.

b c d f

61. An order is written for the patient's indwelling uri- nary catheterization to be discontinued. The unit manager is observing the new staff nurse provide care to this patient and implement the prescriber's order. The unit manager determines that further instruction is required for the new staff nurse in catheter removal if he is observed a. draping the female patient. b. obtaining a specimen before removal. c. cutting the catheter to deflate the balloon. d. checking the patient's output carefully for 6 to 8 hours after removal.

A patient is scheduled for a colonoscopy. After preprocedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. "I can have coffee the morning of the procedure." b. "I should drink a red sports drink the day before to stay hydrated." c. "I should drink clear liquids for 2 days before the procedure." d. "I will be able to drive home immediately after the procedure."

Based on knowledge of the physiology of the gastrointestinal tract, what type of stools would the nurse assess in a patient with an illness that causes the stool to pass through the large intestine quickly? A) hard, formed B) black, tarry C) soft, watery D) dry, odorous

In the immediate postoperative period after open-heart surgery, a patient who is not a diabetic has elevated blood glucose levels. What physiologic stress response would the nurse recognize as being directly responsible for the patient's increased blood sugar? a. Release of epinephrine b. Circulation of endorphins c. Increase in corticosteroids d. Secretion of corticotropin-releasing hormone (CRH)

The patient is complaining of cramping during instillation of the enema solution. What is the most appropriate action by the nurse? a. Stop the installation and remove the tube from the rectum b. Raise the height of the enema container c. Have the patient take deep breath's in and out through the nose d. Lower the height of the enema container or clamp the tubing until cramping subsides

The nurse is preparing to administer an oil-retention enema and understands that it works primarily by which action? a. Stimulating the urge to defecate b. Lubricating the sigmoid colon and rectum c. Dissolving the feces d. Softening the feces

60. The nurse is aware that normal bowel sounds are a. loud and slow. b. heard every 5 to 10 minutes, c. absent between meals. d. high-pitched and irregular.

Which food may alter the results of a patient's fecal occult blood test? Select all that apply. One, some, or all responses may be correct. a. Carrots b. Cereals c. Red meat d. Grapefruit e. Milk products

a c d

How often should an ostomy pouch be changed? a. Every 3 to 7 days b. Every other day c. Every two weeks d. Every 2 to 3 weeks e. Daily to prevent infection

Which physiological change that occurs with aging causes stress incontinence? Select all that apply. One, some, or all responses may be correct. a. Estrogen deficiency b. Prostatic enlargement c. Decreased bladder capacity d. Decreased sensory receptors e. Unstable bladder contractions f. Weakening of the urinary sphincter

a f

Which medication would be involved in the treatment regimen of a patient who reports abdominal pain and the urge to pass feces and who has hyperactive bowel sounds? Select all that apply. One, some, or all responses may be correct. a. Ibuprofen b. Loperamide c. Acetaminophen d. Naproxen sodium e. Diphenoxylate-atropine

b e

Which manifestation would the nurse assess for in a client with a blood pressure of 190/94 who reports minimal urinary output despite adequate fluid intake? a. Thirst b. Weight gain c. Urinary retention d. Urinary hesitancy

The nurse is caring for a patient with hypersomnia. Which medical condition does the nurse expect to find in this patient? a. Obesity b. Cardiac arrest c. Diabetic acidosis d. Hyperthyroidism

7. Which of the following are more specifically associ ated with the local adaptation syndrome (LAS)? Sele all that apply. a. Palpitations b. Inflammation c. Hypoxia d. Decreased gastric motility c. Hypertension f. Reflex response to pain

b c f

34. A 72-year-old patient is in a long-term care facility after having had a cerebrovascular accident (CVA. or stroke). The patient is noncommunicative, the enteral feedings are not being absorbed, and respirations are becoming labored. Which stage of GAS is the patient experiencing? a. Alarm reaction b. Resistance stage c. Exhaustion stage d. Reflex pain response

36. The patient is assessed by the nurse as experiencing a crisis. The nurse plans to a. complete an in-depth evaluation of stressors and responses to the situation. b. allow the patient to work through independent problem-solving. c. focus on immediate stress reduction. d. recommend ongoing therapy.

39. An individual who is overwhelmed with and dis- traught over the new diagnosis of heart disease will most likely use which strategy to relieve stress? a. Direct action b. Problem focused c. Emotion focused d. Physiological

24. Which of the following would be an expected outcome for a patient when the nurse is conducting a bowel training program? A) Have a soft, formed stool at regular intervals without a laxative. B) Continue to use laxatives, but use one less irritating to the rectum. C) Use oil-retention enemas on a regular basis for elimination. D) Have a formed stool at least twice a day for 2 weeks

35. A corporate executive works 60 to 80 hours/week. The patient is experiencing some physical signs of stress. The practitioner teaches the patient to direct her attention to positive memories or views, such as a favorite vacation spot. This is an example of which of the following health promotion interventions? a. Guided imagery b. Time management c. Regular exercise d. Progressive relaxation

48. The patient is seen in the gastroenterology clinic after having experienced changes in his bowel elimination. A colonoscopy is ordered, and the patient has questions about the examination. Before the colonoscopy, the nurse teaches the patient that a. light sedation is normally used. b. no metallic objects are allowed. c. no special preparation is required. d. swallowing of an opaque liquid is required.

49. A patient is going to have an IVP. Which of the fol- lowing reflects the most critical assessment question for this patient before the procedure? a. "Are you allergic to iodine? b. "Did you remove all metal?"' c. "Have you had this procedure before?" d. "When did you last have a procedure that required sedatives?"

Which instruction would the nurse provide a client needing to collect a clean-catch urine specimen? a. "Urinate a small amount, stop flow, and then fill one half of the specimen cup." b. "Collect a sample of the last urine voided during the night." c. "If anticipating a delay in delivery, keep the urine sample in a warm, dry area." d. "Send the urine sample to the laboratory within 6 hours of collection."

A single mother lives with her 10-year-old son who has Down syndrome. The mother's facial expressions demonstrate fatigue and malaise. She has an unkempt appearance and has no interest in going out and meeting people. The nurse understands that the mother is experiencing caregiver role stress. Which finding noted by the nurse indicates caregiver role stress? Select all that apply. One, some, or all responses may be correct. a. Fatigue and malaise b. Unkempt appearance c. Lack of interest in socializing d. The disease condition of the patient's son e. Single motherhood

a b c

The physician has prescribed enemas for Mr. Gray until the return is clear. The nurse is to use a hypertonic solution. The nurse would question the order if Mr. Gray had which of the following conditions? A. Constipation B. Chronically elevated BUN and creatinine C. Peptic ulcer disease D. Multiple sclerosis

Which of the following statements accurately describes the act of defecation? A) Defecation refers to the emptying of the small intestine. B) Centers in the medulla and the spinal cord govern the reflex to defecate. C) When sympathetic stimulation occurs, the internal anal sphincter relaxes and the colon contracts sending fecal content to the rectum. D) Rectal distention leads to a decrease in intrarectal pressure, causing the muscles to stretch and thereby stimulating the defecation reflex.

62. A condom catheter is to be used for an adult male patient in the extended care facility. In the appli- cation of the condom catheter, the nurse employs appropriate technique when a. using sterile gloves. b. wrapping adhesive tape securely around the base of the penis. c. leaving a 1- to 2-inch space between the tip of the penis and the end of the catheter. d, taping the tubing tightly to the thigh and attaching the drainage bag to the side rail,

A client scheduled for a hemicolectomy because of a small lesion in the colon asks if having the procedure means that "I have to deal with one of those pouches and have bowel movements into the pouch." How would the nurse respond? a. "Yes, a hemicolectomy means that you will need a colostomy." b. "Yes, but it will be temporary until the colon has healed." c. "No, only part of the colon is removed and the rest is reattached." d. "No, that is necessary only when a tumor is blocking the rectum."

9. The following foods are a part of a patient's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the patient to change? A) decrease high-fiber foods B) decrease amount of fluids C) omit fruits if eating vegetables D) nothing; this is a good diet

A female patient has had frequent urinary tract infections. Which statement by the patient indicates that the nurse's teaching on prevention has been effective? a. "I will limit my fluid intake to 40 ounces per day." b. "I will use only organic bath bombs when bathing." c. "I will wait to wear my tight jeans until after my urine is clear." d. "I will wipe from the front to back after voiding."

A patient with iron deficiency anemia reports rhythmic movements of the feet and legs and an itching sensation in the muscles before sleep. Which condition is likely to be found in the patient? a. Insomnia b. Cataplexy c. Narcolepsy d. Restless leg syndrome

At a routine clinic visit, an athlete training for a major sports event reports difficulty sleeping that is affecting the training schedule. What would be the best recommendation by the nurse for this patient to promote sleep? a. Increase the use of electrolyte-enriched drinks to increase stamina. b. Obtain a short-term prescription for sleeping medications. c. Plan to arise later in the morning to accommodate sleep changes. d. Avoid vigorous exercise for at least 2 hours before bedtime.

In which manner do body systems respond to stress? a. Always fail and cause illness and disease b. Cause structural damage to the body c. React the same way for all individuals d. Protect an individual from harm in the short term but cause negative responses over time

19. Which of the following questions by the nurse will specifically assess information on stress-related physical symptoms? Select all that apply. a. How have you dealt with stressful situations in the past? b. Have you experienced any changes in your life recently? c. Whom do you talk to about your feelings and problems? d. Have you experienced episodes of hyperventilat- ing? e. Does your cultural or spiritual background pro- vide you with certain beliefs that are helpful in times of stress? f. Do you experience any muscle tension in your neck, back, and head?

d f

Which food item would the nurse include in the diet of a patient who is bedridden to relieve constipation? Select all that apply. One, some, or all responses may be correct. a. Refined grains b. Fresh fruits c. Onion d. Cauliflower e. Beans

b c d e

53, The nurse is caring for patients on a postoperative unit in the medical center. The nurse is alert to the possibility that for 24 to 48 hours of the postopera- live period, patients may experience the following as a result of the anesthetic used during the surgery a. colitis. b. stomatitis c. paralytic ileus. d. gastrocolic reflex.

58. A patient who is going to have a colostomy done asks the nurse if a "bag" will have to be worn. The nurse recognizes that which of the following ostomies may not require an externally worn appliance? a. Transverse colostomy b. Ascending colostomy c. Sigmoid colostomy d. Loop colostomy

The nurse is caring for a patient with narcolepsy. Which medication does the nurse expect to be prescribed to the patient? a. Zaleplon b. Zolpidem c. Modafinil d. Eszopiclone

45. Identify the expected appearance of an ostomy stoma. Select all that apply, a. Dry b. Dark red with whiter areas. c. Moist d. Reddish-pink e. Purplish-blue f. Budding slightly above the skin

c d f

16. A Hematest for occult blood in the stool has been ordered. What is occult blood? A) bright red visible blood B) dark black visible blood C) blood that contains mucus D) blood that cannot be seen

Which response would the nurse provide to a client who asks about what to expect postoperatively before a transurethral resection of the prostate (TURP)? a. "Your urine will be pink and free of clots." b. "You will have an abdominal incision and a dressing." c. "There will be an incision between your scrotum and rectum." d. "There will be a urinary catheter and a continuous bladder irrigation."

While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia? a. Malabsorption b. Bladder cancer c. Diabetic ketoacidosis d. Urinary tract infection

T or F. The recommended daily intake of fiber is 10 to 15 grams.

False. The recommended intake is 25 to 30 grams a day

What does the RN do if bowel sounds are absent in the left upper & lower quadrants of a post operative patient who states. "May I have a snack? I am so hungry"

I can't give you a snack until you have bowel sounds

39. In teaching methods to promote positive sleep habits at home, the nurse instructs the patient to a. use the bedroom only for sleep or sexual activity. b. eat a large meal 1 to 2 hours before bedtime. c. exercise vigorously before bedtime. d. stay in bed if sleep does not come after half an hour.

An increase in venous pressure caused by liver disease can result in the development of: a. Hemorrhoids b. Flatulence c. Diarrhea d. Impaction

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

A client comes into the clinic with tremors and pitch changes in her voice. She also has facial twitches -and her respiratory and heart rates are slightly elevated. At the end of her assessment she tells you, "I feel like I have butterflies in my stomach." Which level of anxiety is this client experiencing? 1. Mild 2. Moderate 3. Severe 4. Panic

The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice and bananas

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

Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) milk and cheese. 2) bread and pasta. 3) fruits and vegetables. 4) lean meats

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

28. The nurse recognizes the stages of sleep and knows that a patient is most easily aroused in which stage? a. NREM 1 b. NREM 2 c. NREM 3 d. NREM 4

A patient is admitted to the hospital with severe diarrhea. The patient should be monitored for which complication associated with diarrhea? 1) Hypokalemia 2) Hypocalcemia 3) Hyperglycemia 4) Thrombocytopenia

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

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, "For 3 days prior to testing, I should avoid eating 1) beef. 2) milk. 3) eggs. 4) oatmeal.

The nurse has taught a client how to manage constipation. Which action by the client would provide evidence of learning? (Select all that apply.) The patient: 1) increases his intake of high-fiber foods. 2) drinks at least four 8-ounce glasses of water a day. 3) goes to the bathroom to evacuate after meals. 4) takes a daily laxative

1 3

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

A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley

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."

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

15. What are two essential techniques when collecting a stool specimen? A) hand hygiene and wearing gloves B) following policies and selecting containers C) wearing goggles and an isolation gown D) using a no-touch method and toilet paper

20. A patient tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which of the following? A) Habitual laxative use is the most common cause of chronic constipation. B) If laxatives are not effective, the patient should begin to use enemas. C) A laxative that works by a different method should be used. D) Chronic constipation is nothing to be concerned about.

27. A nurse is documenting the appearance of feces from a patient with a permanent ileostomy. Which of the following would she document? A) "Ileostomy bag half filled with liquid feces." B) "Ileostomy bag half filled with hard, formed feces." C) "Colostomy bag intact without feces." D) "Colostomy bag filled with flatus and feces."

Which complication would the nurse monitor for in a pregnant patient who is taking prenatal vitamin tablets with iron? a. Diarrhea b. Flatulence c. Constipation d. Fecal incontinence

Which sign or symptom supports the nurse's suspicion that a client has overflow incontinence? a. Constant dribbling of urine b. Abrupt and strong urge to void c. Loss of urine with physical exertion d. Large amount of urine loss with each occurrence

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

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

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 3 4

The nurse knows that when patients are experiencing stress, which physiologic changes can be seen in their signs and symptoms? (Select all that apply.) 1. Increase in heart rate 2. Flaccid muscles 3. Pupil dilation 4. Decrease in blood pressure 5. Increase in respiratory rate

1 3 5

A mother brings her toddler for a well-child checkup and mentions that she is having a lot of trouble getting the child to go to bed. The nurse understands that which interventions would promote good sleep habits? a. Establish and maintain a consistent bedtime routine. b. Put the child to bed immediately after the evening meal. c. Allow the child to stay up as long as desired to increase sleepiness. d. Allow the child to sleep with the parents until the child is older.

T or F. It is important for the nurse to assess the results of the serum blood urea nitrogen and serum creatinine lab tests for the patient receiving certain chemotherapy agents.

28. A recommended intervention for a lifestyle stress indicator and reduction in the incidence of heart disease is which of the following activities? a.Regular physical exercise b. Attendance at a support group c. Self-awareness skill development d. Time management

29. Which of the following is an antidepressant medica- tion that may be prescribed to promote sleep? a. Trazodone b. Haloperidol c. Midazolam d. Diphenhydramine

The nurse is caring for a patient who reports chronic insomnia. Which drug does the nurse expect to be prescribed to the patient? a. Zaleplon b. Zolpidem c. Modafinil d. Eszopiclone

A 25-year-old female patient demands that her mother or father be present during all blood testing. Which defense mechanism could the nurse document as being used by this patient? a. Sublimation b. Repression c. Projection d. Regression

The nurse is caring for a client who has cancer of the rectum and is scheduled for an abdominoperineal resection with creation of a colostomy. For which type of surgery would the nurse prepare the client? a. Permanent sigmoid colostomy b. Permanent ascending colostomy c. Temporary double-barrel colostomy d. Temporary transverse loop colostomy

Which finding would the nurse expect to observe in a patient with prolonged periods of stress? Select all that apply. One, some, or all responses may be correct. a. Loss of potassium and calcium b. Increased sodium reabsorption c. Increased extracellular volume d. Reduced gastrointestinal motility e. Reactivation of herpes infections

a b c

Which psychological symptom may be found in a patient who has sleep deprivation? Select all that apply. One, some, or all responses may be correct. a. Irritability b. Disorientation c. Difficulty concentrating d. Increase in sleeping time e. Decreased sensitivity to pain

a b c

40. The nurse is discussing sleep habits with the patient in the sleep assessment clinic. Of the following activities performed before going to bed, the nurse is alert to which one that may be interfering with the patient's sleep? a. Listening to classical music b. Finishing office work c. Drinking warm milk d. Reading novels

Which type of bowel diversion allows the patient to be free from an appliance? 1) Colostomy in the transverse colon 2) Double-barreled colostomy 3) Ileostomy 4) Kock pouch

A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Impaired Skin Integrity b. Fluid Imbalance c. Acute Pain d. Self-Care Deficit (i.e., toileting)

A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, it is most important for the nurse to coordinate with which member of the health care team? a. Home care nurse b. Wound ostomy continence nurse c. Registered dietitian d. Primary care provider

59. The nurse is instructing the patient in stomal care for an incontinent ostomy. The nurse evaluates achieve- ment of learning goals if the patient a. cuts the opening 1/16 inch larger than the stoma. b. uses peroxide to toughen the periostomal skin. c. applies commercial deodorant around the stoma. d. uses alcohol to cleanse the stoma.

62. The nurse instructs the patient that, before the fecal occult blood test (FOBT), which of the following may be eaten? a. White bread b. A lean steak c. Grapefruit d. Beets

A patient is newly diagnosed with diabetes and requires insulin injections. He requests information about classes offered by the diabetes educator. Which type of coping technique is this patient using? a. Emotion-focused b. Problem-focused c. Avoidance d. Denial

A male patient is told that he may have colon cancer. Which response by the patient best indicates that his initial appraisal of the situation is that it is primarily a challenge to be met? a. Requesting information on various treatment options b. Demanding to see another physician immediately c. Storming out of the gastroenterologist's office d. Yelling at the nurse who is scheduling his colonoscopy

A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. b. Reassure the patient that it is not possible to void while catheterized. c. Catheterize the patient again with a larger gauge catheter. d. Notify the primary care provider.

11. A patient with terminal cancer is taking high doses of a narcotic for pain. The nurse will teach the patient or family about what common side effect of opioids? A) inability to change positions B) problems with communication C) diarrhea D) constipation

21. A patient who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora? A) stool-softening laxatives, such as Colace B) increasing fluid intake to 3,000 mL/day C) drinking fluids with a high sugar content D) eating fermented products, such as yogurt

23. A patient is having liquid fecal seepage. He has not had a bowel movement for 6 days. Based on the data, what would the nurse assess? A) amount of intake and output B) color and amount of urine C) color of the feces D) consistency of the feces

28. A nurse is assessing the stoma of a patient with an ostomy. What would the nurse assess in a normal, healthy stoma? A) pallor B) purple-blue C) irritation and bleeding D) dark red and moist

32. The mother of a 2-year-old tells the nurse that the child has started crying and resisting going to sleep ar the scheduled bedtime. The nurse should advise the parent to do which of the following? a. Offer the child a bedtime snack b. Eliminate one of the naps during the day c. Allow the child to sleep longer in the mornings d. Maintain consistency in the same bedtime ritual

Which disorder would the nurse suspect in an elderly African American patient who reports a change in bowel habits with rectal bleeding and a sense of incomplete bowel evacuation? a. Infection b. Colon cancer c. Irritable bowel syndrome d. Inflammatory bowel disease

Which finding would the nurse expect in the urinalysis report of a client with diabetes insipidus? a. pH of urine: 9 b. Specific gravity of urine: 0.4 c. Red blood cells (RBCs) in urine: 6 hpf d. White blood cells (WBCs) in urine: 8 hpf

The nurse is monitoring the patient for a possible vagal response while removing a fecal impaction. If the patient had a vagal response, what would the nurse most likely observe? A Hypertension B Tachycardia C A decrease in respirations D Bradycardia

What condition is recognized when the nurse learns that a young woman who was in an automobile accident 6 months before has vivid images of the crash whenever she hears a loud, sudden noise? a. Fight-or-flight response b. General adaptation syndrome c. The exhaustion stage d. Posttraumatic stress disorder (PTSD)

When inserting a catheter to irrigate a client's colostomy, the nurse meets some resistance. Which action would the nurse take? a. Probe with the irrigating catheter to determine the contour of the bowel. b. Obtain a more rigid tip for the irrigating catheter to insert into the stoma. c. Apply pressure to the irrigating catheter to overcome the spasm of the bowel. d. Instill a small amount of solution from the irrigating container into the stoma.

A student nurse is studying the Gl system in preparation for an exam. Which statement indicates correct understanding? A The ascending colon would be found in the right side of the patient's abdomen B A patient's heart rate may increase with rectal manipulation, such as removing an impaction C Most absorption of water occurs in the small intestine D The use of opioids for pain relief and anabiotic therapy place a person at risk for developing diarrhea

Match each of the following numbered items with the correct nursing action. Items- 1. Impaction 2. Pinworms 3. Valsalva maneuver 4. Ileostomy 5. Constipation Nursing Action- A. Assess surrounding skin every shift B. May cause bradycardia and should be discouraged in the post-MI (heart attack) patient C. Remove stool manually D. Encourage a high-fiber diet E. Test for eggs with tape

1, C 2, E 3, B 4, A 5, D

Which information would the mentor include in the explanation about the role of the large intestine to nursing students? Select all that apply. One, some, or all responses may be correct. a. The large intestine excretes potassium. b. The large intestine has no absorptive role. c. The large intestine has a role in elimination function. d. The large intestine is composed of the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anus. e. The ileocecal valve prevents regurgitation (backflow) of chyme.

a c d e

Which behavior by a patient recently diagnosed with diabetes indicates that the patient is applying a problem-focused coping strategy? Select all that apply. One, some, or all responses may be correct. a. Asking for literature on diabetes b. Not accepting the diagnosis c. Being eager to learn about medication d. Withdrawing and expressing despair e. Willing to accept lifestyle changes

a c e

A patient is anxious about upcoming medical treatments and is having difficulty falling asleep. Which nursing interventions would promote the patient's ability to sleep? (Select all that apply.) a. Give the patient a back rub. b. Take the patient for a brisk walk right before bedtime. c. Provide a warm, quiet environment. d. Encourage the patient to eat a large meal in the evening. e. Give the patient a diet carbonated cola beverage. f. Play soft music during the 30 minutes before bedtime.

a c f

Which enema can be administered when the health care provider has prescribed a cleansing enema for a patient with constipation? Select all that apply. One, some, or all responses may be correct. a. Hypertonic enema b. Oil retention enema c. Carminative enema d. Isotonic enema e. Return-flow enema

a d

Which intervention would the nurse anticipate when, during a colonoscopy, the health care provider finds a polyp in the patient's colon? Select all that apply. One, some, or all responses may be correct. a. Removal of the growth b. Cauterization of the growth c. Institution of cryotherapy d. Sample collection for pathologic analysis e. Spraying of numbing medication

a d

When administering a cleansing enema, which techniques should the nurse use? (Select all that apply.) a. Assist the patient to a left side-lying (Sims) position. b. Add room-temperature solution to enema bag. c. Lubricate 2 to 4 cm (1 to 2 inches) of tip of rectal tube with lubricating jelly. d. Raise container, release clamps, and allow solution to fill tubing before administration. e. Clamp tubing after solution is instilled

a d e

Which intervention would the nurse make to reduce complications in a patient who has hyperactive bowel sounds and diarrhea? Select all that apply. One, some, or all responses may be correct. a. Suggest small, bland meals. b. Encourage the patient to drink fruit juices. c. Instruct the patient to have milk products. d. Have the patient drink lukewarm liquids. e. Monitor the fluid and electrolyte balance.

a d e

18. A patient has had frequent watery stools (diarrhea) for an extended period of time. The patient also has decreased skin turgor and dark urine. Based on these data, which of the following nursing diagnoses would be appropriate? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Fluid Volume C) Impaired Tissue Integrity D) Impaired Urinary Elimination

30. A nurse is providing discharge instructions for a patient with a new colostomy. Which of the following is a recommended guideline for long-term ostomy care? A) During the first 6 to 8 weeks after surgery, eat foods high in fiber. B) Drink at least 2 quarts of fluids, preferably water, daily. C) Use enteric-coated or sustained-release medications if needed. D) Use a mild laxative if needed.

A nurse is admitting a patient to the unit. The nurse is aware that the patient is at increased risk for constipation if the following are present in the patient's health history or admission assessment: (Select all that apply.) a. The patient eats whole grains, raw fruits, and green leafy vegetables b. The patient is an elderly woman c. The patient reports daily exercise and remains active d. The patient takes daily iron and calcium supplements e. The patient reports rare laxative use f. The patient takes opioids for chronic pain

b d f

Which colostomy creates an opening on the left lower side of the patient's abdomen? Select all that apply. One, some, or all responses may be correct. a. Loop colostomy b. Sigmoid colostomy c. Ascending colostomy d. Transverse colostomy e. Descending colostomy

b e

Which condition is a predisposing factor for the development of hemorrhoids? Select all that apply. One, some, or all responses may be correct. a. Diarrhea b. Pregnancy c. Renal failure d. Diabetes e. Obesity

b e

Which information would the nurse ensure that the student knows about bowel sounds before starting to auscultate? Select all that apply. One, some, or all responses may be correct. a. Normal bowel sounds are slow and sluggish. b. Normal bowel sounds occur every 5 to 15 seconds. c. Hypoactive sounds tend to be loud, high-pitched, and rushing. d. Hyperactive sounds may occur in cases of constipation. e. Normal bowel sounds are irregular, high-pitched, and gurgling.

b e

Which risk factor is related to sudden infant death syndrome (SIDS)? Select all that apply. One, some, or all responses may be correct. a. Depression b. Prone sleeping c. Hypertension d. Hyperthyroidism e. Soft bedding in cribs

b e

19, Which of the following is (are) associated with sleep deprivation? Select all that apply. a. Excitability b. Nausea c. Extreme weight loss d. Increased focus. e. Hallucinations f. Increased sensitivity to pain

b e f

Which pattern would the nurse record when caring for a patient with abdominal discomfort who has bowel sounds that are loud, high-pitched, and rushing? a. Normal b. Hypoactive c. Hyperactive d. Tympanic note

19. An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea? A) heart tones B) lung sounds C) skin turgor D) activity level

29. A nurse is caring for a patient who is 1 day postoperative for a temporary colostomy. The nurse assesses no feces in the collection bag. What should the nurse do next? A) Notify the physician immediately. B) Ask another nurse to check her findings. C) Nothing; this is normal. D) Recheck the bag in 2 hours

30. A child and his mother have gone to the playroom on the pediatric unit. His mother tells him he cannot have a toy another child is playing with. The child cries, throws a block, and runs over to kick the door. This child is using a mechanism known as a. denial. b. conversion. c. displacement. d. compensation.

Which purpose is served by a cystoscopy ordered for a client experiencing decreased and difficult urination? a. To ascertain the size of the kidneys b. To ascertain the protein content in urine c. To ascertain the presence of urethral wall abnormalities d. To ascertain the total amount of catecholamines excreted

Which term describes the body's response to stress? a. Distress b. Eustress c. Allostasis d. Homeostasis

Which clinical manifestation would the nurse identify as an indicator suggesting a client has urinary retention and overflow after sustaining a cerebrovascular accident (CVA, also known as a "brain attack")? Select all that apply. One, some, or all responses may be correct. a. Edema b. Polyuria c. Frequent voiding d. Suprapubic distention e. Continual incontinence

c d

Which recommendation would the nurse include when educating a patient about ways to promote bowel motility? Select all that apply. One, some, or all responses may be correct. a. "Refrain from eating grapefruit." b. "Eliminate cereals from your diet." c. "Perform regular aerobic exercises." d. "Walk for 10 to 15 minutes per day." e. "Exercise immediately after a meal."

c d

38. Identify the correct procedures for administration of a rectal suppository to stimulate bowel evacuation. Select all that apply. a. Apply sterile gloves for the procedure. b. Place the patient in a right, side-lying position. c. Insert the suppository with the rounded end inserted first. d. Insert the suppository above the internal anal sphincter. e. Embed the suppository into the feces, f. Return to evaluate the response in about 30 to 45 minutes.

c d f

When using a stress assessment tool with a patient from another culture, what factors must the nurse take into consideration? (Select all that apply.) a. Specific methods of managing stress are revealed in using stress assessment tools. b. Stress assessment tools should be used only for persons living in North America. c. Stress assessment tools may not be appropriate for all people of all ages. d. Resistance resources become evident when stress assessment tools are analyzed. e. Adaptations may need to be made to the assessment tool based on circumstances.

c e

29. The nurse is involved in crisis intervention with a family where the father has just lost his job and is experiencing periods of depression. The mother has a chronic debilitating illness that has put added responsibilities on the adolescent child, who is hav- ing behavioral problems. The nurse intervenes to specifically focus the family on their feelings by a. discussing past experiences. b. working on time management skills. c. encouraging the use of the family's current coping skills. d. pointing out the connection between the situation and their responses.

34. In describing the sleep patterns of older adults, the nurse recognizes that individuals in this age group a. require more sleep than middle-aged adults. b. are more difficult to arouse. c. take less time to fall asleep. d. have a decline in deeper stages of sleep.

47. The patient has an indwelling catheter. The nurse should obtain a sterile urine specimen by a. disconnecting the catheter from the drainage tubing. b. inserting a needle into the catheter tubing. c. opening the drainage bag and removing urine. d. using a syringe to withdraw urine from the cath- eter port.

51. The nurse is visiting the patient who has a nursing diagnosis of Alteration in urinary elimination, reten- tion. On assessment, the nurse anticipates that this patient will exhibit a, a loss of the urge to void. b. severe flank pain and hematuria, c. pain and burning on urination. d. a feeling of pressure and voiding of small amounts.

52. The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement to obtain a clean-voided urine specimen? a. Apply sterile gloves for the procedure. b. Restrict fluids before the specimen collection. C. Place the specimen in a clean urinalysis container. d. Collect the specimen after the initial stream of urine has passed.

65. The nurse recognizes that postrenal failure is associ. ated with a. renal damage. b. low cardiac output. c. vascular collapse. d. functional obstruction.

For a patient with a newly fractured pelvis, not yet in a cast, which of the following actions is appropriate when placing the patient on a bedpan? 1) Place the patient in semi-Fowler's position to defecate. 2) Ask the patient to push up with his feet to lift his hips while you place the bedpan. 3) Place a fracture pan under the buttocks, small end toward the feet. 4) Raise the siderail on the opposite side from where you are working.

12. A nurse is assessing a patient the first day after colon surgery. Based on knowledge of the effects of anesthesia and manipulation of the bowel during surgery, what focused assessment will be included? A) bowel sounds B) skin turgor C) pulse character D) urinary output

33. An 11-year-old child in middle school is currently experiencing sleep-related fatigue during classes. Which of the following should the nurse ask the par- ents first? a. What are the child's usual sleep patterns?" b. "Is there anything else going on at home or school?" c. "Do you think that there is a medical reason for the problem?" d. "Are you allowing the child to stay up late?"

37. A 74-year-old patient has been having sleeping dif- ficulties. To have a better idea of the patient's prob- lem, the nurse should respond with which of the following? a. "What do you do just before going to bed?" b. "Why don't you try napping more during the day- time?" c. You should always eat something just before bedtime." d. "Let's make sure that your bedroom is completely darkened at night."

45. A patient in the hospital has an indwelling urinary catheter, and the nurse is instructing the nursing assistant in the appropriate care to provide. The nurse teaches the assistant to do which of the following? a. Empty the drainage bag when two-thirds full b. Cleanse up the length of the catheter to the perineum with an antiseptic c. Open the drainage system to obtain a specimen for culture and sensitivity d. Place the drainage bag on the patient's lap while transporting the patient to testing

50. The patient asks the nurse to recommend bulk-form- ing foods that may be included in the diet. Which of the following should be recommended by the nurse? a. Whole grain cereals b. Fruit juice c. Rare meats d. Milk products

22. Which of the following is/are accurate statements regarding bowel elimination? Select all that apply. a. The meconium passed by newborns is brown and liquid. b. Breastfed infants have feces that are yellow, soft, and liquid. c. Control of defecation starts at about 3 years of age. d. Constipation can be a problem for school-aged children. e. Bowel elimination problems are prevalent in long- term care facilities, f. Older adults suffer more from diarrhea.

b d e

The nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. One, some, or all responses may be correct. a. "I can eat potatoes at dinner daily." b. "I should drink at least six glasses of water every day." c. "I should eat eggs for breakfast three times a week." d. "I can include bran muffins in my breakfast daily." e. "I will walk every day as part of my exercise regimen."

b d e

Which age group is most likely to have nocturnal emissions? a. Infants b. Toddlers c. Adolescents d. Older adults

The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema? a. The proper way to position the patient b. Signs and symptoms of intolerance to the procedure c. Vital signs before the procedure d. History of surgery of the anus or rectum

Which indicators of a developing infection would the nurse teach to the male client who has had a ureterolithotomy? a. Urgency or frequency of urination b. An increase of ketones in the urine c. The inability to maintain an erection d. Pain radiating to the external genitalia

Which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections? a. "Wear cotton underwear or lingerie." b. "Void at least every 6 hours around the clock." c. "Increase foods containing alkaline ash in the diet." d. "Wipe the perineum from back to front after toileting."

Which color of stool does the nurse anticipate when caring for a patient admitted for gastrointestinal (GI) bleeding? Select all that apply. One, some, or all responses may be correct. a. Red b. Black c. Green d. Orange e. Pale

a b

66. Which of the following urinary diversions requires that the patient has a stoma created? a. Ileal conduit b. Kock pouch c. Mainz pouch d. Ileal neobladder

Which intervention is most important in preventing hospital-acquired catheter-associated urinary tract infections (CAUTIs)? a. Removing the catheter b. Keeping the drainage bag off of the floor c. Washing hands before and after assessing the catheter d. Cleansing the urinary meatus with soap and water daily

58. A patient is receiving closed catheter irrigation. Dur- ing the shift, 950 mL of normal saline irrigant are instilled, and there is a total of 1725 mL in the drain- age bag. The patient's urinary output is calculated by the nurse to be a. 775 mL. b. 950 mL c. 1725 mL d. 2675 mL

A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this baby? A) yellow, loose, odorless B) brown, paste-like, some odor C) brown, formed, strong odor D) black, semiformed, no odor

The nurse recognizes that changes in elimination occur with the aging process. An expected change in bowel elimination is that a. chewing processes are less efficient, b. esophageal emptying time is increased, c. changes in nerve innervation and sensation cause diarrhea d. absorptive processes are increased in the intestinal mucosa.

Which manifestation would the nurse find in a patient with constipation? Select all that apply. One, some, or all responses may be correct. a. Development of hemorrhoids b. Changes in cardiac rhythm c. Decrease in intraocular pressure d. Increase in intracranial pressure e. Decreased intrathoracic pressure

a b d

31. Patients undergoing stress may have periods of regression. For which of the following individuals does the nurse assess regressive behavior? a. An adult patient who exercises to the point of fatigue b. An 8-year-old child who sucks his thumb and wets the bed c. An adult patient who avoids speaking about health concerns d. An 11-year-old child who experiences stomach cramps and headaches

40. Which of the following interventions requires a referral to a therapist with specialized training? a. Guided imagery b. Biofeedback c. Time management d. Progressive relaxation

48. Two patients with suspected kidney disease have had laboratory testing. The nurse will report which abnormal blood urea nitrogen (BUN) or creatinine result? a. BUN 14 mg/dL b. BUN 26 mg/dL c. Creatinine 0.9 mg/dL d. Creatinine 1.1 mg/dL

A patient is scheduled for an intravenous pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out? a. Urinalysis negative for sugar and acetone b. History of allergies c. History of a recent thyroid scan d. Frequency of urination

A patient's urine specific gravity has been reported at 1.035. Which of the following nursing actions would be appropriate? A. Start an IV of normal saline at 150 mL per hour. B. Encourage the patient to increase fluid intake. C. Insert a straight catheter to assess for urinary retention. D. Obtain an order for fluid restriction from the physician.

An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the priority concern of the nurse performing the procedure? a. Teaching deep-breathing techniques b. Maintaining strict aseptic technique c. Medicating the patient for pain before the procedure d. Positioning the patient for comfort during the procedure

The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining and that the patient's bladder is distended. What action should the nurse take next? a. Notify the primary care provider. b. Assess the tubing for kinks and ensure downward flow. c. Change the catheter as soon as possible. d. Aspirate the stagnant urine in the catheter for culture.

A patient is diagnosed with end-stage prostate cancer. The patient is depressed and approaches the nurse to seek advice regarding nonpharmacologic therapies to manage depression. Which information would the nurse provide to the patient about meditation? Select all that apply. One, some, or all responses may be correct. a. It improves the life span. b. It creates a state of relaxation. c. It requires the patient to be receptive and be able to focus attention. d. It helps reduce the dose of chemotherapeutic agents. e. It lowers blood pressure, heart rate, and metabolism.

b c e

Which nursing intervention would help an older adult experiencing urinary incontinence? Select all that apply. One, some, or all responses may be correct. a. Provide nutritional support. b. Provide voiding opportunities. c. Avoid indwelling catheterization. d. Provide beverages and snacks frequently. e. Promote measures to prevent skin breakdown.

b c e

A woman who is 34 weeks' pregnant is hospitalized for pyelonephritis. Which assessments would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct. a. Homan sign b. Urine output c. Temperature d. Dietary sodium e. Blood pressure f. Uterine contractions

b c e f

Which dietary instruction would the nurse give to improve the bowel health of a patient with constipation? Select all that apply. One, some, or all responses may be correct. a. "Stay away from spicy foods." b. "Include prunes or figs daily." c. "Increase your fluid intake." d. "Include eggs and lean meat." e. "Eat at the same time daily." f. "Include fiber in your diet."

b c e f

A nurse is explaining the physiologic mechanism underlying the fight-or-flight mechanism to a patient. The nurse says that "the medulla oblongata plays a major role in controlling the response of the body to a stressor." Which function does the medulla oblongata perform when the body is stressed? Select all that apply. One, some, or all responses may be correct. a. Constrict pupils b. Increase respiratory rate c. Increase mental alertness d. Increase blood pressure e. Increase blood glucose levels

b d

31. The patient has expressed difficulty in sleeping. On further investigation by the nurse, the patient iden- tifies the following behaviors. Which one should the nurse focus on that may be interfering with the patient's sleep? a. Exercising after work b. Taking a warm bath before bedtime c. Having one or two glasses of wine after dinner d. Eating a bedtime snack of crackers and juice

33. Nurses in the medical center are working with patients experiencing posttraumatic stress disorder (PTSD) after a natural disaster. An approach that is appropriate and should be incorporated into the plan of care is which of the following? Suppression of anxiety-producing memories b. Reinforcement that the PTSD is short term c. Promotion of relaxation strategies d. Focus on physical needs

41. Older adults at the community center are having a discussion on health issues that is being led by a nurse volunteer. One of the participants asks the nurse what to do about not being able to sleep well at night. The nurse informs the participants that sleep in the evening may be enhanced by a, drinking an alcoholic beverage before bedtime. b, using an over-the-counter sleeping agent. c. wearing loose, comfortable clothing. d, eating a large meal before bedtime.

49. The patient has been admitted to an acute care unit with a diagnosis of upper GI bleeding. The nurse sus- pects that the feces will appear a. bright red. b. pus filled. c. black and tarry. d. white or clay colored.

50. A postpartum patient has been unable to void since her delivery of her baby this morning. Which of the following nursing measures would be beneficial for the patient initially? a. Increase fluid intake to 3500 mL b. Insert an indwelling catheter c. Rinse the perineum with warm water d. Apply firm pressure over the bladder

52. While undergoing a soapsuds enema, the patient complains of mild abdominal cramping. The nurse should a. clamp the tubing b. immediately stop the infusion. c. lower the container to slow the infusion. d. advance the enema tubing 2 to 3 inches.

54. In determining the patient's urinary status, the nurse anticipates that the urinary output for an average adult should be approximately which amount? a. 400 mL/day b. 800 mL/day c. 1400 mL/day d. 2000 mL/day

57. The nursing instructor is evaluating the student during the catheterization of a female patient. The instructor determines that the student has imple- mented appropriate technique when observed a. keeping both hands sterile throughout the proce- dure. b. reinserting the catheter if it was misplaced ini- tially in the vagina. c. inflating the balloon to test it before catheter inser- tion, if indicated by the manufacturer. d. advancing the catheter 7 to 8 inches.

59. A toileting program for a patient in an extended care facility should include which of the following? a. Providing negative reinforcement when the patient is incontinent b. Having the patient wear adult diapers as a preven- tative measure c. Putting the patient on a q2h toilet schedule during the day d. Promoting the intake of caffeine to stimulate void- ing

Which factor would cause the nurse to inform the patient about the need to obtain a stool specimen for fecal occult blood testing when a 55-year-old patient is in the clinic for a routine physical? a. If patient reports rectal bleeding b. When there is a family history of polyps c. As part of routine recommended colorectal screening guidelines d. If a palpable mass is detected on digital examination

Which information about benign prostatic hyperplasia (PH) is important for the nurse to consider when caring for a client with that condition? a. It is a congenital abnormality. b. A malignancy usually results. c. It predisposes to hydronephrosis. d. Prostate-specific antigen decreases.

Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? a. Pouring warm water over the perineum b. Ensuring the patency of the catheter c. Removing the catheter within 24 hours d. Cleaning the catheter insertion site

Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise

Which of the following is considered a sterile procedure and therefore requires sterile gloves? a. Pouching an ostomy b. Administering a cleansing enema c. None of the mentioned d. Preparing a soapsuds enema for administration

Which finding, when assessing a patient who has undergone formation of an ostomy, does the nurse immediately report to the health care provider? Select all that apply. One, some, or all responses may be correct. a. Moist stoma b. Reddish-pink stoma c. Rashes around the stoma d. Budding of stoma slightly above skin e. Whitish area around the stoma

c e

41. For female catheterization, identify the correct sequence of steps in this portion of the skill: a. Insert the catheter 2 to 3 inches, advancing after urine appears. b. Inflate the balloon. c. Prepare the sterile field and catheter. d. Connect the drainage system. e. Cleanse the perineal area. f. Release the labia.

c e a b f d

63. The patient has a suprapubic catheter in place. Which of the following is correct for this type of catheterization? a. Irrigation is required for urine to drain. b. The catheter is secured with adhesive tape. c. Lotions or creams are used around the site to pro- tect the skin, d. Daily cleansing is done around the site with soap and water.

Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data, the patient states, "I've taken a tablespoon of milk of magnesia every day for 3 years, and I still don't have a BM every day." Which nursing diagnosis is most appropriate for the nurse to use as a possible problem in her plan of care? A. Diarrhea B. Constipation C. Risk for Dysfunctional GI Motility D. Perceived Constipation

The nurse is assessing an obese patient with constipation. The nurse places the patient in the supine position and inspects the abdomen for abnormalities. The nurse auscultates the abdomen beginning with the right lower quadrant and then moves on to light palpation of the abdomen. Which action of the nurse indicates the need for further teaching? a. Beginning the assessment by inspecting the abdomen b. Beginning the auscultation in the right lower quadrant c. Asking the patient lie in the supine position during inspection d. Using a light touch to detect underlying abdominal organs

The nurse is caring for a client 5 days after the surgical creation of a colostomy. The client has displayed signs of depression since the surgery. The nurse would determine that there is some movement toward adaptation to the change in body image when the client exhibits which behavior? a. The client discusses the necessity of the colostomy. b. The client requests the nurse to change the dressing. c. The client looks at the face of the nurse during care. d. The client stares at the stoma during dressing changes.

Which instruction would the nurse give after asking the patient to take deep breaths when teaching progressive relaxation to a patient? a. Sit in a comfortable position. b. Close your eyes and try to relax. c. Relax all the muscle groups at one time. d. Intentionally relax tense muscle groups.

55. A timed urine specimen collection is ordered. The test will need to be restarted if the a. patient voids in the toilet. b. urine specimen is kept cold. c. first-voided urine is discarded. d. preservative is placed in the collection container.

The nurse is reviewing enema administration with nursing assistive personnel (NAP). Which of the following statements by the NAP indicates further instruction is necessary? a. The rectal tube of an enema should be inserted 5 to 7.5 cm or 2 to 3 inches into the rectum of an adolescent b. The rectal tube of an enema should be inserted 2.5 to 3.75 cm or 1 to 11/2 inches into the rectum of an infant c. The rectal tube of an enema should be inserted 5 to 7.5 cm or 2 to 3 inches into the rectum of a child d. The rectal tube of an enema should be inserted 7.5 to 10 cm or 3 to 4 inches into the rectum of an adult

The nurse understands the important role in helping the patient with an ostomy accept their change in self-image. Which of the following indicates the patient is having difficulty with this change in body image? a. The patient continues to rely on the nurse to change the ostomy pouch b. Patient holds a gas pad over the stoma while cleaning the peristomal skin c. The patient is asking many questions d. The patient is willing to look at the stoma

The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal

The urinalysis report of a client reveals a pH of 6.0, turbidity/cloudiness, specific gravity of 1.020, and 0.6 mg/dL of proteins. Which condition can be inferred from the findings? a. Infection b. Glomerular disorder c. Acid-base imbalance d. Decreased kidney perfusion

Which condition would the nurse check for in the patient's medical record to ensure safe laxative administration? Select all that apply. One, some, or all responses may be correct. a. Nausea b. Joint pain c. Vomiting d. Undiagnosed abdominal pain e. Use of barrier cream on the skin

a c d

To prevent constipation in an inactive patient, which early interventions should the nurse implement? (Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake

a c d e

The nurse is caring for a patient with stated difficulty sleeping after the death of his spouse of 56 years. Which of the following would be the most appropriate action? a. Assess the patient for possible use of sedatives. b. Obtain a health history regarding sleep hygiene. c. Assess the patient's nutritional habits and intake. d. Contact the provider to request a sleep study.

The nurse is placing an indwelling catheter in a female patient. The nurse accidentally inserts the catheter into the vagina. What is the next action for the nurse to implement? a. Collect a urine specimen and notify the primary care provider (PCP). b. Leave the catheter in place and insert a new catheter into the urethra. c. Remove the catheter from the vagina and place it into the urethra. d. Ask another nurse to attempt the catheterization of the patient.

6. A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior? A) "When he does this, scold him and he will quit." B) "I don't understand why this child is losing control." C) "This is normal when a child this age is hospitalized." D) "I will have to call the doctor and report this behavior."

The nurse knows that the patient has understood teaching related to urinary incontinence when the patient states which of the following? A. "I'll just get those disposable pads because there is nothing to be done." B. "I'll limit my fluid intake so that I won't dribble so much." C. "I will do my Kegel exercises every day." D. "I'm going to have surgery, and the doctor will make a neobladder."

The physician prescribes a test for occult blood to be done on Mrs. Petrowski's stool. The result has come back negative. To be sure you do not have a false negative reading, which information do you need to ask Mrs. Petrowski? Whether she has been A. using iron preparations B. eating red meat in the past 3 days C. taking vitamin C D. taking the diuretic, furosemide

What self-care measure is most important for the nurse to include when developing a teaching plan for a patient who will be discharged with a urostomy? a. Change the appliance before going to bed. b. Cut the wafer 1 inch larger than the stoma. c. Cleanse the peristomal skin with mild soap and water. d. Use firm pressure to attach the wafer to the skin.

Which nursing intervention would be the highest priority when caring for a patient complaining of voiding small amounts of urine in relation to his fluid intake? a. Placing a disposable waterproof pad on the patient's bed before he goes to sleep. b. Documenting in the patient's electronic health record that he is complaining of anuria. c. Notifying the patient's primary care provider (PCP) of the need for intermittent catheterization. d. Palpating the patient's bladder for distention before scanning for possible retention.

Which patient requires the use of a fracture pan for a bowel movement? a. A patient who is obese b. A patient experiencing confusion c. A patient on bedrest d. A patient recovering from hip surgery

Which problem is the nurse trying to prevent by encouraging a client with a spinal cord injury to increase oral fluid intake? a. Dehydration b. Skin breakdown c. Electrolyte imbalances d. Urinary tract infections

The spouse of a client is discussing the difference between anxiety and fear. Which of the following statements indicates a need for further teaching? 1. "The source of anxiety is identifiable and the source of fear may not be identifiable." 2. "Anxiety is related to the future, that is, to an anticipated event. Fear is related to the present." 3. "Anxiety is vague, whereas fear is definite." 4. "Anxiety is the result of psychological or emotional conflict; fear is the result of a discrete physical or psychological entity."

A nurse is planning a seminar on minimizing stress and anxiety. Which of the following statements is NOT correct? 1. Provide an atmosphere of warmth and trust; convey a sense of caring and empathy. 2. Listen attentively; try to understand the client's perspective on the situation. 3. Control the environment to minimize additional stressors, such as by reducing noise, limiting the number of individuals in the room, and providing care by the same nurse as much as possible. 4. Communicate in long, detailed sentences.

Which information would the nurse include in the teaching plan for a client who will receive total parenteral nutrition (TPN) at home? a. Showing how to mix the nutritional solutions b. Demonstrating how to test capillary glucose levels c. Identifying the types of infusion pumps that can be used d. Checking for catheter placement by palpating the insertion site

Which intervention related to post-cerebrovascular accident (CVA) urinary incontinence would the nurse include in the client's plan of care? a. Insert a urinary retention catheter. b. Institute measures to prevent constipation. c. Encourage an increased intake of caffeine. d. Suggest daily ingestion of a carbonated beverage.

A nurse is preparing to administer an soap suds enema. Which of the following actions indicates correct understanding? a. The nurse holds the tubing in the patient's rectum constantly until the end of fluid installation b. The nurse places the patient in the prone for enema administration c. The nurse administers a normal saline enema without a healthcare providers order when the patient hasn't had a bowel movement after three days d. The nurse fills the enema bag to the prescribed level with warm water

Which action would be appropriate to implement when collecting a 24-hour urine test? a. Start the time of the test after discarding the first voiding. b. Discard the last voiding in the 24-hour period for the test. c. Insert a urinary retention catheter to promote the collection of urine. d. Strain the urine after each voiding before adding the urine to the container.

Which action would the nurse take after identifying that a client's urinary output is less than 40 mL/h over the past 3 hours? a. Assess breath sounds and obtain vital signs. b. Decrease the intravenous flow rate and increase oral fluids. c. Insert an indwelling catheter to facilitate emptying of the bladder. d. Check for dependent edema by assessing the lower extremities.

Which dietary instruction would be beneficial to a client who has undergone a hypophysectomy and has difficulty passing stools? a. "Drink plenty of water." b. "Eat foods rich in protein." c. "Drink a glass of milk daily." d. "Eat foods rich in carbohydrates."

Which nursing intervention helps prevent complications associated with a shortened urethra revealed by a recent intravenous pyelogram? a. Providing thorough perineal care after each voiding b. Encouraging the client to use the toilet or bedpan every 2 hours c. Responding quickly to the client's indication of the need to void d. Applying voiding stimulants to the perineum

A client is scheduled for a kidney ultrasound. Which instructions would be given by the nurse? Select all that apply. One, some, or all responses may be correct. a. "Drink plenty of fluids." b. "Eat foods rich in fiber." c. "Do not urinate before the examination." d. "Lie flat and perfectly still during the test." e. "A urinary catheter may be needed temporarily for the test."

a c d

8. A patient is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem? A) It is painful to sit on a bedpan. B) The position does not facilitate downward pressure. C) The position encourages the Valsalva maneuver. D) The cause is unknown and requires further study

If a patient had to have part of the colon (large intestine) removed, which of the following may result? a. The patient could experience fluid volume overload with increased absorption b. The patient could experience an acid base in balance c. Once healed, it would be unlikely for the patient to experience any alteration in elimination d. Patient could experience increased amounts of mucus in the stool

The client reports abdominal cramping while undergoing a soapsuds enema. Which action would the nurse take? a. Immediately stop the infusion. b. Lower the height of the enema bag. c. Advance the enema tubing 2 to 3 inches (5-7.5 cm). d. Clamp the tube for 2 minutes and then restart the infusion.

Which response would the nurse give to a client who had a transurethral resection of the prostate (TURP) who experiences dribbling after removal of the indwelling catheter? a. "I know you're worried, but the dribbling will go away in a few days." b. "Increase your fluid intake and urinate at regular intervals." c. "Limit your fluid intake and urinate when you first feel the urge." d. "The catheter will have to be reinserted until your bladder regains its tone."

7. A nurse caring for elderly patients in an assisted-living facility encourages patients to eat a diet high in fiber to avoid which of the following developmental risk factors for this group? A) diarrhea B) fecal incontinence C) constipation D) flatus

A client has a surgically created colostomy. Which is the most effective nursing intervention initially to help the client accept the colostomy? a. Provide literature containing factual data about colostomies. b. Ask a member of a support group to come to speak with the client. c. Begin to teach self-care of the colostomy by introducing equipment. d. List the names of important people who have had colostomies.

The NAP tells the nurse she doesn't want to care for a certain patient because she is afraid of contracting C. difficile. Which is the best response by the nurse? a. "C. difficile is the organism responsible for duodenal ulcers." b. "I can reassign you to care for à different patient." c. "Good hand hygiene with soap and water is your best defense against C. difficile." d. "C. difficile can only be acquired through antibiotic therapy, chemotherapy, or invasive bowel procedures."

Which assessment finding would the nurse report to the health care provider when giving immediate postoperative care to a client with a newly placed ostomy? a. Moderate edema of the stoma b. Excessive gas issuing from the stoma c. Blanching, dark red to purple color of stoma d. Small amount of blood oozing from the stoma

A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. Which is a nursing responsibility common to preparing both of the clients for these procedures? a. Withholding food for several hours b. Giving castor oil the afternoon before c. Administering soapsuds enemas until clear d. Ensuring an understanding of the procedure

The comatose patient in the intensive care unit (ICU), who has not had a bowel movement in 4 days, suddenly is incontinent of liquid stool. What should the nurse suspect? a. The patient had a vagal response b. Diarrhea as a result of decreased muscle tone c. Flatulence d. Impaction

Which action by the nurse would be best when a client who has been admitted with pulmonary edema and received furosemide intravenously needs to void? a. Place the client on a bedpan. b. Use adult diapers for the client. c. Help the client walk to the bathroom. d. Assist the client to a bedside commode.

Which response would the nurse give to a client who asks if having a hemicolectomy means wearing a pouch and having bowel movements in an abnormal way? a. "Yes, hemicolectomy is the same as a colostomy." b. "Yes, but it will be temporary until you are cured." c. "No, that is necessary when a tumor is blocking the rectum." d. "No, part of the colon is removed and the rest is reattached."

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