final 4

The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing?

Functional

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

Straight catheter

A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? a. urge b. total c. reflex d. stress

d. stress

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? a. indwelling urethral catheter b. intermittent urethral catheter c. Foley catheter d. retention catheter

b. intermittent urethral catheter

A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A) A clean catheter and rubber gloves B) A sterile catheterization kit or tray C) Solutions to sterilize the urethra D) Solutions to sterilize the vagina

B) A sterile catheterization kit or tray

What type of leader shares decisions and activities with group participants? A) Democratic B) Autocratic C) Laissez-faire D) Situational

A) Democratic

What type of leadership can a graduate nurse working in a magnet hospital expect? A) Democratic B) Autocratic C) Situational D) Quantum

A) Democratic

While at lunch, a nurse heard other nurses at a nearby table talking about a client they did not like. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating? A) The importance of food in meeting a basic human need B) Basic respect for human dignity C) Men do not gossip with women D) A low value on collegiality and friendship

B) Basic respect for human dignity

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? A) Condom catheter B) Urinary bag C) Straight catheter D) Retention catheter

C) Straight catheter

A nurse is described as a "quantum leader." Which action characterizes this type of leadership? A) A nurse conducts a blind survey to evaluate her leadership skills. B) A nurse relinquishes power to a group deciding hospital policy. C) A nurse makes policy decisions for coworkers without consulting them. D) A nurse sticks to the "tried and true" methods when implementing client care.

A) A nurse conducts a blind survey to evaluate her leadership skills.

A nurse is caring for a client who is a practicing Jehovah's Witness. The physician orders two units of packed cells based on his low hemoglobin and hematocrit levels. The nurse states to the surgeon that it is unethical to go against the patient's beliefs even though his blood counts are very low. What is the best description of the nurse's intentions? A) Acting in the patient's best interest B) Siding with the patient over the surgeon C) Observing institutional policies D) Being legally responsible

A) Acting in the patient's best interest

A group of nurses working in a long-term care facility fails to keep the narcotic medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in what type of disciplinary action? A) Action against the nurses' licenses B) Action against the facility's state license C) Action against the state regulating body D) Action against the pharmacist's license

A) Action against the nurses' licenses

After surgery, a postoperative client has not voided for eight hours. Where would the nurse assess the bladder for distention? A) Between the symphysis pubis and the umbilicus B) Over the costovertebral region of the flank C) In the left lower quadrant of the abdomen D) Between ribs 11 and 12 and the umbilicus

A) Between the symphysis pubis and the umbilicus

An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging? A) Diminished kidney ability to concentrate urine B) Increased bladder muscle tone causing urinary frequency C) Increased bladder contractility causing urinary stasis D) Decreased intake of fluids during daytime hours

A) Diminished kidney ability to concentrate urine

A nurse is scheduling diagnostic studies for client. Which test would be performed first? A) Fecal occult blood test B) Barium study C) Endoscopic exam D) Upper gastrointestinal series

A) Fecal occult blood test

While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. What stool characteristics are expected in breast-fed infants? A) Golden yellow and loose B) Dark brown and firm C) Yellow-brown and pasty D) Green and mucusy

A) Golden yellow and loose

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on: A) Habitual laxative use is the most common cause of chronic constipation. B) If laxatives are not effective, the client 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.

A) Habitual laxative use is the most common cause of chronic constipation.

A student nurse has just graduated with a baccalaureate degree in nursing. What type of nursing leadership will this nurse be expected to provide? A) Nursing care of the individual client B) Demonstration of selected critical skills C) Ability to be a follower rather than a leader D) Nursing care of groups of clients

A) Nursing care of the individual client

A head nurse assumes the leadership role when directing and supervising coworkers. Which of the following are attributes of a leader? Select all that apply. A) Philosophical B) Task-oriented C) Charismatic D) Dynamic E) Intimidating

A) Philosophical C) Charismatic D) Dynamic

A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected? A) Respecting the client's desire to have the uncle make choices on her behalf B) Revisiting the decision when the uncle is not present at the bedside C) Teaching the client about her right to autonomy D) Holding a family meeting and encouraging the client to speak on her own behalf

A) Respecting the client's desire to have the uncle make choices on her behalf

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A) Suprapubic catheter B) Indwelling urethral catheter C) Intermittent urethral catheter D) Straight catheter

A) Suprapubic catheter

Which of the following aspects of nursing would be most likely defined by legislation at a state level? A) The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs). B) The criteria that a nurse must consider when delegating tasks to unlicensed care providers. C) The criteria that clients must meet in order to qualify for Medicare or Medicaid. D) The process that nurses must follow when handling and administering medications.

A) The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs).

A nurse is providing client care in a hospital setting. Who has full legal responsibility and accountability for the nurse's actions? A) The nurse B) The head nurse C) The physician D) The hospital

A) The nurse

During a clinical placement on a subacute, geriatric medicine unit, a student nurse fed a stroke client some beef broth, despite the fact that the client's diet was restricted to thickened fluids. As a result, the client aspirated and developed pneumonia. Which of the following statements underlies the student's potential liability in this situation? A) The same standards of care that apply to a registered nurse apply to the student. B) The student and the nursing instructor share liability for this lapse in care. C) The patient's primary nurse is liable for failing to ensure that delegated care was appropriate. D) The student's potential liability is likely negated by the insurance carried by the school of nursing.

A) The same standards of care that apply to a registered nurse apply to the student.

A nurse in a physician's office has noted on several occasions that one of the physicians frequently obtains controlled drug prescription forms for prescription writing. The physician reports that his wife has chronic back pain and requires pain medication. One day the nurse enters the physician's office and sees him take a pill out of a bottle. The doctor mentions that he suffers from migraines and that his wife's pain medication alleviates the pain. What type of nurse physician ethical situation is illustrated in this scenario? A) Unprofessional, incompetent, unethical, or illegal physician practice B) Disagreements about the proposed medical regimen C) Conflicts regarding the scope of the nurse's role D) Claims of loyalty

A) Unprofessional, incompetent, unethical, or illegal physician practice

The nurse reports a nursing colleague on the unit who is lethargic and verbally responding in a slow manner. What is this an example of? A) Whistle-blowing B) Collective bargaining C) Delegating nursing care D) Ensuring adequate staffing

A) Whistle-blowing

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

A) Yellow, loose, odorless

A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply. A. Advocacy is the protection and support of another's rights. B. Patient advocacy is primarily performed by nurses. C. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities. D. Nurse advocates make good health care decisions for patients and residents. E. Nurse advocates do whatever patients and residents want. F. Effective advocacy may entail becoming politically active.

A. Advocacy is the protection and support of another's rights. C. Patients with special advocacy needs include the very young and the older adult, those who are seriously ill, and those with disabilities. F. Effective advocacy may entail becoming politically active.

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? A. Position the client in a supine position. B. Administer a diuretic, as ordered. C. Have the client rest for 15 minutes before the assessment. D.Assess the client's need for analgesia.

A. Position the client in a supine position.

The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? A. The male urethra is more vulnerable to injury during insertion. B. In the hospital, a clean technique is used for catheter insertion. C. The catheter is inserted 2 to 3 in into the meatus. D. Since it uses a closed system, the risk for UTI is absent.

A. The male urethra is more vulnerable to injury during insertion.

A nurse is a servant leader working in an economically depressed community to set up a free mobile health clinic for the residents. Which actions by the leader BEST exemplify a key practice of servant leaders? Select all that apply A. The nurse motivates coworkers to solicit funding to set up the clinic. B. The nurse sets only realistic goals that are present oriented and easily achieved. C. The nurse forms an autocratic governing body to keep the project on track. D. The nurse spends time with supporters to help them grow in their roles. E. The nurse first ensures that other's lowest priority needs are served. F. The nurse prizes leadership because of the need to serve others.

A. The nurse motivates coworkers to solicit funding to set up the clinic. D. The nurse spends time with supporters to help them grow in their roles. F. The nurse prizes leadership because of the need to serve others.

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as NORMAL? Select all that apply. A. dark brown B. light brown C. black D. clay colored E. yellow

A. dark brown B. light brown

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? A) Urinary incontinence B) Urinary retention C) Involuntary voiding D) Urinary frequency

B) Urinary retention

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. A. A patient who is taking narcotics for pain B. A patient who is taking metformin for type 2 diabetes mellitus C. A patient who is taking diuretics D. A patient who is dehydrated E. A patient who is taking amoxicillin for an infection F. A patient taking over-the-counter antacids

B. A patient who is taking metformin for type 2 diabetes mellitus E. A patient who is taking amoxicillin for an infection F. A patient taking over-the-counter antacids

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A. Students are not responsible for their acts of negligence resulting in patient injury. B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse.

A charge nurse in a busy hospital manages a skilled nursing unit using an autocratic style of leadership. Which leadership tasks BEST represent this style of leadership? Select all that apply. A. The charge nurse polls the other nurses for input on nursing protocols. B. The charge nurse dictates break schedules for the other nurses. C. The charge nurse schedules a mandatory in-service training on new equipment. D. The charge nurse allows the other nurses to divide up nursing tasks. E. The charge nurse delegates nursing responsibilities to the staff. F. The charge nurse encourages the nurses to work independently.

B. The charge nurse dictates break schedules for the other nurses. C. The charge nurse schedules a mandatory in-service training on new equipment. E. The charge nurse delegates nursing responsibilities to the staff.

A client, unsure of the need for surgery, asks the nurse, "What should I do?" What answer by the nurse is based on advocacy? A) "If I were you, I sure would not have this surgical procedure." B) "Gosh, I don't know what I would do if I were you." C) "Tell me more about what makes you think you don't want surgery." D) "Let me talk to your doctor and I will get back to you as soon as I can."

C) "Tell me more about what makes you think you don't want surgery."

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."

C) "This is normal when a child this age is hospitalized."

A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? 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."

C) "When you increase fiber in your diet, you also need to increase liquids."

Which of the following is the most frequent reason for revocation or suspension of a nurse's license? A) Fraud B) Mental impairment C) Alcohol or drug abuse D) Criminal acts

C) Alcohol or drug abuse

The nurse is caring for a client who had a sudden episode of vomiting, which produced 900 mL of frank blood. The nurse directed and delegated to colleagues in order to notify the physician. She started intravenous fluids, and provided physical and emotional support for the client. Different situations call for different leadership styles. Which of the following leadership styles did the nurse display in this situation? A) Democratic B) Laissez-faire C) Autocratic D) Transformational

C) Autocratic

A woman age 83 years who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. This is an example of what ethical principle? A) Nonmaleficence B) Veracity C) Autonomy D) Justice

C) Autonomy

A nurse working in a long-term care facility has an elderly male client who is very confused. What ethical dilemma is posed when using restraints in a long-term care setting? A) It limits personal safety. B) It increases confusion. C) It threatens autonomy. D) It prevents self-directed care.

C) It threatens autonomy.

Which type of stool would the nurse assess in a client 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

C) Soft, watery

Which of the following accreditations is a legal requirement for a school of nursing to exist? A) National League for Nursing Accrediting Commission B) American Association of Colleges of Nursing accreditation C) State Board of Nursing accreditation D) Educational institution accreditation

C) State Board of Nursing accreditation

A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? A. Irrigation of long-term urinary catheters is a routine order. B. Irrigation is recommended to prevent the introduction of pathogens into the bladder. C. A blood clot threatens to block the catheter. D. It is preferred to irrigate the catheter rather than increase fluid intake by the patient.

C. A blood clot threatens to block the catheter.

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A. Accreditation B. Licensure C. Certification D. Board approval

C. Certification

A nurse working on leadership skills should keep in mind which of the following accurate statements regarding leaders? A) People are born leaders. B) Leadership should be approached quickly. C) Leaders develop leadership skills in undefined situations. D) All nurse leaders began as inexperienced nurses.

D) All nurse leaders began as inexperienced nurses.

A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen? A) Pour urine from the collecting bag. B) Remove the catheter and ask the client to void. C) Aspirate urine from the collecting bag. D) Aspirate urine from the collection port.

D) Aspirate urine from the collection port.

A nurse manager makes all of the decisions for staff activities. What type of leadership is demonstrated by this action? A) Democratic B) Self-governance C) Laissez-faire D) Autocratic

D) Autocratic

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

D) Blood that cannot be seen

Two children need a kidney transplant. One is the child of a famous sports figure, whereas the other child comes from a low-income family. What ethically relevant consideration is important to the nurse as an advocate for these clients? A) Balance between benefits and harms in patient care B) Norms of family life C) Considerations of power D) Cost-effectiveness and allocation

D) Cost-effectiveness and allocation

A client 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

D) Eating fermented products, such as yogurt

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client 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

D) Nothing; this is a good diet

A baccalaureate-prepared nurse is applying for a nurse practitioner position. The nurse is: A) Well educated and can perform these duties B) Able to practice as a nurse practitioner C) Educated to practice only with pediatric patients D) Practicing beyond his scope according to licensure

D) Practicing beyond his scope according to licensure

A nurse leader is described as charismatic, motivational, and passionate. Communications are open and honest, and the nurse is willing to take risks. What type of leadership is the nurse practicing? A) Democratic B) Autocratic C) Quantum D) Transformational

D) Transformational

Which medication causes constipation? A. Magnesium antacids B. Bisacodyl C. Aspirin D. Iron supplements

D. Iron supplements

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? A. The stoma is hard and dry. B. The stoma is a pale pink color. C. The stoma is swollen. D. The stoma is a purple-blue color.

D. The stoma is a purple-blue color.

Which symptom is a known side effect of antibiotics?

Diarrhea

The nurse has provided instructions to a client having a fecal immunochemical test (FIT). The client states, "I am menstruating right now. Is it okay to still do the test?" What is the best response by the nurse?

Wait to do the test 3 days after your finish menstruating.

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed?

b, a, d, c

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

c. functional incontinence

The nurse has received an order to catheterize a female client. What action should the nurse perform? a. Lubricate 3 to 4 in of the catheter tip before insertion. b. Using both hands, hold the catheter near the tip and insert slowly into the urethra. c. Advance the catheter until slight resistance is felt. d. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm).

d. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm).

An older adult woman tells the nurse that she has trouble controlling her urine. She states, "The urine starts dripping even before I feel like I have to go." The nurse interprets this as:

reflex incontinence